Clinical standards in the reformed NHS.

Unfettered by such restraining influences as a clear view of the end results, in 1991 the government of the UK made a fundamental change to the administration of its 43 year old NHS. Previous reorganisations had merely tinkered with the machinery for cascading funds from the chancellor of the exchequer to the NHS foot soldiers. This time there was a revolutionary idea at the core. Right down to a local level those deciding how and where to spend NHS money were to be separated from those running NHS hospitals. The result of this is that medical service providers now have to haggle over contracts with numerous public sector health purchasers in a nationwide clinical bazaar. An unsurprising consequence is that, desperate to cut costs and increase revenue, many hospitals have developed business management systems where words like 'restructure', 'contracting out', and 'down sizing' are in everyday use. Pressures of this type pose a potential threat to standards of clinical practice. Not, perhaps, to the extent that some doctors imply (hell hath no fiuy like a vested interest when paraded as a moral principle), but nevertheless there is a real risk. For example, pathology laboratories are the first clinical services that hospital managers will be encouraged to subject to 'market testing'. In plain English this means the work will be put out to tender, almost certainly resulting in some acute hospitals losing their on-site departnents. That may or may not be a sensible decision, but it raises questions about the service to patients. Similar problems are bound to arise in other departments, so the protection of clinical standards is presently an important consideration. Aware of all this, NHS purchasers try to ensure that the issue of quality is addressed (as they usually put it) when negotiating contracts. They stipulate standards, define specifications and look for hallmarks, but are still rather clumsy and insecure in the process. To help them, a number of initiatives have been developed.