Rotten boroughs of the unaccountable

July 3, 1998

THE job of a good scandal is to jemmy open cans of worms to public view in the hope that someone will pour in some worm killer. But some scandals are just not up to it.

One of this kind briefly occupied those few Brits whose minds were not on football in June. Three consultants at a Bristol hospital were disciplined by the self-regulatory body of their profession for longstanding incompetence in the treatment of babies and young children, many of whom died. Two consultants, who had already retired, were struck off. A third, still of working age, was not, but had to be found other duties.

Ministers, leader writers and sensible people in saloon bars all agreed that they had got off lightly. The consensus was that medical self-regulation is not working.

Flopped scandals of this kind occur every few years in medicine. But the power of the medical profession is too great and the political costs for any government in taking on the profession too frightening for much to happen.

Doctors gently remind politicians that, unlike Adam Smith's butcher and baker who provide our dinner, doctors keep the National Health Service staffed to provide our butchery only by their philanthropic willingness to accept the lavish settlement on them of the taxpayers' money by Aneurin "I stuffed their mouths with gold" Bevan and his successors.

Should they find the terms unacceptable or should there be any threat to their clinical and professional autonomy, the medical profession implies, they will desert the public sector for the more lucrative shores of Harley Street.

Kenneth Clarke, who almost a decade ago dared to introduce reforms that would pit GPs against hospital consultants, was followed by years of concessions under Virginia Bottomley and Stephen Dorrell. They memorably pursued the Bevan policy of shiny metal transfer and allowed doctors massively to reorganise their working patterns to suit themselves (remember after-hours services by GPs?) The Thatcher governments had the political sense to take on professions only one at a time - teachers in 1987, doctors in 1990, lawyers in 1992. New Labour, by contrast, appears too dependent for votes on the public sector professions to challenge radically their independent self-regulation and right to determine what their jobs consist of.

The government has agreed to give teachers what they have demanded for 100 years - a General Teaching Council. In short, the same self-regulatory system as the doctors. It will doubtless similarly stifle innovation and increase costs just as professional autonomy and self-regulation did in medicine, dentistry and the law. There could still be a steady supply of scandals.

Could New Labour do better? Is there enough breezy modernising left in them to open up the rotten boroughs of unaccountable professional power and self-protection? Reforming professions is expensive in the short run, although it can save money in the long run as cheaper and more flexible auxiliaries are trained to take over many of the traditional activities of accredited professionals.

Winning public opinion also costs time and money - particularly because the medical profession can find flags to wave that few politicians have the courage to pull down, even after a scandal of incompetence and mutual protection by self-regulation like this.

But there is hope. Health secretary Frank Dobson has promised to publish hospital death rates, but not yet those of individual consultants. Perhaps he could be emboldened to force lay management representation into the fortress of clinical audit as a step towards tackling self-regulation. Real hope, however, lies with the Chancellor, whose fiscal tightness of revenue spending could yet be the jemmy we need for some of these cans of ermine-wrapped worms.

Perri 6 is director of policy and research at Demos, the independent think tank.

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