Healthcare works very differently north of the border, but Scotland can still learn from the inquiry into Mid-Staffordshire NHS Trust. The first lesson should be the need for an integrated and robust scrutiny system
On the very day that the Francis Report into care failings at Mid Staffordshire NHS Foundation Trust was published, the Scottish Parliament approved its budget. Almost one third of the £34bn total is for health and wellbeing.
Most of this is passed to Scotland’s health boards to fund local health care. In the words of the Cabinet Secretary’s foreword to the budget, there is ‘real-terms protection for the NHS revenue budget supporting frontline services’. The budget then goes on to describe the proposed improvements to Scotland’s healthcare, all set within a compelling ‘2020 Vision’.
The NHS trust regime has not been implemented in Scotland, but we can still learn from the lessons emerging from Mid-Staffordshire.
There are references to the failure of scrutiny throughout the report – whether it be external scrutiny or that undertaken by internal systems and committees – all set within a context of dominant financial pressures. It serves as a reminder that public inquiries aren’t held because services have performed well or because we want to learn from good practice. Rather, they are usually held because there is service failure, in this case catastrophic service failure.
The report, while making recommendations on external scrutiny bodies and strengthening the role of (local) governors, makes no recommendation on the accountability of members of parliament – those responsible at the outset for the NHS trust legislative framework in which service failure arose. What does not seem to have been tested is the robustness of that national legislative framework and what role it has, if any, on the financial and service pressures that emerged.
It is on this specific point where Scotland could identify its own beginning on how to learn lessons and this starting point could come from a third unconnected event. The Scottish Parliament Standards and Procedures Committee has just concluded an inquiry into how Parliament should conduct post-legislative scrutiny. The intention of this inquiry was to consider how Scotland’s MSPs should best consider how their legislative intervention has performed.
It is a form of scrutiny not undertaken at the moment. The committee’s inquiry provides the opportunity to reflect upon how Scotland’s decision makers are at present largely disconnected from the end service delivery their legislation results in, bringing a remarkably similar comparison to the disengagement of MPs and governors in Mid-Staffordshire.
This combination of scrutiny, finance and performance was at the heart of CIPFA’s evidence to the Committee. We recommended the introduction of a more rounded form of scrutiny that commences with a more robust test of the proposed legislation, including stringent assessment of why legislative intervention is necessary in the first place.
The integrated model requires robust and ongoing financial scrutiny to be embedded as part of the process to ensure that the financial consequences are clear at all stages. This ongoing scrutiny would continue throughout policy implementation and service delivery, and would be further strengthened with robust post-legislative scrutiny.
CIPFA’s model envisages a seamless and integrated form of scrutiny. It should ensure that the legislators, who currently pass laws and then move on, would have to retain a direct and more transparent link to the consequences of their legislative intervention. Some would call this accountability.
The importance of enhanced scrutiny could appear trite especially when lives are at stake or, in the case of Mid Staffordshire, have been lost. But the consequences of more integrated scrutiny would ensure that national politicians remained accountable. So the first lesson could be that the introduction of a more integrated and robust scrutiny system would mean that rather than waiting for service failure, the system of scrutiny produces the proper signals at the right time.
We will have to wait to see if the Standards and Procedures Committee is brave enough to recommend an integrated scrutiny model. But in future it could mean that when the Scottish budget sets out the ‘protection’ for frontline services, Scotland’s scrutineers will have better information on which to make their assessment of health service performance, hopefully without resort to a public inquiry.
Don Peebles is policy and technical manager at CIPFA in Scotland