As the year draws to a close, it’s an apt moment to reflect on 2024 and discern its lasting imprint on the healthcare sector in the UK. Among the numerous events, several prominent themes stand out: a change in government, once more strained public finances, an unprecedented surge in demand for NHS services1,2 and a series of public inquiries or reports that have cast harsh, albeit fleeting, light on some troubling realities.
The change in government has naturally prompted shifts in healthcare policy and priorities. However, the chronic issue of underfunded public services has persisted, with the healthcare system struggling to cope with ever-increasing demand. This year saw NHS services stretched to their limits, further exacerbating existing challenges in delivering timely and effective care.
Public inquiries and reports made significant impacts this year, unveiling uncomfortable truths about various aspects of healthcare governance. These revelations, spotlighted by the media3, prompted public concern and debate over accountability and the need for reform. Unfortunately, the familiar cycle of media attention followed by fleeting acknowledgement highlights a systemic issue in governance: the need for not just transparency and accountability but sustained action and innovation to address the underlying problems.
Three reports have particularly resonated with those of us who, with years of experience, have witnessed the effects of dysfunctional governance frameworks in healthcare. The first of these is Nazir Afzal’s4 Independent Culture Review of the Nursing and Midwifery Council, which sheds light on cultural issues within the organisation. The second is the Independent Review into the Operational Effectiveness of the Care Quality Commission: Interim Report by Dr. Penelope Dash5. This report critically examines how the Care Quality Commission (CQC) operates and identifies areas in need of improvement. Complementing this is the third report, Professor Sir Mike Richards’ Review of the CQC’s Single Assessment Framework and Its Implementation6, providing further insights into the effectiveness of the CQC’s assessment processes.
Collectively, these reports underscore the persistent challenges within UK healthcare governance. They highlight organisational and operational inefficiencies and also cultural aspects that hinder progress. By bringing attention to these issues, the reports reinforce the need for systemic reform and a concerted effort to ensure accountability, transparency, and improvement across the sector.
Nazir Afzal’s report, released in July, went largely unnoticed by many7 but highlighted yet another case of a healthcare institution plagued by a toxic culture that undermines its fundamental mission. This scenario is all too familiar to many clinicians in the UK, some having personally experienced similar issues. The predictable response7 from a Department of Health and Social Care spokesperson, emphasising the importance of whistleblowers being able to speak up without fear, serves as a reminder of another missed opportunity to address systemic problems. Without a robust process in place to truly protect whistleblowers, critical issues in healthcare often remain unreported or lead to severe consequences for those who dare to speak out. This reality highlights the urgent need for genuine reform to foster a culture of transparency and accountability, ensuring that systemic failures are identified and addressed proactively rather than reactively.
Afzal’s report presents a sobering analysis, made all the more compelling by his initial acknowledgement of the high praise and gratitude he has for the nurses he encountered during the darkest days of the COVID-19 pandemic. This context lends weight to his findings and underscores the contrast between the dedication of individual healthcare workers and the systemic issues within the institutions they serve.
Is it possible for a healthcare regulator to permit the actions highlighted by Afzal to occur? If the professional governance framework is truly fit for purpose, how challenging can it be, and how long should it take, to assess a clear case of malfeasance?
While it certainly requires time and expertise to reach fair, impartial, and transparent decisions, should it really take 10 years? Common sense, professional experience, investigative acumen, and the absence of conflicts of interest are fundamental requirements. Additionally, basic detective skills and a personal commitment to “do the right thing” are crucial.
Furthermore, what about the organisation’s leaders? Can the heads of institutions, which have been criticised on multiple fronts, truly be unaware of the dire state of their organisation during their tenure?
Or, once they become aware, are they truly unable to initiate the necessary changes to reform the troubled organisations they lead?
Does it require an independent inquiry before changes are made to rectify the entrenched injustices within healthcare systems? What does this suggest about the quality of leadership in governance? Who are these individuals, and what qualifications or experiences positioned them as suitable candidates for their roles? Are these leaders able to ensure fair, impartial, and transparent governance?
Many roles in healthcare are vocational for a high proportion of those entering their profession. A deep sense of duty and a feeling of privilege to be trusted by patients – people when at their most vulnerable, motivates many in the clinical team, which is why there is a strong drive to see poor practice corrected and fail-safes against recurrence put in place when it comes to light.
The public expects leaders in healthcare to promote and uphold values that might be considered somewhat traditional within the workforce. For a world-class public healthcare system such as the NHS to thrive, trust and accountability are essential. This requires proper governance, to be implemented and visibly demonstrated.
We have fostered a culture within the NHS where communicating issues or delivering unwelcome news is discouraged. When clinical staff raise concerns about situations that jeopardise patient safety or compromise their own professional environment—whether through potential threats to their license, livelihood, or incidents of bullying and discrimination—many of these warnings go unheeded, and some whistleblowers face professional retaliation.
Clinical governance can be misused as a tool to discredit colleagues and whistleblowers by reporting them to their regulatory bodies. This tactic discourages others from supporting the complainant. While some may dismiss such incidents as mere rumours or assume there’s always some truth to them, it becomes very real when it happens to them or someone they know. This strategy is often employed by individuals and institutions attempting to deflect attention from their own more significant issues8.
Regulators and senior NHS managers often have a broad overview that should allow them to recognise potential issues when clinicians are scrutinised or suspended. There are clear-cut cases where a clinician is rightly judged guilty and others where both parties share the blame.
When unjustifiable attacks on clinicians can be demonstrated, however, it’s concerning that no action is typically taken. Healthcare managers do not have a regulatory body overseeing their conduct, leaving a gap in accountability. There are no proactive consequences for healthcare professionals in senior management positions, such as medical or nursing directors, who make unfounded referrals, which is comparable to ‘wasting police time.’ This lack of oversight creates an environment where such actions can go unchecked.
One would expect regulators to recognise situations accurately, given their considerable experience and training. Do they not detect something amiss when examining the non-clinical ‘facts’? For example, claims like ‘this patient died’ when they hadn’t, or ‘this patient was harmed’ — although true, the records show the accused was not involved in their care. Isn’t there a moment of realisation when serious inconsistencies or falsehoods are exposed? The National Audit Office’s 2014 paper, “How to Recognise and Deal with Vexatious and Malicious Grievances9,” offers valuable insights in the broader context of employment relations and could be highly applicable in this context.
Those of us with decades of experience in healthcare understand that it’s a field just like any other, populated by individuals with a wide range of personalities, including some with problematic traits. Not every nurse is an angel, nor is every doctor a saint. This reality underscores the vital role of effective regulatory bodies for healthcare professionals. Their dual purpose is crucial: protecting the public from practitioners who are genuinely unfit for practice, while also safeguarding practitioners from baseless and malicious attacks that could harm their professional standing and livelihood, regardless of the motives behind these attacks.
The Care Quality Commission (CQC) regulates all health and adult social care providers in England. In 2023, a new single assessment framework (SAF) was introduced and presented as a simpler system to enable more frequent inspections. However, its effectiveness has been questioned. An independent interim report by Dash, last updated on the government website in October 2024, highlights several ’emerging findings’: poor operational performance, significant IT issues with the regulatory platform, a loss of CQC credibility within the sector, concerns regarding the SAF, and flawed processes for rating services. These findings were corroborated by Professor Sir Mike Richards, the former Chief Inspector of Hospitals, in a report commissioned by the CQC itself, to address Dash’s findings.
They highlight the anger and desperation among staff, a significant adverse impact on the working conditions within provider organisations, and the CQC’s failure to fulfil its statutory functions. Additionally, there is a noted loss of clinical oversight at the CQC.
In summary, the state of UK healthcare in 2024 provides crucial lessons for governance, organisational leadership, the importance of adequate funding, and the need for continuous, long-term strategic planning to meet the nation’s healthcare needs. As these challenges persist, it remains vital to heed these lessons to improve the system for future generations.
Fingers crossed that 2025 is a better year for UK governance in healthcare.
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