All I have is a voice to undo the folded lie.
W.H. Auden

Council for Health Regulatory Excellence [CHRE]

Public meeting of the Board, held at 11 The Strand, London. 13 Feb 2008

report by Janet Low

Video

I attended a public meting of the Board of the CHRE on February 13, 2008. The Council for Health Regulatory Excellence (CHRE) is the alias of the Council for the Regulation of Healthcare Professionals. The CRHP is the legal name of the organisation, which was established in April 2003 by the National Health Service Reform & Health Care Professionals Act 2002. This Act is very closely associated with Ian Kennedy (an academic lawyer) whose name became widely known after his BBC Reith Lecture in 1980 on the subject of "Unmasking Medicine" (Kennedy 1981). He went on to become the lead author of the Bristol Royal Infirmary Inquiry into the row over the success rate of a children's heart surgeon. (Kennedy et al, 2001), and this report is credited with the creation of the CRHP (CHRE).

There were two members of the public in attendance at the February Board Meeting. The other one worked for the Scottish Government as a Professional Adviser. As an old hand here, she took me under her wing and told me that the CHRE was set up to 'Protect the Public'. This rationale points in the direction of Ian Kennedy. His 1,200 page report of the public enquiry into the children's heart surgery at the Bristol Royal Infirmary (Kennedy et al 2001) is not renowned for its impartiality, and 'can be read as a sustained argument for doctors … to be subject to greater regulation" (Travers 2007, p 29). His Reith Lecture gives a good indication of the critical position he takes in relation to the medical profession. I questioned the idea of 'protecting the public' and she agreed, but then mentioned Harold Shipman.

Both Harold Shipman and the trouble at the Bristol Royal Infirmary were local dramas that affected real people in particular places at a specific time. They both had tragic consequences, but these were very different from each other. The use of the names of Shipman and Kennedy in relation to each other are wrong, and in relation to the CHRE are very misleading - they displace the reality of the complex cases, substitute fear and anxiety for information, and kindle distrust without touching on the practical details that might be useful in order think about the problems they raise.

Marilyn Strathern (1997, 2000) and Michael Power (1994, 1997) have both done useful work on rituals of verification and are both very relevant here. Each of these authors make good argument and present useful information to demonstrate the difference between creating systems that actually help, and those that simply put on a show. The latter tends towards perverse effects when they are called on to pretend they are in fact true. Fear and anxiety can be the result - with obvious consequences for trust.

The CHRE is the regulator of regulators and covers 1.1 million practitioners whose work is represented by nine other groups. Eight of these groups are recognisable as existing councils whose history is grounded in practice:

The General Chiropractic Council, The General Dental Council, The General Medical Council, The General Optical Council, The General Osteopathic Council, The Nursing and Midwifery Council, The Pharmaceutical Society of Northern Ireland, and the Royal Pharmaceutical Society of Great Britain.

The ninth group is a little different. This is the HPC. Like the CHRE (CRHP) it was created with the rhetoric of 'protecting the public' and also gains its power not from savoir faire of practice, but through a piece of legislation (the Health Professionals Order 2001).

Also, the HPC does not cover a single profession; it has 13 existing groups at present:

art therapists, biomedical scientists, chiropodists, clinical scientists, dieticians, occupational therapists, operating department practitioners, orthoptists, paramedics, physiotherapists, podiatrists, prosthetists, orthotists, radiographers, speech and language therapists.

Within the next few months it aims to incorporate part of the British Psychological Society, and after this there are plans afoot to capture the psychotherapy and counselling organisations. This means that one of the groups regulated by the CHRE (CRHP) is itself an anomalous group that tries to regulate a diverse group of people whose practice is outside its own speciality. The potential for misunderstanding is really very high. The possibility for sensible and effective regulation is very small indeed.

The CHRE (CRHP) is answerable to government. At present this is a very problematic position to be in, and in part is the consequence of Ian Kennedy's proposition that medicine needs to be unmasked. There is an assumption that the professionals themselves cannot be trusted, and need to be scrutinized by someone more trustworthy, but not exactly the government. Who is more trustworthy? And trustworthy in what respect? Not to become a mass murderer like Harold Shipman? Even if we remove the red herrings from the scene (and that would be a sensible first step), we are left with the dubious question of objectivity, which in this case seems mixed with something close to envy. Who is capable of judging practitioners? If one is prejudiced against them, and this is not an unreasonable assumption to make if you read Ian Kennedy, then you must insist that objectivity must reside outside the profession itself. In this way all practitioners are treated as a threat. So who is to be trusted? Won't they soon find themselves soon bracketed into a group that is also presented as a threat? A regulator will be needed to regulate the regulator of the regulator. Any sign of professionalism could easily be taken as a sign of bias, and we could find ourselves in the rather stupid position of searching for 'innocent' unprofessional people to make judgements on something about which they have no idea whatsoever. In the meantime, the logic that has set up the council seems to create enough confusion to cause people to mistake objectivity for a lack of local or practical and above all specialised knowledge.

The CHRE website (consulted 19 Feb 2008) says that it is "needed to reassure the public that healthcare regulation is operating properly". To manage this reassurance, there is an executive team of twelve full-time staff and nineteen Board Members. Nine of these members are drawn from the nine member organisations, the other ten are lay members, four are appointed by the health minister of each of the countries in the UK, and the rest by the NHS appointments commission.

Some of the business of February's Board Meeting was taken up with problems of establishing their independence from the power of the government. The power of the CHRE, and also the HPC, is, however, highly dependent on government instruments. This can only change if they can win the trust of their members (the professionals), whence some power might begin to emanate from its roots, and might be transferred from government. However, because of the bias that created the CHRE (that people in medical practice cannot be trusted), they could then become vulnerable to the same idea of bias unless this nonsense is addressed properly. Presently, all the Board can hope for is a carefully crafted form of words to disguise their embarrassing predicament, and the assurance from the four different Ministers (one for each country) that they won't abuse their power.

There is plenty here already to be concerned about, but there is more that also needs to be noted:

- the board is concerning itself with the problem of defining 'good character';

- there exists a Public Guardian (Richard Brook) - a post created by The Mental Capacity Act 2005 for England and Wales;

- the Health and Social Care legislation is due to be passed in Autumn 2008, which raises the possibility that all the social workers will be soon considered health care professionals and thence eligible for regulation;

- this legislation will also review the function and composition of the CHRE (CRHP), and apparently proposes to reduce the Board to just three people.

Each of these four points raises a lot of questions. To try to tackle all four at the same time is impossible. The main direction of my concern here is this: centralisation coupled with the power of the state changes the nature of these questions. The pressure to make 'one answer' for a very diverse set of people and practices creates conditions for too many unpredictable and unintended consequences. Some of these consequences could even be exactly counter to the idea of protection intended.

Lastly, I found on the table in reception three well-written booklets to take away that represent some of the work done by the Council. All three were dedicated to making clear the sexual boundaries between healthcare professionals and patients, one for the professionals, one for trainers and educators, and one for the panels that would have to judge.

Perhaps it is because the Board has been set up on a spurious idea rather than grounded in mundane facts and practice that it finds itself making up rules for fellow citizens on matters of sexual relations and good character. Perhaps it is the difficulty of being in such a highly abstract position in relation to such a diverse and large body of practitioners that forces the Board into such a peculiar generalizing position. Perhaps it is the proximity of the state and its power that makes it such a troubling issue. Probably what is needed now is a gentle but definite movement from engaged and thoughtful people to counter this centralising tendency and stop it messing up this country. The Regulator needs to know that we will regulate it in our turn. Certainly this will involve differences across the UK, across the practices (think of it as diversity and choice). Possibly this is a modern revolution. For sure we must not snooze through it.

Janet Low,

March 2008

Kennedy, Ian (1982) The unmasking of medicine, London, George Allen and Unwin

Kennedy I, Howard R, Jarman B and McLean M (2001) Learning from Bristol: The report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995 London HMSO

Power, Michael (1994) The audit explosion. London Demos

Power, Michael (1997) The audit society, rituals of verification. Oxford OUP

Travers, Max (2007) The new bureaucracy: quality assurance and its critics. London Polity Press.

Strathern, Marilyn (2000) The tyranny of transparency, British Education Research Journal, 26: 309-21. Also published in H Nowotny & M Weiss (eds), Shifting boundaries of the real: Making the invisible visible, vdf Hochschulverlag AG an der ETH, Zürich, 2000.

Strathern, Marilyn (ed) 2000 Audit Cultures : Anthropological studies in accountability, ethics and the academy. London Routledgeaus