Author's reply

I am delighted that the CHI has identified similar improvements through its internal monitoring as I suggested in my editorial. I was trying to be helpful.

I did not question the assessment and training of CHI reviewers but theirexperience as reviewers. Obviously, CHI is new and so its current reviewers are new. A useful exercise at 2 years or so would be to report the average number of reviews conducted by members and to check the number where the seconded members are all first-timers. How comparable and consistent the reports are is also a judgement of outcome, not just of process. Stake-holders will make their own judgements — probably in the same way I did by reading a couple side by side and trying to compare and contrast. Time will tell but shorter reports will certainly help.

Linda Patterson's and Jocelyn Cornwall's comments on my ‘unhelpful comparisons’ with homicide inquiries do, however, warrant a reply. Homicide inquiry panels would also consider their aim to be ‘to help encourage improvement where improvement can be made’. The point I was trying to make is that there can be a gulf between this wholly admirable ambition and the impact of such reports (and that this impact is both direct and indirect through the media).

This point is being made infinitely more eloquently by the Cambridge University philosopher Onora O'Neill in the BBC Reith Lectures entitled ‘A question of trust’ (O'Neill, 2002). In these she analyses with devastating precision how a pursuit of accountability and transparency at all costs can, and does, lead to the erosion of trust and, paradoxically, a reduction in disclosure and honest communication.

Having started my psychiatric training at a time when consultants really did seem free to do exactly what they wanted, I warmly welcome review and the establishment of consistent standards of clinical care. However, the age of innocence is surely passed. Professor O'Neill's analysis is a call to more careful thought on how accountability and transparency can be achieved without damaging the process they are meant to foster. Hopefully, now it will be accepted that we can have a debate on these issues without it being seen simply as protectionism. I wish the CHI well.