A succession of regulators-cum-inspectors was established, including the Commission for Health Improvement, the Healthcare Commission, and the Care Quality Commission. They mainly focused on clinical governance and the quality of care provided by health and (latterly) social care organisations. Assessments were made through a combination of visits and inspections, and self-assessment by NHS organisations.
Regulators used the results of their assessments to publish information about performance – partly to inform the public (thus supporting greater patient choice) and partly to stimulate the organisations being regulated to improve their own performance. Through the system of star ratings (and subsequently the annual health check), variations in quality and performance became more transparent; this meant it was easier to identify organisations that needed intervention and support. The ‘earned autonomy’ regime meant that organisations assessed as performing well received financial bonuses and increased freedom to manage their affairs.
What does the evidence say about the impact of inspection and regulation?
The evidence is difficult to interpret, mainly because of frequent changes in the organisations responsible for carrying out this work and in the methods they use. There are some clear examples of regulatory failure during the reform period, concerning NHS providers such as Stoke Mandeville Hospital, Maidstone and Tunbridge Wells NHS Trust, and Mid Staffordshire NHS Foundation Trust, where there were serious shortcomings in patient care despite visits by the regulators. (In the case of Mid Staffordshire, the Healthcare Commission rated the trust as ‘good’ in its annual health check in 2007/8 even though it had high standardised mortality ratios.)
The role of the regulators was one of the issues examined in the two Francis inquiries into the failures of care that occurred at Mid Staffordshire. Major changes have subsequently been implemented in the approach taken by the Care Quality Commission, with the appointment of chief inspectors for hospitals, primary care and social care, and the development and testing of a new regime making use of experts in the areas of care being inspected. The fundamental nature of these changes suggests that inspection and regulation has not yet had the impact that was hoped for when it was introduced in 2000.
Regulated trust or real trust?
A recurring theme in critiques of NHS reform has been the importance of fostering commitment rather than compliance as the most effective means to bring about improvement and change. With regard to inspection and regulation, there is an important distinction to be made between regulated trust and real trust – with the latter prone to being jeopardised by over-reliance on regulation and inspection by external agencies. Some have even argued that over-regulating professionals can be counterproductive, suggesting that self-regulation and peer regulation are likely to be more effective than regulation from the outside.