In its response to the Francis Inquiry report, the government has avoided some of the more obvious wrong turns, such as the regulation of managers. Much of it contains ideas that were already in train – including the review of nursing – and the continuation of long-term trends in policy – for example increased transparency and the requirement for candour. However, some concerns remain.
The response highlights the paradox created by setting up a major public inquiry to report just before the largest ever piece of NHS legislation comes into force. It proposes a system in which Monitor, the Care Quality Commission, the Trust Development Authority and the NHS Commissioning Board (now known as NHS England) have to collaborate very closely. How this will work and who will become responsible for what is not very clear, and local commissioners, who were supposed to be driving the system, do not really feature in the way that might be expected.
The response gives an upbeat assessment of how the new commissioning system, which is focused on outcomes, will drive improved quality. Yet it does not acknowledge that commissioning has been fragmented across different parts of the system or that it is now significantly less well resourced than it was when Mid-Staffordshire NHS Foundation Trust was having problems. The proposed development of quality surveillance groups seems to add another layer of complexity into an already somewhat byzantine system. And this misses one of the key problems highlighted by Francis – the lack of clarity about who was responsible.
There is also a recurring policy idea that inspection, coupled with naming and shaming, ratings and public information, is a key driver of change. The changes to the Care Quality Commission already under way represent the fourth reform of regulation in the last 14 years.
For some decades now there has been a consensus among quality experts that, while inspection may be a guarantor of minimum standards, it is a relatively ineffective method for improving quality – even with the welcome change of making sure that inspectors have some expertise in the area they are inspecting. There is a pattern to this policy cycle – scandal, introduce inspection, complain about the burden of inspection, scandal that the inspectors fail to spot, further reform. The problems are well documented. Inspectors have a tendency to be risk averse and driven by an anxiety that they will be criticised for missing something. Organisations complain about the burden of inspection, the reliability of the judgements and the onerous requirements to produce data that is not used for management purposes. The government’s response says this about the regulation of health care assistants: ‘Regulation is no substitute for a culture of compassion, safe delegation and effective supervision.’ It is not clear why this logic has not been consistently applied.
The hope that providing composite ratings for hospitals will create change is questionable. Are they designed to improve choice, drive quality improvement directly, facilitate naming and shaming or increase public accountability? Trying to achieve these different aims with the same measure doesn’t work.
To be fair to the government, this issue demonstrates the limits of their reach. Transparency, more information and openness are very powerful mechanisms and are an area they can influence. Others are less easy. A commitment to outcomes limits how far the government can intervene in the process of care, unless it is prepared to redefine targets as standards (and there are signs that this is happening). The rules of the ‘liberated’ NHS means that it has to try to reinvent levers it has just abolished, but using a more circuitous route for doing so.
The real answer lies in: strong commissioners setting high-quality aspirations, clear minimum standards, peer review and inspection where necessary and, above all, high-quality governance, great frontline leadership, and a willingness to learn and improve. There are already great examples of this and a focus on these areas is more likely to provide a defence against poor-quality care than an approach that prepares to fight the next quality battle with the strategies of the last.