01.02.15
Too many NHS organisations ‘aren’t getting the basics right’
Source: National Health Executive Jan/Feb 2015
David Stevenson hears from the main health regulators on their role and the future of regulation, including the heads of Monitor, the NHS Trust Development Authority and the Care Quality Commission.
Regulation has a big role to play in a sector where patient safety and public confidence are crucial, but what this should look like and how ‘heavy-handed’ it should be are always up for debate.
During a strand session on ‘The future of provider regulation’ at the Foundation Trust Network’s (FTN’s) annual conference, senior industry figures did just that.
NHS England’s former director of strategy Professor Robert Harris, now a general partner at Lakeside Health Partnership, said regulation is a “curious beast”.
“In part it is libertarian, saying we need to break free from it, but then it is part totalitarian as you are likely to get bashed on the head with it,” he said.
Chris Hopson, CEO of FTN, now called NHS Providers, said the existing regulatory system is “fragmented” and increasingly “interventionist”.
Regulators and NHS England need to recognise that it is just as important for the system to support local providers as it is to regulate and risk-manage them, he said.
This view was shared by the delegates NHE spoke to during the conference. Even Prof Harris said: “I’m not anti-regulation in the health industry, but it does need to be proportionate.”
There needs to be more clarity of the roles of the various regulators, he said – and clarity on why each has which role.
Easy to criticise
In the same session Monitor’s executive director of provider appraisal, Miranda Carter, said the “real challenge for us as regulators is making sure we work well together and that nothing falls between the gaps and we minimise duplication”.
She added that in provider regulation, Monitor recognises that it is extremely challenging to manage performance within the operating environment.
“So we are looking at ways we can develop and improve function as a regulator,” said Carter, adding. “We need to work with partners and listen when we talk with you [the providers] to fully understand the needs of the system to make sure quality is delivered.”
Kieran Walshe, professor of health policy and management at Manchester Business School, said it is very easy to criticise the regulators, “but they fulfil a crucial public protection role”.
Prof Walshe argued that regulators whose role is to improve the organisation-wide performance of those they regulate, rather than just deal with failure, must be good at ‘differentiation’. By this, he means that high and low performers are not simply opposites – they are qualitatively different.
The question he left hanging for delegates was: “For FTs and others, in the next 10 years, where do you want to be? Do you want to be engaged in the debate in shaping regulatory policy or do you want to be complaining about what the regulators have decided to do after that policy has been made?”
Local autonomy – not working?
During the final plenary of day one, the leaders of Monitor, NHS Trust Development Authority (TDA) and the Care Quality Commission (CQC) gave their perspectives on the industry.
This was after Ben Page of Ipsos MORI presented data from an FTN survey showing that 62% of the public and 52% of FTN members think spending on the NHS should be increased to maintain services.
Dr David Bennett, chief executive of Monitor, suggested though that providers have still not seen enough reform, and new models of care must be delivered to drive change.
He added that only a third of FTN members think services will be the same or better within the next few years, and “two-thirds of you don’t…However, both you and the public feel the answer is to spend more money.
“My own view is that there is a much better version of the NHS out there, which is better for patients and value for money,” said Dr Bennett. “I do not argue any of this is easy, and that better NHS is still a way off.
“But what troubles me most is that there are still some organisations out there that aren’t getting the basics right.”
He stated that some providers don’t have the right protocols in place for discharging patients, or their lengths of stay are too long. “I’d even go as so far as to say, which I know will be controversial, that not everywhere is local autonomy working as it should be,” said Dr Bennett.
‘I fear for the money’
TDA boss David Flory acknowledged the “fantastic work” of NHS provider organisations still delivering for patients, especially as the Ipsos MORI data revealed that 75% of respondents believe the NHS to be one of the best health systems in the world.
“The very short-term challenge for us is to all still be standing through this winter period, in terms of service delivery. We all need to be on the front foot, in a strong position, once we get into the period immediately the other side of the election,” he said. “Then we need to talk to the new government about what we want to do.”
He also called for a leadership style enabling strategic decisions and transformational change.
“There are still, in my view, too many discussions where the provider starts by saying ‘if only the commissioners would do x, y and z, then we’d be fine’. And far too many places where the commissioners say ‘the provider is letting us down’,” said Flory. “I fear for the money. If the money continues to drift in the way some of our projections show it will do, we won’t all be on the front foot and still standing come next May, we’ll have more of yesterday’s problems to deal with.”
Quality cannot be regulated into services
Prior to attending the conference, the CQC’s chief executive, David Behan, visited Alder Hey Children’s Hospital, where he met a group of children who had been advising the trust about changes they were making.
“What I saw there were some children who had said they were a bit worried when they came into the hospital, and needed a guide,” he said. “One of the consultants there had designed an app, in the form of a game, that allows people to be introduced to the hospital. I thought it demonstrated people working together, listening to the voice of the people who use their services, to improve service provision.”
He added there has been too much emphasis on regulation and the way that should be improving quality. “Regulation should be shining a light on services, but we cannot regulate quality into services,” he said. “The people who put quality into services are the executive team and board at, for instance, Alder Hey.”
Behan added that he believes there are five influences on the quality of care and services: what commissioners do; what providers do; how professionals take their responsibilities; what regulators do; and the voice of people that use services.
“I think each bit of those five need to be operating together, and if they don’t operate together the improvements in quality and safety aren’t actually going to occur,” he added.
He asked the audience how many people had read the CQC’s ‘state of care’ report, with about 10% putting up their hands.
“One of the key criticisms I got when I took this job was that CQC didn’t identify what ‘good’ and ‘outstanding’ look like,” stated Behan. “But the state of care report very deliberately had as many examples of these as it did about poor care.
“Why did we do that? We thought we had a responsibility to identify the good carers, so it can be replicated. I need to ask the question why only 10% of you have read it, are you not bothered about it? Is it not a good enough document? Or are we saying the wrong things?”
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