Joy Furnival looks at proposed changes to the health watchdog in the UK and asks if the system will work.
Last month, Jeremy Hunt, Secretary of State for Health, announced that the healthcare regulatory and scrutiny bodies, Monitor and the Trust Development Authority (TDA) were to merge into one body, named NHS Improvement, with an increased focus on learning, improvement and safety including a new in-house support function for NHS Trusts and Foundation Trusts.
Monitor has responsibility for overseeing and holding to account NHS Foundation Trusts (FTs) and the TDA has similar responsibility for non-FTs. (The third national regulatory body, the Care Quality Commission, (CQC), has responsibility for care quality, remains separate). Critics have been increasingly vocal about the confusing landscape and overlap of regulation and scrutiny across the NHS and this simplification is welcomed. The reliance on ‘prod’ mechanisms (Health Foundation, 2015) and punitive approaches by regulators has been heavily criticised, thus this shift to a developmental regulatory approach with a combination of improvement support and scrutiny is also welcomed. It follows a regulatory trend towards developmental approaches using both enforcement and improvement.
This shift, may also signal the early development of a national quality improvement strategy for England, something that they have had in Scotland for some time. Further, this regulatory gesture, increasing focus and emphasis on improvement, may be positively responded to by Trusts, strengthening their investment, oversight and energies in this area, giving welcome oxygen, visibility and clarity on priorities to improvement teams.
But, is it possible for a regulator to scrutinise and enforce, to be both ‘good cop’ and ‘bad cop’, to deal robustly with poor performance while also helping those same organisations to develop and improve? Deming, one of the ‘Gurus’ of the modern improvement movement, indicated that organisations should cease dependence on inspection, and in doing so, develop a proactive approach where things are ‘right first time’. This development perhaps moves in this direction, recognising the shortcomings such as ritualistic compliance, gaming and regulatory capture of a pure inspection and enforcement approach. Our research (in development) has identified that new developmental approaches show promise in delivering improved healthcare provided that three areas of challenge are overcome.
First, regulatory priorities, goals and timelines will need clarifying. Potential conflicts such as that between investing in safe staffing including increasing agency expenditure and balancing the bottom line in financially challenged trusts will need to be agreed with the merged regulator who is also accountable for both. Nor is it clear the time period in which improvements will be expected, though it may be as simple as the time period between CQC inspections, or a financial year or a political cycle, all of which may not be long enough for improvement support to really start to deliver ‘measurable’ results?
Second, what improvement approach will be taken by the regulator itself to demonstrate its own commitment to improvement? Will this approach be used both internally and externally with Trusts? Will this approach enhance Trusts own improvement approaches or will those in need of support be required to use this centrally mandated approach, with for example, standardised improvement templates, and terminology, potentially losing local ownership, adaption and adoption of improvement plans and best practice? Further, the merged organisation is unlikely to have all the improvement skills and expertise needed to deliver this improvement approach, rather than scrutinise, monitor and inspect. New resources and expertise will need to be developed and acquired by the regulator in order to deliver this new approach.
Third, regulatory relationships with Trusts will be critical. How will regulators support Trust development when the ‘bad cop’ powers to sack the board and impose new leadership and solutions may remain in the ‘back pocket’ of the regulators as a subtle reminder of their power, despite leadership continuity being one of the most critical success factors for improvement work? Will this potential threat, together with increased transparency of data, good or poor, help or hinder relationship development and collaboration between organisations? Will regulators be able themselves to lead by example and demonstrate behaviours congruent with improvement or slip back into ‘old habits’ if results don’t materialise as quickly or deeply as planned? And what will the relationship of this new regulator be with local commissioners and other system leaders, whilst supporting Trusts? For example, if progress is slower than hoped, will there continue to be the political will to support a collaborative improvement approach or will there be increased pressure to revert to disciplinary action, as was demonstrated with the former Commission for Healthcare Improvement (CHI), (a predecessor of the CQC), which was pushed to be more punitive after an initial supportive regulatory stance.
The move towards a regulatory focus on developing and supporting improvement in English NHS provider Trusts as they face mounting financial pressures and ongoing need to improve safety and quality is a belated and positive step for the NHS and patients. Nevertheless challenges will need to be overcome in the long term, for the regulator to achieve its improvement aims with NHS provider Trusts.
