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What the NHS did on April Fool’s Day

Civitas, 2 April 2009

1st April.  April Fool’s Day.  A day for multiple press releases from the Department of Health.  The new super-regulator, the Care Quality Commission comes into force.  New Integrated Care Organisation (ICOs) pilots are announced. The Performance Framework is announced: minimum standards of quality, safety and financial management that patients can expect from the NHS.  Patient Reported Outcome Measures (PROMs) are to be collected.  The National Quality Board meets for the first time.  A new, ‘simpler’, complaints system is introduced.  And the payment framework for Commissioning for Quality and Innovation (CQUIN) starts life.

Wow.  So will it all make a difference?  Some of the initiatives, most notably ICOs and PROMs certainly have the potential to, if clinically-owned and operating in the right contexts.  But the rest?  Is it not just likely to add to the already over-bearing burden of regulation and bureaucracy that NHS organisations have to deal with?

The current climate is already, to put it kindly, confused.  In 2007, the NHS Confederation estimated that at least 56 bodies, from the Healthcare Commission to the Environment Agency, currently regulate, inspect, audit or demand information from NHS organisations – and this does not include core strategic NHS bodies, such as SHAs and the DH.

The time taken complying with the requirements of these bodies (typically around 1,000 separate data requests per year) is multiplied by the uncoordinated nature of them.  Regulators vary significantly in their statutory authority, powers, scope of action and approach.  Some have general powers of enforcement (such as the Health and Safety Executive); some have specific powers relating to the NHS (such as the foundation trust regulator, Monitor).  Some are public bodies (such as the National Audit Office, Care Quality Commission and the Health Protection Agency); some are special health authorities (such as the National Patient Safety Agency and NICE); some are DH creations (such as the Cancer Peer Review) and some are generated by the NHS (such as the new National Quality Board).  Most deal with a single facet of organisations, such as health and safety, medical education, professional standards et cetera, but some, such as the CQC and NICE have more overarching roles. There is now even a body, the CHRE, that is charged with ‘ensuring consistency and good practice in healthcare regulation’; a regulator regulating the regulators, if you like.

According to the NHS Confed, large proportion of data requests received from these organisations are, in fact, for very similar information, just in different and incompatible formats.  Little account is taken of the way in which data is collected, processed and recorded within them, with the result that significant amounts of NHS resources are diverted to chasing information, re-formatting data and preparing for an inspection.

A further trick – exemplified in these announcements – is for government to change the regulatory climate just as regulators are getting used to working with each other; and individuals and NHS organisations are getting used to, and have calibrated their systems, to work with them.  Since being founded in November 1999, the Commission for Health Improvement (CHI) became the Healthcare Commission in 2004, and today – along with the Commission for Social Care Inspection (CSCI) and the Mental Health Act Commission – is being subsumed into a ‘super-regulator’, the CQC.  The transition has already been uncomfortable, with the handover recently rated as ‘red risk’, but further problems are likely.  With extended powers of enforcement (including issuing financial penalty notices and suspending registration of an organisation), the CQC has defined its mission as not just to set, monitor and enforce minimum standards, but also to drive improvements in the quality of care.  It is, therefore, difficult to see how it will not clash with other regulators, such as NICE, the National Quality Board and Monitor that also have a stake in this field.

The conclusions of the NHS Confed in 2007 that ‘the present regulatory processes are piecemeal, complex [and] confused, being made up of many different bodies who [sic] hold different statuses…and have different powers to control behaviour’ are just as true today.

The NHS would do well to look at things the other way around.  Bureaucracy should never serve as a barrier to doing the right thing.  Regulators may well all have good intentions, but how they go about their business may actually have a negative impact on those delivering health care.  For every expense made, every department created, every project taken on, a basic question should be asked: will this help patients?  If the answer is not a ringing and positive ‘yes’, we might do well to ask why it is there at all.

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