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Inspection a key driver of change?

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In its response to the Francis inquiry, the government has avoided some of the more obvious wrong turns, such as the regulation of managers. Many ideas were already in train, such as the review of nursing, 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 NHS Trust Development Authority and NHS England collaborate closely.

How this will work 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 is upbeat about how the new commissioning system, which is focused on outcomes, will drive quality. Yet it does not acknowledge that commissioning has been fragmented and is now less well resourced than it was when Mid Staffordshire NHS Foundation Trust was having problems.

There is 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 14 years.

There is a pattern to this policy cycle: scandal, inspection, complaints about the burden of inspection, scandal that the inspectors fail to spot, further reform.

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.

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 real answer lies in: strong commissioners setting high-quality aspirations, clear minimum standards, peer review and inspection where necessary and, above all, great frontline leadership and a willingness to learn.

Nigel Edwards, senior fellow, the King’s Fund


This is an edited version of an article that first appeared in Health Service Journal

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