What to do about regulation?

Quality of care Regulation

What to do about regulation. It’s a pretty big question and I don’t think there’s a small answer.

The range of views includes:

  • Hospitals and other providers need to be accountable for the services they provide and self-regulate through their boards and internal procedures
  • Some form of externally imposed or central regulation is essential if providers are to be kept honest and standards maintained across the board
  • Quality is the business of commissioners and should be enforced through contracts and good procurement

My answer is that you need all of the above. Providers who rely on being told what to do will game the system and learn to stop thinking for themselves. But as no amount of regulation will deal with demoralised, overworked, badly led and poorly motivated staff, something fundamental has to change in way providers run themselves. This is the stuff we usually lump together under the heading “culture”.

At the other extreme, self-regulation does not work.

Commissioners in the past have proved pretty hopeless at doing their bit. There are still going to be problems and it remains to be seen if Clinical Commissioning Groups can make a difference. For instance millions of pounds of commissioning budget is not properly accounted for because of problems with hospital payment data – CCGs can address this, but it will take work.

Better providers and better commissioners would make the work of a regulator pretty straightforward. Instead of the depressing and impossible work programme of the Care Quality Commission, you could rely on much lighter touch approach, concentrate on tackling the real problems and leave commissioners to deal with the routine business of keeping primary care up to snuff. That’s not to say you wouldn’t have the odd difficulty that needed to go upstairs to the regulator, but with a lighter workload there would be more chance of stopping future Shipmans and Winterbourne Views.

There is undoubtedly a lot wrong with the way CQC was conceived and what it was tasked to do. The problems of realigning its role and changing its aims are surmountable.

Any system of regulation will depend on the quality of the people in charge and mending a public sector that breeds cowardice, bullying, selfishness, risk aversion, buck-passing and institutional helplessness. I don’t know what you do about that bit.