OFF Sick

Quality of care Regulation

The latest in the depressingly long line of attempts to “regulate” healthcare appear to be an Ofsted for Hospitals.  Is this the magic bullet to solve quality issues?

It is well established that given any framework of outcomes, objectives or targets there will be a tendency amongst some to game the system – but the latest Ofsted makes that very hard as most of it is based on direct observation of actual teaching.  In schools Ofsted has been evolving for many years and the latest incarnation is probably the least bad.

It has a number of key features:-

  • The framework is well documented and understood – those who inspect are knowledgeable and experienced – usually ex heads.
  • In principle it is focused on the schools performing less well and an outstanding school will not be inspected again for some years but it also uses data scanning to look for “coasting” which can trigger a look.
  • No (or the minimum necessary) warning is given – there is not enough time to “game” the inspection to any significant extent.
  • It relies on the fact that all the necessary data is already in place and in use there is no mad scramble to find all the documents.  Tools and methods for recording pupil progress and attainment and pretty well developed.  Gaming the data may take place but it is not easy and it can’t disguise bad teaching.
  • It relies on direct expert inspection of the actual teaching!  The inspectors are experienced senior teachers.
  • It uses data on parental experience that is already in place – each school has to have a website set up recording parent experience) – there are no set piece meetings, no questionnaires sent out, no engagement with wider community.
  • It does evaluate management and leadership but it is based mostly on outcomes with some direct connection through interviews.
  • The report is put into public domain and names of inspection team are known.

In a few years time we could assemble the evidence to evaluate if this framework actually does improve standards – but you suspect that will never be done.  Faith is enough.

Could it work for hospitals?

Here a few obstacles:-

  • Hospitals are in fact aggregates of very different and separate services – maybe 25 in a normal DGH – and variation between service quality in a single hospital can be as great as variation between the same service in different hospitals.  A single rating for one hospital is daft.
  • In large complex organisation it is much harder to assess what contribution is made by management and leadership – compared say to evaluation of surgical skills (which in itself is hard enough).
  • There is not a well established and widely accepted framework of data and analysis – far from it.
  • Inspection of actual delivery would require surgeons observing surgery; nurses observing nursing, radiographers etc, maybe even IT experts looking at IT deployment.  A large number of inspectors would be necessary; trained in the new tasks – a whole new profession?
  • To set up a documented evaluation and inspection framework could take a long time; it should be consulted on; pilots run; evaluation undertaken – 3 or 4 years maybe.
  • Putting your name to criticism of the performance of professionals is risky.
  • Most commentators would argue that patients and public have to be involved as the patient experience is important (pupil experience is not evaluated in that sort of way).  This is a major complication.

At this point you give up – it’s a good idea in principle but totally unworkable in practice.  If we have another badly implemented and then discredited system for regulation it will do more harm than good.

Maybe we rely on managers to manage and on commissioners to do their job and on the power of information in an open and transparent system to show when they don’t.