The 'tyranny' of NHS inspection
- 16 December 2013
- From the section Health
NHS inspection has moved to a new level. Last week saw the publication of data from the inspection of GP surgeries - which found maggots in two - and a new hospital inspection regime is currently being introduced in England, in the wake of the Stafford Hospital scandal.
But in this week's Scrubbing Up column, Prof David Hunter, director of the Centre for Public Policy and Health at Durham University, suggests increased checking breeds furtive behaviour, and he says there should be more trust and less suspicion.
Among the many contested issues arising from the government's NHS changes is the burgeoning industry in regulation and inspection.
New bodies charged with ever-expanding powers, and staffed by some of the most highly paid managers in the health sector, ostensibly exist to ensure quality and patient safety in the aftermath of the failures at Mid Staffordshire hospital.
But wait a moment. Given that these failures escaped the attention of the regulators at the time, how confident can we be that the new inspection regime will prevent future lapses?
Might it not be the case that the disproportionate focus on inspection is part of the problem rather than the solution?
The evidence is clear: fear and blame are toxic to safety and improvement.
Yet regulation and inspection breed both thereby encouraging furtive behaviour and lying on the part of managers and clinical staff in an effort to avoid exposure and blame.
'Culture trumps inspection'
The government's own adviser, Don Berwick, acknowledges the place of regulation and inspection but calls for a simple and clear system and an end to the "bewildering complexity" that is a feature of current arrangements.
But he also knows that inspection will not solve the problems highlighted by Mid Staffordshire. We have to understand the root causes of what happens in cases like this and why.
Culture trumps inspection every time.
Securing a safer NHS depends on bringing about major cultural change not on a new inspection regime. It needs to be made the focus of attention.
The Francis Inquiry concluded that the events at Mid Staffordshire reflected systemic failure rather than the actions of a few rogue managers, nurses or clinicians.
But the causes of this failure are complex and largely arise from misconceived NHS changes.
These centre on a preoccupation with markets, competition and choice and with meeting performance targets.
The cavalier dismissal of staff opposition to the changes on the grounds that their objections amount to little more than self-interest and protectionism has only served to fuel the growing resentment among staff.
Research shows that effective and sustainable change demands the engagement and cooperation of those affected by it.
In a context where trust between professionals and managers, and between the NHS workforce and government has all but broken down, resorting to more and more regulation is self-defeating.
It flies in the face of all the evidence about how to motivate staff, boost morale and ensure a happy workforce in place of one that is distrusted, devalued and working under extreme pressure in an atmosphere of bullying and "naming and shaming".
So why does the government persist in its perversity, spawning a hugely costly bureaucracy aimed at endless checking?
Not only is it a case of acting after the horse has bolted, but the inspection industry is sucking value from the frontline at a time when services are under severe resource pressure.
Moreover, it will result in more "gaming" to avoid sanctions.
Could the government's investment in inspection be part of a plot to weaken public confidence in the NHS thereby softening it up for further privatisation?
If that is being too cynical, perhaps the government wants to be seen to be doing something in order to reassure a sceptical public and keep a feral media at bay? Or is it just cock-up and bad government?
Perhaps it's a mix of all three.
Whatever is driving current action, if the NHS is not to be irretrievably damaged by policies that are compounding rather than tackling the problems, we urgently need a new and different response.
More of the same won't work. Structural "re-disorganisations" are destabilising and leave culture intact.
Unfashionable though it may seem, rediscovering the notions of professionalism and public service ethos, recognising that improved quality of care and patient safety demand trust and not suspicion, might be a good place to start.