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Getting better every day, by Sir Ian Kennedy

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16 December 2005

Some people see regulation as more a matter of accreditation than ensuring improvement, but not the Healthcare Commission. Its system is designed to prompt changes for the better, its chair explains

The Healthcare Commission has a statutory duty to 'encourage improvement in the provision of health care'. Note that the statute does not ask us to improve things but to facilitate improvement. We are to do so by 'taking account' of standards issued by the government. Currently, ministers are reviewing the regulation of health and social care, including the role of the commission. One recurring question being asked is: should (or can) a regulatory body be concerned with improvement?

But to contrast regulation with improvement creates a false antithesis. Regulation based on standards is inextricably connected to improvement. They are two sides of the same coin. At the commission, we have taken a radical approach where the very process of regulation brings about the improvement.

We resist the rhetoric currently associated with regulation: that it is a 'burden'; that a 'lighter touch' is needed. To us, it is either efficient or inefficient. Efficient means that the benefits outweigh the costs, a complex calculation.

We also regard it as one of a series of mechanisms that must be aligned to maximise the opportunities for improvement.

Our principal statutory duty is to use our assessments of the NHS's performance to facilitate improvement in health care. These assessments take account of, and reflect, the framework of policy, particularly standards, laid down by government.

The standards are grouped under domains, such as 'safety', 'clinical effectiveness' and 'focus on patients'.

We must define the domains and standards by reference to the things that matter to two principal audiences: those who use health care services and those who provide them (without prejudice to the concerns also of the general public and of government). 'What matters' must be defined in terms of what facilitates improvement in health care. As an organisation, we do not necessarily know what facilitates improvement – but those who receive and provide health care do. We must, therefore, listen to them.

While there are some differences between the matters chosen by the various audiences, there is a significant degree of overlap: a common set of things that matter.

Having identified these, we must discover whether they are being complied with. And, for a twenty-first century regulator, the best way of doing this is through data. These need not be bespoke nor new. In fact, most should already be collected by the organisation. If not, it is the organisation that should change, not the data. Only dysfunctional organisations that are not geared to the service of patients complain about the 'burden' placed on them. To provide assurance, data will be cross-checked against other sources.

The data will be routinely collected, allowing for regular surveillance of performance. Visits to organisations will be for specific purposes, together with the occasional spot check.

When trusts are clear about what we will assess, they can direct their energies to providing what matters. If we are assessing the right things - and we should be because we have taken account of the views of those affected - then trusts will, by responding to the assessment, be delivering these objectives and therefore improving.

At the same time, those who have contributed to the identification of the things that matter will recognise that the system of assessment reflects their interests and will, therefore, support it.

Finally, the approach is not static, but dynamic; kept under constant review and revised as appropriate.

This approach contemplates a system of regulation that has at its heart a virtuous cycle of improvement. It is not imposed from above and from outside the groups whose interests are crucial, and thus resisted or rejected. Rather, it is designed and therefore 'owned' by them.

Improvement becomes both the purpose and the result of regulation. Talk of 'burden' becomes part of a different conversation, concerned not with the inherent nature of regulation, but with the detail of what information is needed and how it is best collected. Indeed, so far from being a burden, regulation, as conceptualised here, is beneficial, serving to facilitate continuous improvement.

Moreover, based as it is on the collection, analysis and dissemination of data in the form of intelligible information, it also meets three other fundamental goals: it allows government and taxpayers to identify where and how well money has been spent; it allows those who provide health care to be held to account; and it allows the public and patients to inform themselves about the safety and quality of the health care available to them.

Of course, translating into practice what is described here is an extremely complex undertaking. This cannot be surprising given the size and scale of the NHS and the soon-to-be-integrated independent sector. But the thesis is simple. And the process has already begun and is producing results, as trusts recognise where they need to improve.

Sir Ian Kennedy is chair of the Healthcare Commission

PFdec2005

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