The news that Dame Dierdre Hine, an old friend of Wales, has
left the Commission for Health Improvement because it was moving in a different
direction makes the development of the new Commission of particular interest
The Department of Health has produced a new policy document
– The NHS Plan: next steps for investment, next steps for reform –
packed with a raft of freshly minted ideas. Released in the shadow of chancellor
Gordon Brown’s Budget, Next steps contains some radical proposals for
further change.
In particular, it heralds a major re-organisation – some
might even say a revolution – in healthcare regulation. Under the proposals, a
new, more independent regulator called the Commission for Healthcare Audit and
Inspection will take over the job of scrutinising the NHS from the Commission
for Health Improvement and the Audit Commission, as well as taking on regulation
of the private sector from the National Care Standards Commission. This will
have a different organisation in Wales, the Care Standards in Wales group.
At the same time, a new Commission for Social Care Inspection
will be fashioned out of the Social Services Inspectorate, the remains of NCSC,
and some parts of the Audit Commission. While the shake-up comes very soon after
the formation of CHI, which is only two years old, and NCSC only started
operating last month – the logic of bringing healthcare regulation under one
roof is pretty strong. But this is more than just a re-organisation – it also
signals three major changes in the way the NHS will be regulated in future.
First, CHI has tried hard to build a collaborative
relationship with NHS organisation – ‘we’re here to help’ has been the
mantra. And while it may not have seemed so for those on the receiving end of a
CHI review, the commission has largely lived up to its improvement ideals. That
seems likely to change. CHAI is being badged by politicians as an inspectorate
– tough, demanding and sceptical. It may be pushed into adopting a more
punitive, sanctions-based approach than CHI has done.
CHAI is also to regulate both the NHS and the private sector
– which will immediately prompt calls for a level playing field and common
standards and methods across both areas. That presents problems, because CHI and
NCSC have taken different approaches to regulation. CHI focuses on systems and
processes for clinical governance, while NCSC standards are more about
facilities and structures.
CHI was moving towards directly inspecting the quality of
clinical care but it seems unlikely that CHAI will want to adopt wholesale the
NCSC standards and use them in the NHS. Plus it will be difficult to write good
standards that cover everything from a small private clinic to a major acute
hospital.
Another difference is that CHI has few formal powers – it
relies on the DoH to enforce its recommendations. In contrast, NCSC can fine or
even close down private healthcare providers. CHAI will need to have a similar
approach to standard-setting and enforcement across both sectors, or it will be
accused of double standards.
We are also being told that CHAI will be more independent of
both the DoH and the NHS than its predecessor bodies, because its board will not
be appointed by the health secretary but by the NHS Appointments Commission.
However if it is going to be independent, CHAI should be funded independently,
either through government allocation, which is not controlled by the DoH, or
through fees charged to the bodies it regulates. The latter approach is probably
the best way to give CHAI autonomy.
CHAI will be a powerful regulator, and it could be argued
that the new chief inspector of healthcare may end up wielding more power and
influence in the NHS than the permanent secretary at the DoH. That makes CHAI’s
accountability to Parliament and the NHS a crucial concern. Rather than its
board simply being appointed, perhaps a model should be adopted in which
different key groups – patients, professionals, NHS organisations, and
managers – are formally represented.
All in all, the regulation proposals in Next steps seem
to signal a real transfer of power from the DoH to CHAI, and a step towards the
DoH disengaging from the day-to-day management of the NHS.
Ref
(web)
