Breakfast Seminar

The origins of most regulation were in the protection of trade, markets and professions, Nigel Clarke told Care Conversation delegates. Now, however, regulation was very much focused on the public experience.

There were nine healthcare regulatory bodies – not including commercial regulators – plus umbrella organisations, he pointed out, with a combined cost of around half a billion pounds per year. These costs, however, were dwarfed by the costs of compliance. “I’m acutely aware that we are a burden on the people we regulate,” he said. “You can’t regulate without the consent of the regulated – that’s something you don’t see much about in the press.”

These various bodies did not always interact with each other in the way they should, he said. “The CQC regulates pharmacies in hospitals, for example – unless that pharmacy has anything like a retail arm, in which case we regulate it.”

So how did a regulator know when it was succeeding – was it a question of minimum standards? “The way we approach it, at the heart is quality of outcomes. Does it deliver better care and better value?” These could be measured in a number of ways, he said. “From the point of view of pharmacies, 7% of hospital admissions are the result of people not taking their medicines correctly. This shows that something in the communication between the public and healthcare professionals is not working.”

Having involved patients was vital, he stressed. “You have to interact properly, but what about those patients who don’t want to be involved?” Some patients routinely made poor decisions – going to A&E instead of their GP, for example – while others would turn up at a GP’s surgery with reams of information printed from the internet. “Broadly speaking, we’re less tolerant than we were and we have greater expectations of all our interactions. We’re seeing 40% increases in complaints a year. Are doctors, nurses, pharmacists becoming 40% less competent every year? That doesn’t make sense.”

On the issue of quality, his starting point was a basic philosophical view that if an organisation was not dedicated to improvement it would fail, he stated. “There are lots of reasons why things deteriorate, including lack of investment. But it’s abundantly clear that doing things badly is more expensive than doing them well, even in the short term.”

Another key issue was technology, he told the seminar. “The NHS has only just discovered email, and they still use fax machines. Would another business seriously operate in a way that didn’t share core information?” If a patient’s prescription was changed while in hospital, a letter would need to be sent to their GP and pharmacists would take even longer to find out, he explained. “If you want the information to be consistent then you need a single record, and it shouldn’t cost £14bn. We need this – it will save a lot of inappropriate treatment.” Implementation, however, was being held up partly by issues around confidentiality, he said.

Another vital issue was whether organisations had structures that allowed the full input of managers, clinicians and boards. “Can they properly identify risks?” It ultimately came down to a question of accountability, he said, which was traditionally determined by reporting structures. “You’d follow the money. But as healthcare people are now working in teams I’d argue that you have to have a way of making the team accountable, rather than it being top-down.

“You need to ask whether you’ve got the right people in the right jobs,” he continued. “If corporate governance isn’t working in the NHS how can you expect it to work in trusts or in CCGs? Inevitably you’re going to get management failure, and there will be knock-on effects to the public.”

In terms of lessons learned, his organisation regularly published outcomes, he said. “And in terms of what a good pharmacy looks like, it’s not our job to stand in the way of innovation. You have to allow people to be constantly thinking of how they can do things better. And not get in their way.”