Failure to limit expectations is blighting NHS regulation
Is running the NHS care regulator an impossible job? Answering that question depends on success in one key area. It is not competence or commitment, although those are a given. But even the cleverest, most dedicated leader will fail if they do not control expectations.
The resignation of Care Quality Commission chief executive Cynthia Bower sparked a lengthy debate on HSJ’s website. The initial thrust of the argument was summed up by NHS London chief executive Dame Ruth Carnall, who wrote: “Cynthia has handled unbelievable pressure in this role and has retained her compassion and her focus on improving services for patients. Very few of us could handle this role with such resilience”.
Less sympathetic commentators suggested anyone in the role should expect to have a hellish time, but be comforted by the rewards on offer. Others simply said she did a bad job and deserved the sack.
HSJ’s view of Ms Bower’s leadership is that she failed to control expectations by taking on new responsibilities and/or deadlines without convincing herself the CQC had the culture and/or capability to deliver. The kind would say her loyalty and willingness to shoulder burdens was her undoing, the cruel that she lacked courage and the clear-sightedness to see troubles ahead.
The recruitment process for her successor should test candidates robustly on their track record of telling bosses things they do not want to hear and surviving the fallout. But that is only part of the skill of controlling expectations. For the leader of the CQC it involves an even more challenging task.
The Department of Health is undertaking a second review of the watchdog. Whatever efforts the government undertakes to make regulation “proportionate” to care risks and to clarify the CQC’s role, pressure will continue to grow for more safeguards applied to a wider set of risks experienced by those receiving services from a greater range of providers.
The public’s awareness of risk and variation of outcome in healthcare is accelerating at an unprecedented rate, as is its expectation of address. These factors are good in themselves, but the speed of change is leaving the service gasping for breath and reaching for its wallet.
With such a bewildering increase in scope it is tempting to say one über-regulator will always struggle and it would be better to have sector-specific regulators – especially in areas where quality is still relatively unexamined, such as primary and residential care.
But, build a matrix of regulators and you run counter to the drive to deliver integrated services. It is in handovers between services that many problems arise.
No, the answer to this growth in demand on regulation is to actively control expectations.
The temptation of any leader – especially a new one appointed by politicians – is to preach the gospel of certainty, to suggest all issues will now be resolved and concerns dealt with.
The opposite of course is true. The complexity of health and social care means new issues and concerns will emerge to which the regulator will have to react, not always in time. This is the message the public and politicians must hear if we are to clamber off the merry-go-round of regulatory upheaval.
The new leader of the CQC could do worse than repeat the words of Lisa Rodrigues, chief executive of Sussex Partnership Foundation Trust, on hsj.co.uk: “Getting things right for patients is the responsibility of individual staff, their professional supervisors, managers, employing organisations, commissioners, professional bodies, educators, referrers, planners, government and Parliament. Regulators are simply the backstop.”
This is not an abrogation of duty – it is a call to arms.
Have your say
You must sign in to make a comment.
Share
Readers' comments (9)
Anonymous | 1-Mar-2012 8:29 am
Managing expectations? Let's look at why they didn't do it. Promises to take on extra work were made to the DH without checking that there were enough staff to do the work. They did this so as not to look incompetent in the DH's eyes. If CQC had limited the DH's expectations, and said that this could not be done without extra resources, this would have made a difference.
This was poor judgement- and those people below Cynthia who said it could be done are those largely to blame for this fiasco. When she asked them, they said yes. (or they would have looked bad) . The knock on effect was to massively increase the workload of already overworked staff at the coalface, and they were criticised by managers if they weren't able to "go the extra mile"..Ridiculous!
Staff members did say these things to Cynthia (at their peril-how dare they? ) but as she preferred to listen to the managers of such people, and they were desperately trying to look good, nothing was done, and the people complaining were shuffled off somewhere else, or worse, forced to go off sick.
So who looks bad now? The DH for asking the impossible, or the CQC for not saying no? It is certainly NOT the worker bees who are still doing their work to the best of their ability.
Unsuitable or offensive?
Anonymous | 1-Mar-2012 2:30 pm
Sadly Cynthia made the job a bed of nails when she could have moulded it to what she must have outlined at her interview for the job. It will be wrong for those who follow to be made to feel its impossible before they start. A good CEO will work through the politics and the perceptions and deal with the reality and the outcomes.
Unsuitable or offensive?
Patrick Newman | 1-Mar-2012 4:45 pm
Bowers goes but the culture remains. Perhaps an anonymous staff survey may help to understand the true extent of the resource and perception mismatch. Not unique to CQC in the attempt to deliver a 'day' job and undertake serious organisation change. I have seen it many times and neither the service nor the change is done justice. Heads of becoming like Chelsea football managers but with 10% of the salary.
Unsuitable or offensive?
Barbara Bradbury | 2-Mar-2012 1:13 pm
I have not worked at the CQC and do not know Ms Bower so do not comment from an insider's perspective. There seems to be a consistent theme from all the comments that have been written on this subject and that is one of the culture of leadership and management.
Many organisations operate within a culture of fear. Staff are discouraged from questioning their managers and colleagues for fear of the consequences. When they do question they often stand out as lone voices, unsupported by other colleagues, even though they may be firing a loaded gun that was handed to them. This exposure and its consequences do not go unnoticed and makes it less likely that another challenge will be made.
Within the health care system in the UK, both public and private organisations, challenging clinical and non-clinical middle and senior managers is difficult for many. There is not a single reason for this. For example, junior doctors do not readily question the practice of their consultants, even when they have serious concerns, because they are dependent on that person for their reference and possibly their entire career.
Also, too few people, from my observations, have the ability to challenge assertively and then remain assertive in the face of an aggressive response.
Furthermore, assertive challenge is often mistaken for outright criticism or aggression, hence the aggressive response. We grow, develop, improve by seeking honest feedback on our actions and behaviours, and making changes as necessary. Many people find it difficult to hear honest feedback and use it as a positive learning opportunity, particularly if they are receiving negative feedback.
Developing a culture of honesty and openness, being supportive and able to receive challenge is essential if an organisation is to flourish. Staff must be able to challenge decisions taken by senior staff, without being fearful for their future. Those seniors must be able to listen without taking a defensive attitude, and acknowledge that they don't always get things right, if they are serious in wanting to continually improve the quality of the service they are responsible for. Such a maturity in communication is essential if we are serious in improving our health services.
Taking a developmental approach to our inter-personal communications, from "Board to Ward" - led and practiced from the top, and mirrored throughout the organisation - is vital.
Unsuitable or offensive?
Anonymous | 2-Mar-2012 1:34 pm
Dear, oh dear! I can't believe you have proposed that quote as a motto or even an idea to be contemplated by the next CQC leader.
The shorter version is this: "Don't blame us, it's not our fault, it's somebody else’s". And that’s the same tune the CQC and MHRA have been singing for years now.
But you are right that it's all about expectations. The new head of the CQC should be absolutely clear that if something preventable goes wrong on their watch it will be their fault. They are being paid to make sure patients are safe (no buts). If that does not seem a fair or proper expectation, they should not expect to get the job.
A better inspirational quote for the next leader of the CQC is provided by Eliot Spitzer, one-time scourge of corporate America. When challenged to tone the regulatory temperature down early on his career by someone with a vested interest in him doing so, he replied: "Listen, I'm a f - - -king steamroller and I'll roll over you and anybody else".
True, Spitzer eventually went down in flames but no one could ever accuse him of selling-out on the ordinary consumer.
Unsuitable or offensive?
Kay Sheldon | 2-Mar-2012 3:58 pm
I don't think it is is simply about managing expectations but also about establishing what it is reasonable and appropriate to expect of the health and social care regulator. As far as I can tell, from within and without CQC, this has never been adequately addressed.
It is true that CQC has agreed or decided to do/not do certain things without sufficient thought, analysis & oversight. This led to intolerable pressures, failures in performance and sudden compensatory actions. I agree that the DH has some responsibility but my experience has been that the DH actually want the regulator to give them some answers as the 'experts' in regulation.
The public/patients need a regulator that is willing & able to take up the gauntlet to ensure the regulatory system protects us and promotes high quality care. The latter in particular needs to be achieved in partnership with others and with the regulator(s) playing their part, leading when indicated.
In response to other posts I would say unequivocally that values are just as important as vision, leadership and skills. Values are integral to culture. A culture where people cannot contribute honestly and if they do, face significant consequences is unlikely to be a positive indicator of a successful (and happy) organisation.
Unsuitable or offensive?
Anonymous | 5-Mar-2012 4:00 pm
1. The cult of light touch regulation is not appropriate to the healthcare industry which suffers from the information gap between providers and consumers.
2. Lack of resources is an excuse - there was plenty of things that could have been done if there was a will to tackle quality issues e.g. getting providers to commission their own independent audits of quality to demonstrate commitment to quality and working with the royal colleges to outlaw bad practices.
3. Leadership is the issue and Parliament have consistently failed to demonstrate it for fear of either undermining the NHS or opening the floodgates of more money having to be spent.
4. The NHS gets the leaders it recruits and trains and too often they are timid and easily bullied.
5. Quality is not a backstop issue it is the most important issue.
6. Give the job to someone who can be the next Chief executive of the NHS , who has real power
and wants to use it.
Unsuitable or offensive?
Anonymous | 5-Mar-2012 4:58 pm
Well said Anon @4.00pm
Bring on Spitzer!
Unsuitable or offensive?
Kay Sheldon | 5-Mar-2012 8:03 pm
So, am I reading this correctly...light touch regulation out...heavy handed in...?
Sounds good to me ;)
Unsuitable or offensive?