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How many care scandals are we missing as reform rolls on?

HSJ this week reveals there has been a massive rise in the turnover in staff responsible for monitoring quality for commissioners since the reforms began.

This loss of corporate memory and severing of relationships can cause quality issues to slip through the cracks.

As the inquiry into care failings at Mid Staffordshire Foundation Trust has already discovered, commissioning overhauls can mean problems go undetected. What is more, the reorganisation in the middle of the last decade was relatively minor compared with the root and branch process under way now. If failure as extensive as that at Mid Staffs can be missed as result of a smaller reorganisation, how many equally worrying scenarios may now be developing across the country? Then there are the thousands of smaller quality concerns which are part of any healthcare system – how many of these are now going undetected or unresolved?

In time, clinical commissioning groups will fill the gap, but it is likely to be years before the majority establish a sufficiently strong feel for all the quality issues within their area. 

Some PCT cluster chiefs admit they are now effectively flying blind on quality – trusting the professionalism of colleagues, whistleblowers and media scrutiny.

The simple – and worrying – truth is that across the NHS as a whole we have at best a partial picture of the quality of healthcare and how it is being affected by the reforms or the efficiency drive. The fact that no scandals on the scale of Mid Staffs have emerged may be just that no one has noticed them – yet. The problems which came to light at Morecambe Bay soon after it became a foundation trust should have sent a shiver up the service’s collective backbone.

We should not be too reassured by the otherwise welcome aggregate national performance figures. Myriad scandals of the past have shown us that major failures are often successfully hidden from detection by normal data collection.

For that reason, among others, increasing regulation is not the best answer. With a system on the scale of the NHS, national agencies will always have to have their attention brought to most failings.

The solution is robust, coherent and consistent local arrangements for monitoring quality. Underpinning this approach should be two givens: that staff leading the work have the appropriate skills and information and that they are given time to develop and maintain knowledge and a network of relationships.

The Department of Health and the NHS Commissioning Board have been making the right noises. They are not unaware of the problem, but as HSJ’s research shows, this concern has not yet translated into an effective response on the ground.

Compared, for example, with the rush to get CCGs ready for business by April next year, there appears to be a lack of urgency. This has been partly created by the delay in the publication of the Mid Staffs report – which would have focused attention on the issue of quality monitoring.

The commissioning board is feeling its way into its new role in a manner quite different to restructures of the past. Mindful of a range of pressures – from CCG liberty to the need to attract the best staff – it is not afraid to show how it is cutting its cloth to meet the demands.

The drawback of a developmental approach is that it could extend the uncertainty which continues to blight the service. This could further threaten quality.

HSJ would encourage Stephen Dorrell’s influential Commons health committee to investigate the monitoring of quality during the transition. This would be an effective way to drive the issue back up the agenda.

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