Published: 14/08/2003, Volume II3, No. 5868 Page 10 11
There are growing signs that an alliance between CHAI and the Audit Commission may give the commission a pivotal role in the new inspection and regulation regime. Alastair McLellan talked to Audit Commission chair James Strachan
Could the Audit Comm-ission become the local eyes and ears of the new über-watchdog the Commission for Healthcare Audit and Inspection?
Will the 1,200 regionally based Audit Commission staff provide the backbone of the 'local information units' which CHAI chair Professor Sir Ian Kennedy told HSJ would make the new regulator super-sensitive to local issues ('Kennedy pushes for 'intelligent' scrutiny', page 5, 26 June)?
'That is just conjecture, ' says Audit Commission chair James Strachan. 'I do not know. It might be or might not be. It is something for CHAI to decide.'
But the very fact that the question can be asked - and not instantly dismissed - is a clear sign of how the two commissions are forming a close alliance inspired by the developing relationship between their two chairs.
When the creation of CHAI was announced in April 2002, it was perceived as a great blow to the status and influence of the Audit Commission. Even though the national value-for-money work that CHAI will take on is a fraction of its overall workload in the sector, the Audit Commission's role as a significant player in the UK health policy debate was thrown into doubt. The continuing audit and local value-formoney work simply did not carry the same clout - unfairly, as it is clearly vital to proper governance of the NHS.
Nobody really believed existing commission controller Sir Andrew Foster when he expressed 'slight disappointment' over losing the role ('Audit chief warns on regulation 'risk'', page 4, 25 April 2002).
The Commission for Health Improvement - and chief executive Dr Peter Homa in particular - were seen as the greatest influences on the development of CHAI.
Things are very different now.
Dr Homa has come and gone as CHAI's chief inspector, while Audit Commission director of health Peter Wilkinson has been seconded to the new regulator's small shadow team along with two senior colleagues.
From the start of next month deputy director of health Bill Butler will start work as CHAI interim director of finance. 'If that is not a commitment to making CHAI work I do not know what is', says Mr Strachan.
The fact that Department of Health director of policy Andy McKeon has been attracted to the commission as managing director ofits health division further demonstrates a determination to play a significant part in the future direction of NHS regulation.
Mr Strachan joined the commission last autumn at roughly the same time that Sir Ian was appointed shadow chair of CHAI.
'Ian [Kennedy] and I get on extremely well', he says. 'There is pretty much a match in how we would like to see regulation become more strategic, more intelligent.'
The vision for CHAI, which Sir Ian revealed in HSJ, is very similar to the one that Mr Strachan wants to pursue at the Audit Commission.
'Everything we are trying to do here in terms of strategic regulation is essentially saying, 'this is not some sort of audit trail, it is not some kind of superior assurance system'. There must be a clear relationship between our work and improvement.'
Looking more broadly, he stresses the need to establish the correct regulatory framework and governance structures within which services are provided. 'The year in, year out version of the inspection calls' would then no longer be required, regulators could focus on real or potential problems and not 'waste resources running around revalidating the people who've done very well'. The 'excellent and the good' should be 'left relatively alone to flourish.'
It is an approach that local government, through its comprehensive performance assessment framework, has got a lot closer to achieving, according to Mr Strachan.
One of the benefits of the local authority system is its ability to take a cross-cutting approach to local government activity - something that could be usefully applied to the health service in evaluating patient journeys.
'It may make more sense', says Mr Strachan, picking his words carefully, 'to look at health economies and draw lessons from that. This, he suggests, might be a quicker way of driving improvement than trying to 'cover the entire universe' by blanket inspection.
Mr Strachan is keen to 'shout from the rooftops' that CHAI is the 'senior partner' in the partnership and that theirs is 'just one voice among many' to which the new body will want to listen. But he is clear about the specific areas in which the commission can really add value.
Sir Ian has called for CHAI's regulation to be based on 'intelligent information - information that is more than data'.
Mr Strachan comments:
'That intelligent information needs to be as consistent, accurate and high-quality as possible' and adds that in pursuing this approach, 'our information base is critical and will always be critical'.
The commission's information comes, of course, from the audit work it does for NHS trusts. This work is led by its 750 auditors.
Those auditors and commission staff have, claims Mr Strachan, 'a very significant, long-standing set of relationships' with the local NHS.
These relationships, he adds, could help minimise risk during the period in which CHAI establishes itself and also potentially provide ongoing value to the new regulator - hence the question about the Audit Commission playing a role in CHAI's local information units.
'There is a feeling that here is an established regional base - a field force' says Mr Strachan.
'So the question is not how to duplicate it, but how CHAI will extract the value from it. It is not a question of all or nothing - I am sure CHAI will also have its people out in the field too.'
Mr Strachan has been unafraid to attack the way in which targets are being set and used in the public sector, telling the Commons Public Administration Committee, for example, that 'there is a real paucity at the senior level of people who are involved in the setting of targets, a lack of realworld experience'.
The Audit Commission chair believes there should be two distinct kinds of target - a very small number of 'top level aspirational targets' which everyone understands and 'workaday tool kind of targets', which allow teams to measure whether they are improving.
However, Mr Strachan says the government is, 'without question, rethinking how it uses and sets targets'.
He has been 'encouraged' in this belief by 'a number of conversations in the last few weeks' and the work on developing better targets, which appears to be happening across government.
This makes Mr Strachan a happy man because he does not want to see the back of targets - far from it.
'The choice in the media - that there is a choice between targets and no targets - is a ludicrous non-choice. Targets are the essence of improving an organisation - if you do not know where you're going, you're very unlikely to get there.
'The much more interesting debate is about how many targets you have, who sets them, with what intelligence and experience of the activity they're setting them for, the interaction between the setter and the user, and how you refine those targets in the light of experience.
'The Guardian wrote a leader saying that the Audit Commission has given up on targets; you might as well say that the Church has given up on religion.'
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