Anna Walker joined the Healthcare Commission with only two months until its launch. As it prepares to merge into a new super-regulator, she reflects on four testing years at the helm. By Charlotte Santry

When Anna Walker entered the Healthcare Commission as chief executive in February 2004, she was clearly an outsider. With a high-flying career in the civil service behind her but no experience in the health sector, she admits it took a while to feel convinced the job was for her.

“I was contacted by a headhunter, then went home and said to Tim, my husband, ‘They’ve got in touch with me about an organisation called the Healthcare Commission, which I’ve never heard of and doesn’t sound very interesting.’”

She only agreed to apply after husband Timothy Walker, former Health and Safety Executive director general, pointed out the role involved independent regulation, which she knew about as a former deputy head of Oftel.

The commission was shaped around chair Sir Ian Kennedy, who had commanded great respect since leading the public inquiry into children’s heart surgery at Bristol Royal Infirmary in 2001.

His reputation was one of the factors that attracted Ms Walker to the role. “He had a vision of what needed to be done and I found that vision compelling.

“He is a hands-on chair, and that’s just meant we’ve had to learn to work around and with each other. I think we both feel it’s been a successful relationship.”

She says she found asserting authority easy. “He may have views on what he’d like done, but as far as actually getting them done that’s the chief executive’s role… he can have firm views but always, at the end of the day, it’s for me to decide.”

Good cop, bad cop?

They have also had clearly segregated roles, with Sir Ian leading on issues close to his heart such as maternity and public engagement. In a letter leaked to HSJ, he fought a bitter battle of words with the Department of Health after the Maidstone and Tunbridge Wells trust C difficile outbreak, angrily batting off suggestions from health secretary Alan Johnson that the commission could have done more to avert the deaths of at least 90 patients.

Have Ms Walker and Sir Ian consciously taken on a “good cop, bad cop” role? Ms Walker says no, saying they have shared the behind the scenes work involved in influencing policies and listening to concerns.

Not a regular at the late night haunts frequented by the NHS elite during annual conferences, she insists this does not mean she is averse to schmoozing. “I don’t have to work hard at networking, I think it comes quite naturally to me,” she says. “The coffee bar is extremely useful. Building up relationships over time is absolutely invaluable.”

Monthly phone calls to DH director general of NHS finance, performance and operations David Flory and regular meetings with figures such as medical director Sir Bruce Keogh and director general for commissioning and system management Mark Britnell have also kept her in the loop.

She says access to senior decision makers has improved since Sir Ian’s leaked letter, which complained the DH was not sending its top people to meetings with the commission. But the reasons for the change were “much deeper than that”.

“It’s a growing understanding on the part of the DH of how regulation can help move their agenda forward,” she says.

Big successes

She sees the commission’s big successes as bringing out the health check ratings, the annual assessment of trusts based on the quality of their services and financial management.

This replaced the star ratings system, which one chief executive told her meant “you can concentrate on those things in the ratings and let the rest of the organisation go hang”.

She believes the strength of the health check, the latest of which is published today, lies in its breadth. This means “it can’t be gamed”, she says.

While some readers complain it imposes a heavy burden on time-poor managers, Ms Walker argues the commission has become far more light-touch by using sophisticated data that allows inspections to be targeted where they are most needed.

Clashes with managers go with the territory, but the tone of the commission’s press releases has recently been altered to emphasise positive findings.

This decision followed a meeting with former NHS Confederation chief executive Gill Morgan, who protested the commission was not doing enough to celebrate success.

Ms Walker relishes heated debate with managers, claiming she has always made an effort to talk to any chief executive who makes contact.

“You’re making judgements about people and they get very anxious about that, so I’ve found the best thing to do is to keep in contact with those who we’re regulating so when they’ve got concerns they can feed them back.”

Double jeopardy

There have been difficult relationships with other regulators, notably foundation trust regulator Monitor and the Audit Commission.Monitor executive chairman Bill Moyes is known to have been concerned at the replacement of the Healthcare Commission with the Care Quality Commission, fearing overlaps and a weakening of Monitor’s powers of intervention.

There has also been a tug of war with the Audit Commission as both strive for prominence in joint reports such as June’s report on NHS reforms.

Adaptability is crucial, Ms Walker says. “With Bill, we can have very different views but it’s about coming together and having a fantastic discussion.” An example is the way they have collaborated to try to eliminate so-called “double jeopardy” for foundation trusts, meaning they fall under two regulatory regimes.

Ms Walker has some regrets. She wishes the commission had “plunged in” with the annual health checks sooner. New organisations need new work to get stuck into. This is why she approves of the decision by CQC chair Barbara Young and chief executive Cynthia Bower to focus on next April’s hygiene code registration.

As the CQC will be operating in shadow form from this month until April 2009, it has got “luxurious amounts of time” to get it right, Ms Walker says, whereas she had just two months’ preparation.

She also wishes that she had set up the commission’s regional offices earlier, to improve their local presence.

Spectacular failures

Asked for striking themes from the commission’s 16 in-depth investigations, she says: “There aren’t that many spectacular failures but where there are… [the causes] are not fundamentally about healthcare organisations. They’re about poor organisations generally… a lack of overall leadership, a lack of systematic management.

“There tends to be a division between clinicians and general management, and a board which is not routinely identifying and collecting its own performance management information.”

The CQC’s priorities may well differ from her commission’s, especially as it will also absorb the Mental Health Act Commission and the Commission for Social Care Inspection.

But where next for Ms Walker? She did not try to secure the CQC job and defied expectations by not putting her name forward to head the new NHS competition and collaboration panel.

She is passing her time carrying out an independent review for the government into charging and metering for water and sewerage services. But she is holding out for the ideal position, hopefully “something in healthcare”.

WALKER SAYS…

On Healthcare Commission chair Ian Kennedy

“He may have views on what he’d like done but as far as actually getting them done that’s the chief executive’s role.”

On networking

“I don’t have to work hard at networking, I think it comes quite naturally to me,”

On her relationship with managers

“You’re making judgements about people and they get very anxious, so I’ve found the best thing to do is to keep in contact with those who we’re regulating so when they’ve got concerns they can feed them back.”

On running themes from in-depth investigations

“There aren’t that many spectacular failures but where there are, those common threads are really quite striking. They’re about poor organisations generally, because it’s about a lack of overall leadership, a lack of systematic management.”

BIOGRAPHY

Born 1951

Education

  • Oxford High School; Benenden School, Kent

  • Bryn Mawr College, US

  • Lady Margaret Hall, Oxford (MA History)

Employment

  • 1972-73: British Council

  • 1975-94: civil servant, mostly at Department of Trade and Industry

  • 1994-97: deputy director general, Office of Telecommunications

  • 1998-2001: director general for energy, Department of Trade and Industry

  • 2001-03: director general for rural affairs, Department for Environment, Food and Rural Affairs

  • 2004: chief executive, Healthcare Commission