the hsj interview: Dr Peter Homa

Published: 21/11/2002, Volume II2, No. 5832 Page 18 19

With an eye on the top job at the Commission for Healthcare Audit and Inspection, Dr Peter Homa still has some unfinished business at its predecessor, the Commission for Health Improvement, including implementing improvements to the star-ratings system

'Thanks for that; it was a good rehearsal for the interview, ' says Dr Peter Homa, chief executive of the Commission for Health Improvement, as his grilling by HSJ comes to a close.

Dr Homa is a man with a big job, whose eyes are on an even bigger one - the chief inspector's role at the soon-to-be-established ³berwatchdog the Commission for Healthcare Audit and Inspection.

CHAI is to take on the inspection roles currently conducted by CHI and private health watchdog the National Care Standards Commission. It will also inherit the Audit Commission's valuefor-money remit.

Writing in HSJ earlier this year, Manchester University reader in public management and director of research Kieran Walshe claimed that the CHAI chief inspector 'may end up wielding more power and influence in the NHS than the permanent secretary at the Department of Health'.

Dr Homa simply says: 'I do not think you can say one is more powerful than the other.'

The£150,000 chief inspector's post was advertised this month. It called for a 'politically astute' candidate, able to 'command respect and credibility with health professionals, ministers and patients'. A knowledge 'of working within a national framework' and 'performance frameworks' was requested, as was a 'proven interest in public service'.

In other words, the job has Dr Homa's name written all over it.

What is more, there are plenty who think the combination of the recently named CHAI chair Professor Sir Ian Kennedy and the man The Independent named as Britain's top health service manager would be the dream ticket for the new organisation.

But, even as he prepares to apply for the chief inspector's job, Dr Homa - whose doctorate is in business administration - faces the task of guiding CHI through a demanding work programme which includes continuing the round of clinical reviews and investigations which have made CHI's name.New on the commission's agenda is the establishment of the Office of Information on Healthcare Performance, which it is hoped will become 'a leading source of information regarding the performance of NHS organisations, on both a local and national level', and the 'state of the NHS report', which CHI must deliver to the English and Welsh parliaments.

But perhaps CHI's biggest test during the current year will be taking on the role of compiling and awarding the annual star-ratings.

Most projections suggest that CHAI will formally take over from CHI and the other watchdogs in April 2004. This gives CHI two years - 2002-03 and 2003-04 - to develop the ratings system.

The many critics of the starratings will be disappointed to hear Dr Homa say that next year's 'will not look overly different'. He stresses that the commission wants to approach the evolution of the ratings in a 'long-term way', mindful of having them developing in the right direction when CHAI takes over.

From the start of 2003-04, CHI will publish the criteria on which trusts will be measured at the start of the financial year. This will be done to avoid the 'surprises' which many trusts experienced when the 2001-02 ratings were published.

For many, one of these 'surprises' was the influential role of CHI's clinical reviews. Being awarded three stars meant, of course, that trusts received£1m. Dr Homa admits that the part CHI reviews played in trusts receiving - or more particularly not receiving - the extra funds 'certainly caused some difficulties in particular cases', with some complaining they had not known what was at stake during the reviews.

But then, as Dr Homa points out, neither had CHI or its reviewers.

He adds that while it will remain in the government's remit to decide whether any financial reward or penalty should be attached to a particular measure, trusts should in the future be able to proceed on a more secure basis and 'will be able to assess where they are [against the criteria] at any point in the year'.

CHI hopes to publish the criteria for this year's ratings before Christmas.

The biggest difference in the ratings, judging by how many times Dr Homa returns to the subject, will be the desire to establish them as 'an authoritative, authentic statement of what It is like to be cared for as a patient'.

This not only means provoking public interest by asking the kind of questions that patients think are important - and by implication that some people in the NHS may not consider a priority - but also by making sure the ratings are 'intelligible and accessible' to lay people.

This patient-centred approach to measuring performance is just one of the lessons that Dr Homa says the NHS can learn from overseas.

He claims that, for example, some Australian states have managed to bring together the 'different perspectives' needed to produce a comprehensive and robust rating system.

This involves not only judging the quality of institutions and the patient experience, but also developing 'disease-based' methods of measurement. CHI's studies on the national service frameworks for coronary heart disease, older people and mental health may point the way on how to measure 'the process of care', says the CHI chief executive.

NHS managers will breathe a sigh of relief to hear Dr Homa say the indicators will be published with an awareness of the impact they can have on public, patients and staff. He says he recognises that the ratings can be 'a motivator or a demotivator' for the NHS workforce.

One way in which CHI will try to ensure the ratings have a positive effect on the service is by publishing 'a commentary on the adequacy of the indicators'. This will place the ratings in the context of, for example, the relative wealth of a local population.

Another promise from Dr Homa is that CHI will 'test out any new indicators in advance of them being pressed into service'.

By doing all this, he hopes the indicators will be welcomed by trusts as providing an opportunity to 'compare and contrast their performance'.

Of course, one of the most controversial elements of the star-ratings - indeed, of the government's entire approach to measuring success within the NHS - is the prominence of waiting-time targets.

Dr Homa, while recognising the challenges for NHS managers and their clinical colleagues of meeting these long-term targets, believes they are 'a very good thing'.

He does not think they are distorting clinical priorities, as British Medical Association chair Dr Ian Bogle has speculated (the HSJ interview, pages 18-19, 14 November).

Dr Homa says that CHI's clinical reviews have come across 'a few individual examples' of a trust's concentration on waitingtime targets adversely affecting patient care, 'but not in a way that across the board contaminates the approach'.

Looking to the future, it appears eminently feasible that the information produced by CHI and its successor body will play a significant part in the government's attempts to give NHS patients and primary care commissioners greater choice.

Dr Homa is a fan of the policy, saying: 'We have a very, very long way to go before the NHS provides the responsiveness that we expect from other parts of our daily lives. [But] That is what We have got to do.'

He would like to see the commission's reports influencing patients' choices in where they want to be treated.

'I would also like to see GPs or [primary care trust] managers logging on to the new CHAI website and being able to access a range of high-quality data, including patient surveys, and getting a more informed, well-grounded, evidence-based picture of what It is like to be cared for in a hospital.'

Work behind the scenes to establish CHAI is already underway. Dr Homa reveals that a DoH team led by a senior civil servant is undertaking 'a major chunk of work' designed to 'offer some early thoughts' to CHAI's chair and chief inspector on the various models of inspection the new body could adopt.

Dr Homa says the DoH team is 'drawing on experience from inspectorates across the country' to determine how CHAI might undertake the 'very complex' task of carrying out this 'multi-agency merger' and 'synthesise the public and private sector inspection regimes'.

He stresses that CHAI could reject all the options presented by the DoH team, pointing out that, 'It is important CHAI is demonstrably independent'.

But he adds that the speed with which the new body needs to be established means it is 'sheer pragmatism' to offer some suggestions as to possible ways forward.

Previously, it had been widely thought that in terms of approach and organisation, establishing the new body would simply mean CHI adding an A to its acronym.

Whitehall whispers are now suggesting this is not quite the sure thing it was thought to be.

The concern of many, as expressed by former health secretary Frank Dobson, is that by 'bringing in the audit function [it] will give too much emphasis to money and not enough to standards.'

Dr Homa has been a strong champion of CHI's developmental agenda and his appointment as chief inspector would, no doubt, do much to calm Mr Dobson's fears. But others have speculated that the appointment of Sir Ian, another strong believer in the improvement role of inspection, might lead the DoH to balance CHAI's leadership by appointing a chief inspector who favours the stick rather than the carrot.

We - and Dr Homa - should know the truth by the end of January.