With the launch of the National Institute for Clinical Excellence and the essential elements of its infrastructure in place, attention is now turning to that other bit of new machinery designed to raise performance and sort out malfunctioning people and systems - the Commission for Health Improvement.

While the spotlight has been firmly on NICE there has been little comment on CHI, other than to complain about the title. CHI will not be concerned with health but with healthcare which, one hopes, should contribute to improved health.

But there are some critical issues to be addressed at the outset which go to the heart of the kind of beast CHI is intended to be, or might become. If these issues are fudged the result will be a useless bit of kit which the NHS could do without if clinical governance is not to become just another passing wheeze.

The most critical aspect of the new commission concerns its role and ethos.

Is it to be an inspectorate, akin to Ofsted - an Ofhealth, perhaps? Or is it to be in the mould of the Health Advisory Service (HAS) which, in its heyday, offered valuable support to those on the frontline struggling to manage long-stay care services and bring about a shift from institutional to community-based provision?

There are those who believe that a mix of these roles is both possible and in keeping with the government's obsession with sticks and carrots to ratchet up performance.

But if a hybrid agency is envisaged, a sort of combined inspectorate and development agency, then failure is almost guaranteed.

As in other areas of its reform agenda, there is evidence which the government can draw on, should it choose to. An evaluation of the HAS published 10 years ago makes for useful contemporary reading.1

As the researchers state, an evaluative body has to decide whether it should be supportive, or critical, or both.

Can the evaluators be both advisers to professional colleagues, and inspectors, monitors or critics on behalf of the wider society?

The HAS began life as the 'eyes and ears' of the minister, in much the same way as CHI is intended to be. But it rapidly became something else, distancing itself from the centre and promoting good clinical practice as well as encouraging local efforts to raise standards. The HAS had greatest impact when it was encouraging and positive although, as the research team concluded, its development agency role did not always combine easily with an inspectorial strand.

Distinguishing between policing and auditing on the one hand, and development and problem-solving on the other, will be critical to determining the kind of body CHI becomes. Confusion about some of these fundamental issues certainly rendered the HAS less effective than it might have been.

Despite its 'advisory' status, many viewed it as an inspectorate, while others thought it insufficiently inspectorial.

Another issue which urgently needs addressing is the precise nature of the management problem CHI is being established to tackle. A diagnosis would reveal the nature and source of the problem. Does it lie in an inability to spread 'good practice'? Or does it lie in the rigidity of managers and their inability to respond to new problems or solutions? They may talk the language of 'whole systems' and partnerships and health action zones and health improvement programmes, but can they really break the mould into which they have been shaped?

Or is the problem not so much one of managerial competence or ability but of a lack of autonomy in a sharply political context, where the constraints imposed by the centre have become oppressive and overbearing? In practice, the problem may be a combination of all these concerns.

If CHI is seen as too much part of the formal management system, as seems likely, then any supportive, developmental functions it possesses will be undermined.

If, on the other hand, the agency is accorded a degree of independence from the centre then it could function effectively as a development agency, acquiring some of the best characteristics of the HAS and an authority derived from wisdom.

What seems beyond doubt on the available evidence is that CHI cannot simultaneously be both policeman and developer.

Whether an institutional response to the problem is either the correct or most desirable one is also an issue. Maybe we should be concerned with how we can best develop a set of resources and skills with sufficient 'critical mass' to provide development support. Then the various tasks identified above - spreading good practice, improving management processes and so on - can be addressed appropriately.

Regrettably, it is unlikely that any such discussion will occur, since it is unfashionable to talk in 'soft' terms about improving management performance through development and learning.

The incentive structure is being fashioned according to rather crude and outmoded notions concerning effective management practice.

The tragedy is that we have been here before and can no doubt look forward to being here again. A crucial, although often overlooked, aspect of an institution which is over 50 years old is that it has a wealth of experience to draw on in terms of what works and what does not. The NHS possesses an invaluable corporate memory. We make too little use of it in fashioning the future.

But then adolescents have never believed that there is anything to learn from their elders. We can but hope.


1 Henkel M, Kogan M et al. The Health Advisory Service: an evaluation. London: King Edward's Hospital Fund for London, 1989.