Failure to limit expectations is blighting NHS regulation

The resignation of Care Quality Commission chief executive Cynthia Bower sparked a lengthy debate on HSJ’s website. The initial thrust of the argument was summed up by NHS London chief executive Dame Ruth Carnall, who wrote: “Cynthia has handled unbelievable pressure in this role and has retained her compassion and her focus on improving services for patients. Very few of us could handle this role with such resilience”.

Less sympathetic commentators suggested anyone in the role should expect to have a hellish time, but be comforted by the rewards on offer. Others simply said she did a bad job and deserved the sack.

HSJ’s view of Ms Bower’s leadership is that she failed to control expectations by taking on new responsibilities and/or deadlines without convincing herself the CQC had the culture and/or capability to deliver. The kind would say her loyalty and willingness to shoulder burdens was her undoing, the cruel that she lacked courage and the clear-sightedness to see troubles ahead.

The recruitment process for her successor should test candidates robustly on their track record of telling bosses things they do not want to hear and surviving the fallout. But that is only part of the skill of controlling expectations. For the leader of the CQC it involves an even more challenging task.

The Department of Health is undertaking a second review of the watchdog. Whatever efforts the government undertakes to make regulation “proportionate” to care risks and to clarify the CQC’s role, pressure will continue to grow for more safeguards applied to a wider set of risks experienced by those receiving services from a greater range of providers.

The public’s awareness of risk and variation of outcome in healthcare is accelerating at an unprecedented rate, as is its expectation of address. These factors are good in themselves, but the speed of change is leaving the service gasping for breath and reaching for its wallet.

With such a bewildering increase in scope it is tempting to say one über-regulator will always struggle and it would be better to have sector-specific regulators – especially in areas where quality is still relatively unexamined, such as primary and residential care.

But, build a matrix of regulators and you run counter to the drive to deliver integrated services. It is in handovers between services that many problems arise.

No, the answer to this growth in demand on regulation is to actively control expectations.

The temptation of any leader – especially a new one appointed by politicians – is to preach the gospel of certainty, to suggest all issues will now be resolved and concerns dealt with.

The opposite of course is true. The complexity of health and social care means new issues and concerns will emerge to which the regulator will have to react, not always in time. This is the message the public and politicians must hear if we are to clamber off the merry-go-round of regulatory upheaval.

The new leader of the CQC could do worse than repeat the words of Lisa Rodrigues, chief executive of Sussex Partnership Foundation Trust, on hsj.co.uk: “Getting things right for patients is the responsibility of individual staff, their professional supervisors, managers, employing organisations, commissioners, professional bodies, educators, referrers, planners, government and Parliament. Regulators are simply the backstop.”

This is not an abrogation of duty – it is a call to arms.