Getting clinicians to speak up is the real key to fighting poor care

Complaints about bureaucracy diverting clinical staff and others from delivering care lead to promises that the burden of regulation will be reduced. Then along comes a scandal and cries of “something must be done” and the need for “annual inspections” once more becomes imperative.

It is the NHS equivalent of the claim that more bobbies on the beat is the best way to fight crime – an argument which trumps all evidence to the contrary and largely acts as a way to reassure the public.

In December 2009, Care Quality Commission chief executive Cynthia Bower assured HSJ that public and political outcry over care failings would not lead the regulator to increase the intensity of regulation.

Nineteen months later she tells HSJ that Winterbourne View and other scandals have demonstrated the need to “cross the threshold” to assess care.

Ms Bower claims this change of tack is a result of the disappointing findings of the CQC’s reviews into dignity and nutrition, but she also admits the public “want inspectors on wards… talking to frontline staff, observing care”.

The public, she adds “don’t want to hear about light-touch regulation”.

The CQC chief executive must, legally, remain silent on the public inquiry into the care failings at Mid Staffordshire Foundation Trust. So whether the CQC is jumping before being pushed by the inquiry’s recommendations will have to be surmised.

On the ground, inspections have merit, but they have never been a panacea. It is to be hoped the seminar section of the Mid Staffs inquiry scheduled for November and designed to tease out the lessons from witnesses might determine how inspections can be made more effective without placing such a burden on those being inspected that the result is counterproductive. It may also like to consider from where the extra £15m to fund the CQC’s proposed new inspection regime might come – and whether that sum may be better spent.

A far more powerful contribution than increasing the frequency of inspections can be made by those working in the system raising concerns about poor care.

Ms Bower stresses that commissioners and “providers and their boards” must “play their part”.

However, she stresses the role of professional regulators in underpinning the competence of “the person sitting in front of” the patient.

This theme is picked up in another perceptive intervention by Stephen Dorrell’s Commons health committee. In this week’s report on professional regulation he calls on the medical and nursing regulators to remind doctors and nurses that “failure to act” on concerns over the quality of care is “a serious breach of professional obligation”.

While the report focuses on regulators, Mr Dorrell in his usual subtle way is stressing the need for individual clinicians to take responsibility for the overall care system in which they work.

That responsibility is shirked for reasons ranging from apathy to ignorance to fear. Were the professional regulators – together with employers and professional institutions – able to overcome these barriers, it would be a huge advance.

Ms Bower makes one final point – merger with Monitor would remove the CQC’s advantage of not having to “think about money”. She is right about resisting a merger, but it still leaves the question hanging of how staff – particularly clinicians – can make a judgement between sensible efficiencies and dangerous cost cutting.

It is important that this often difficult calculation can be made – as it allows staff to raise concerns before care deteriorates seriously. Given the NHS is likely to need to find ever greater efficiencies for the rest of the decade, it is the crucial question affecting the quality of care.