Friday, 13 December 2013

The trouble with inspection

The NHS blogger Roy Lilley has accelerated his campaign against the Care Quality Commission (CQC), and he is now so influential that he may succeed in winding the old dinosaur up single-handed.

His blog earlier this week, with snippets he has been sent by NHS staff, was pretty devastating. Apparently, a coachload of 130 inspectors turned up to inspect Barking & Dagenham hospital last week.

Yet there were the complaints in other places (not B&D, as far as I know) that, because there had been a tip-off about the arrival of inspectors, staff numbers had been doubled for the day – with managers on the wards handing out biscuits.

As Lilley says, inspection doesn’t drive up quality. Quite the reverse; you can just imagine how much energy has gone into working out when the inspectors would arrive.

But what really caught my attention was the automatic email from CQC, written in response to the complaint about the tip-off:

"Please note that should we not hear back from you within the next 7 working days, we'll assume that you no longer require our assistance. Should this not be the case, we'd request that you resubmit your original email detailing these concerns plus the important details we've requested above, and we'll be happy to assist you."

Now, here, in a nutshell is what happens when government shifts over go digital-by-default. You get the kind of automation dreamed up, if not by someone from McKinsey, then by the McKinseyite demon that stalks the corridors of Whitehall.

It is digital-for-the-convenience-of-the-managers, digital-unrelated-to-the-central-objectives, digital-to-obsess-about-irrelevant detail, digital-to-disempower-the-outside-world.

You do need an NHS watchdog, but there is no point if it just watches and never helps improve. There is no point if it never barks for political reasons.

The real question is this: if targets and inspection shift energy so much in the wrong directions, and away from holistic good care - where are the levers that managers or politicians can use to shift the system.

Friends and Family tests?  Yes, but that isn't the same as quality; though it may be an early warning system.  Minimum standards?  They then tend to act as maximum standards?  

This is the great unanswered question.  How do you roll back from the McKinseyite transformation of public services so uselessly into assembly lines?  I don't know the answer, because it needs to combine the maximum of local creativity and imagination with the maximum of rigour, and it isn't clear how they can be combined.

But although I don't know the answer, I think I know where to look.  It means that transparency assisted by small units and local control, and a powerful leadership for imagination from the centre.  Yes, it is all about culture change - which is difficult, since we have fostered a disempowering culture of compliance.

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