The issues of governance and regulation in the NHS are strongly linked. Currently, the NHS system has a multiplicity of agencies and organisations which carry out regulatory functions.
From a regulatory studies perspective, any body that is in a position to set standards, monitor what happens and take action can be regarded as exercising regulatory functions, even if its purpose is not formally defined as such. So Clinical Commissioning Groups, the NHS Litigation Authority, the Royal Colleges and NHS England are just some of the organisations that can be understood as acting like a regulator.
With the multiplicity of NHS regulators going well beyond the obvious Care Quality Commission, TDA and Monitor, the system involuntarily creates 'priority tickets'. Providers are now faced with a massive number of competing and sometimes conflicting standards and goals, many of which conflict, compete or fail to cohere.
This leads providers into distraction, confusion and loss of focus, and leads into too much servicing of external accountability demands while making it unnecessarily hard to set meaningful internally valued goals.
Alongside this, having such multiple regulators creates problems for intelligence gathering: providers with too many masters, having to give multiple information in multiple formats to feed multiple regulatory mouths. This is not a method bound to capture the kinds of intelligence most likely to be valuable to providers, and makes what we call 'fugitive knowledge' about difficult but hidden problems especially hard to capture.
If the provider system remains too focused on servicing external accountability demands and protecting providers' own reputations, they may be dis-incentivised to find bad news.
Director, THIS Institute and The Health Foundation Professor of Healthcare Improvement Studies
If the provider system remains too focused on servicing external accountability demands and protecting providers' own reputations, they may be dis-incentivised to find bad news. This can easily divert providers from problem-sensing behaviour – looking for bad news (including fugitive knowledge) and instead incentivising 'comfort-seeking' as was seen at its worst at Mid-Staffordshire. Even in the face of challenging information, comfort-seeking finds ways of reinterpreting the data to reduce the sense of threat and shame – "we're not as bad as trust X", or "this is down to how we collect our mortality data".
By international standards, the NHS is by no means alone in creating a complicated, complex regulatory space with many hard edges against which providers can cut themselves. US healthcare is also besieged by massive demands for data. Massachusetts General Hospital now suggests that it is spending 1% of its patient revenue on data, and the sector as a whole is seeing huge growth in the expectations on delivery of data. Often the science underlying the measures is not fully secure, creating perverse effects that may ultimately and paradoxically end up by damaging safety. These effects can be amplified when financial penalties are attached.
We have many of the basic pieces of a useful regulatory system in the NHS, but they lack coherence; are not providing clear direction; fail in delivering high-quality intelligence; and fail to put appropriate corrective mechanisms in place. Regulatory complexity needs to be reduced, and standards, intelligence-gathering, and corrective action should all be based on the best possible science.
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