How do you nationally improve locally run care and health?

Sir David Behan, the out-going Chief Executive of the Care Quality Commission, has called for new powers for the CQC to formally rate local health and care systems. This has reignited a hot debate: how do you best set up a national system to improve health and care services that are run at a local level?

We currently have a tangled mess of support, regulation and inspection across health and care with multiple players (including CQC) inspecting health bodies and social care provider services, (and conducting the new local system reviews), as well as Ofsted inspecting children’s services departments and providers. NHS Improvement and others complicate the picture further…..and adult social care departments are different again, with their Sector Led Improvement (SLI) initiative. Ever since the local system reviews were announced, those involved in SLI have been busy thinking through what it means for them – and will now be doing so with more urgency.

I welcome the debate – it is a smart move to widen the lens to ask “what is best for health and care?”. I also fully support an improvement and support regime with more teeth. We must, however, fully understand that the way we frame (or re-frame) the question will determine the answer.

To properly answer the question about what is best, three important parameters must be considered:

1. What are we going to do with what we find? One observation of the local system reviews is that(so far there has not been a lot of “what happens next?”. When formal inspections are in place, which could lead to intervention or other serious implications, this results in a specific focus. For example, children’s services departments are very aware of their Ofsted rating, and are therefore very focused on being able to demonstrate success in the way that Ofsted will measure it. This has the positive of a clear focus and the negative of not being required to have a local understanding of what good is.
2. Are we looking comprehensively at productivity, not just quality? Productivity for local public services isn’t about efficiency but about outcomes. CQC did not have the remit to consider use of resources or value for money in its local system reviews, but cleverly set up the local system reviews to cover how well the system makes decisions on the use of resources. This was smart, but arguably doesn’t go far enough. A narrow-framed view of any one aspect (e.g. quality) means that real world issues such as financial pressures are ignored. This means it is perfectly possible for there to be multiple reviews of somewhere like Northamptonshire, without getting to the bottom of real pressures in the system.
3. How do we truly think ‘system’, not ‘organisation’? This is the real challenge. As Sir David said, “over the past few years, people have been rewarded for doing their bit and doing their bit well”. We have successfully incentivised individual organisational performance. But how do we also encourage collaboration? There are challenges in widening the lens: pinning down accountability is harder across a system, and there isn’t even a shared understanding of what we mean by a ‘local system’. The local system reviews define a local system geography based on council areas (150 Councils with Adult Social Services Responsibility). If you picked the 210 Clinical Commissioning Groups or 44 Sustainability and Transformation Partnerships areas as your footprint, you would frame the questions differently let alone get different answers.

In our work with 20 local systems at the health and care interface, these are issues we wrestle with every day. We believe that any new regime will need to fully acknowledge that playing a part in a successful complex system is a fundamentally different thing to running an organisation well. I agree with Sir David that, if done well, change could bring the ‘oxygen of transparency’. My fear is that if it is a botch job, it will just add to the smog of confusion.