You can't inspect your way out of trouble

According to Care Quality Commission chair David Prior, hospitals can cause the deaths of up to 10,000 people a year through poor care. It’s not clear how this figure was arrived at, but it’s part of a message that says the quality of service in hospitals, GP surgeries and care homes varies tremendously.

‘There is no convincing evidence that you can inspect your way to a higher quality service’

This is clearly not acceptable. And the proposed answer is intelligent transparency. That is, rigorous in-depth inspections conducted by experts producing clear, well written reports. It might sound like naming and shaming, but the positive spin is that patients can choose the best and clinicians will learn from them – just like with schools.

In an article published in The Guardian in September, Mr Prior dismissed previous initiatives to improve services in the NHS.

He said efforts at “world class commissioning” produced disappointing results, foundation trusts did not live up to expectations, increased regulation just stifled innovation and emphasis on leadership just revealed “there are not enough great management or clinical leaders to go around”.

Intelligent transparency will work, it was claimed, because there would be “no hiding place for hospitals, GPs or care homes” that provide substandard care.

Checks unbalanced

While inspections have not proved infallible at unearthing bad practice, they have tended to ensure minimum standards are met.

‘If hospitals think inspectors come with an agenda, then trusts will have no confidence in the fairness of the process’

But there is no convincing evidence that you can inspect your way to a higher quality service. There is, though, an argument that you can reward quality through contracting and commissioning.

We have been here before: in-depth inspections by experienced and qualified staff, reports published on the internet to inform the public, naming and shaming, benchmarking – only this was for social services and care homes, and was discarded as expensive, overly bureaucratic and unnecessary.

This approach to inspection seems unnecessarily confrontational; it sounds like one of those speeches world leaders make about terrorists: “You can run but you can’t hide.”

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If hospitals, GP surgeries and care homes think inspectors come with an agenda of “we will find and expose bad practise” – a view that trusts are defensive, hide their mistakes and never admit their weaknesses – then trusts will have no confidence in the fairness of the process.

The result will be vigorous challenges to inspection report conclusions. In response, inspectors will let trusts see draft reports only for factual accuracy.

War of words

Trusts will complain about the tone and language of reports; they will say inspectors have been selective in the use of data and ignored what doesn’t fit their preconceived views.

Inspectors will retaliate with “we report what we find and what people tell us”. Trusts will invest a disproportionate amount of time and resources preparing for inspections, briefing staff and producing positional statements pulling together a massive amount of data to evidence performance and progress, and to ensure favourable material informs the inspection.

At the end of all this, some trusts will be put in special measures, which they will find a very negative experience and difficult to get out of.

Public confidence in the trust will be shaken, the senior management team will be replaced, staff morale will suffer, recruitment will be a problem and there will be talk of mergers with a more successful trust.

How do I know? That’s what’s happened in the past when inspections took on a confrontational approach and produced simplified one-word assessments for the public.

Blair McPherson is a former director of community services with experience of getting organisations out of special measures