A regulatory approach can thwart improvement ambitions

The messages from leading thinkers from Deming to Darzi to Berwick are remarkably consistent.

‘Board leaders are vocal about leadership capacity taken up in responding to regulators’

They cite the critical role played by capable, stable leadership, by robust measurement, and by processes of engagement that harness the inherent motivation and commitment of staff.

In his paper on NHS reform, King’s Fund chief executive Chris Ham reflects that the experience of high performing healthcare organisations shows the value of:

• leadership continuity;
• organisational stability;
• a clear vision and goals for improvement; and
• the use of an explicit improvement methodology.

He concludes: “NHS reform has relied too much on external stimuli such as targets and performance management, inspection and regulation, and competition and choice and too little on bringing about improvement ‘from within’.”

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Round tables

At two recent roundtable discussions on “regulation, inspection and the role of the board” hosted by NHS Providers and facilitated by the Foresight Centre for Governance at GE Healthcare Finnamore, we explored the respective roles that board leadership and regulatory scrutiny are playing in enabling improvement, as well as the extent to which the available learning is reflected in the approaches being taken.

The range of perspectives on the role of the board in leading quality improvement (as distinct from quality assurance), reflect an impressive grasp by board leaders of the lessons that Professor Ham identifies.

‘The role played by robust measurement in driving improvement is widely understood’

There is a profound commitment across provider boards to a distributed, collaborative leadership model with empowered and engaged clinical leadership at its heart. The role played by robust measurement in driving improvement is widely understood.

Board leaders increasingly speak the language of “improvement methodology” and are persuaded of the need for organisation-wide – and indeed for certain system-wide – approaches to quality improvement underpinned by a solid evidence base.

The critical importance of board visibility and engagement with the lived reality for patients, carers and staff is now routinely seen as a critical building block of effective governance.

Accountability and transparency

But what of their experience of the relationship between regulation and improvement? There is no doubt about the need for boards to demonstrate accountability and transparency in light of the searing lessons from significant failures in care.

Board leaders embrace the crucial role of the board in shaping a responsive, compassionate, patient centred organisational culture.

They therefore welcome the role that robust, risk based regulation and inspection plays in giving confidence to patients and the public that NHS organisations are open and accountable, in setting clear evidence based standards, and in checking that board governance is effective in shining a light into every corner of the organisation. 

But while the fundamental legitimacy of external regulation is accepted, board leaders are vocal about the degree to which leadership capacity is taken up in responding to regulators.

They are concerned that meeting the needs of the regulators can sometimes crowd out the leading of improvement.

‘Board leaders are keen to meet the standards for a “well led” organisation but too often are thwarted’

They question whether a regulatory approach based on inspection (with its reliance on action plans and emphasis on “compliance”) can lead to improvement when the accepted methodology of improvement, by contrast, seeks to harness energy, motivation, commitment and innovation.

Board leaders are keen to meet the standards for a “well led” organisation but too often find this ambition thwarted by a regulatory approach that, in practice, has the paradoxical effect of sapping the leadership authority and autonomy of the board.

In reflecting on the sustainability challenges of the future, board leaders point to the inconsistency between regulatory frameworks that emphasise the governance of sovereign organisations and wider policy ambitions that grasp the need for system-wide solutions.

In practice, board anxiety about maintaining regulatory compliance can sometimes act as a brake on their confidence and capacity to engage fully with complex, system-wide negotiation, innovation and experimentation.

Five lessons

So does regulation drive improvement?

The answer from the leaders we met is “not necessarily”’. If boards are expected to enable improvement then there are some important lessons to learn:

• There is a crucial role for regulation in ensuring that organisations are open, transparent and held to account including through shining a light on areas of poor performance.
• But regulators need to recognise that real quality improvement can only be led from within: regulation and inspection drives compliance whereas improvement demands commitment.
• Boards need to have the time (and indeed, give priority) to focusing as much on leading and enabling improvement as they currently spend on regulatory issues.
• If we are serious about developing well led organisations, it is important to resist the temptation to disempower boards – even (or perhaps especially) when organisations are deemed to be failing.
• Organisation focused regulatory frameworks need to be aligned with a system focused policy ambition, including new models of care, to create the space for experimentation and a greater tolerance of risk and risk sharing.

Sue Rubenstein and Adrienne Fresko co-lead the Foresight Centre for Governance at GE Healthcare Finnamore; and John Coutts is the governance adviser for NHS Providers