Too much policing will not create a culture of quality. Rather it is
likely to distort practice and prioritise the conventional and the
measurable. (Smith 1995c: 308)
This chapter avoids the limitations of rapid obsolescence and inability to explain change associated with simple 'lists' of contemporary regulatory practice by providing a conceptual overview. Drawing on cultural theory, regulation is considered within the context of international trends in governance, and regulatory approaches such as accreditation, inspection, performance management and peer review are situated within a conceptual framework consisting of two independent dimensions: control location (internal/external); and nature of resultant action (formative/ summative). The axes combine to produce quadrants: internal control, formative action (Q1); external control, formative action (Q2); internal control, summative action (Q3); and external control, summative action (Q4). The focus is firmly on Q4, with a consideration of the interplay of the summative and formative within real-world regulatory and inspection systems.
Recent UK NHS regulatory experience is considered, together with an overview of the generic empirical and theoretical literature on use of performance indicators in performance management. Conceptual and technical issues are explored, including the potential displacement of informal modes of quality assurance; the status of indicators as 'conceptual technologies'; difaculties associated with availability, reliability, validity and confounding; the importance of sensitivity and specificity; and the potential for unintended negative consequences. The chapter concludes with a cautious assessment of the potential value of performance measurement in governance systems.