The Future of Regulation and Governance
Scrivens, Ellie, The Journal of the Royal Society for the Promotion of Health
The NHS in England is undergoing considerable structural change as it introduces more locally accountable hospitals, greater patient choice, payment by results and local general practitioner based commissioning of services. To deliver the anticipated service improvement associated with these changes, there is a need to ensure that the reformed NHS provides incentives for service improvement, while at the same time maintaining consistency in access to services and the safe delivery of services. The UK government is committed to reducing bureaucracy, which is based upon the associated desire to reduce the overall costs of regulation, while increasing the accountability of health services. This requires a new approach to regulation, balancing a standardised concept of quality with incentives to encourage local innovation in service design and delivery.
Accountability through regulation brings with it the burdens of supplying information for audit and inspection, which are placed upon the organization. This article examines the issues that need to be considered in the design of an effective regulatory system; one that must operate within a restricted cost envelope, and in particular focuses on the concept of reducing the administrative burden associated with both inspection and self-assessment and the need to make these proportionate to a demonstrable contribution to the improvement in regulation and the ultimate goal of improvement in quality of healthcare.
Devolution; governance; healtncare; inspection; quality
The UK National Health Service (NHS) is currently being reformed to introduce radical change to the operating relationships of the NHS to create more patient choice and to deliver more personalized care. The government has stated that:
the ambition for the next few years is to deliver a change which is even more profound to change the whole system so that there is more choice, more personalised care, real empowerment of people to improve their health - a fundamental change in our relationship with patients and the public. In other words, to move from a service that does things to and for its patients to one which is patient led.1
The NHS was founded and operates on two key principles: universal access; and services provided free at the point of consumption, funded from taxation. The desire for change has been prompted by the recognition of the need to change existing health service approaches to delivery. The need for change has been more acutely felt following unfavourable comparisons with the quality of care provided in other European countries (in areas such as cancer survival rates) and also recent catastrophic events (such as the deaths of children undergoing surgery in Bristol and the murders of elderly patients at the hands of their GP Harold Shipman). Government policy has focused on attempting to devolve power within the decisionmaking system away from central government to local service delivery, creating greater local accountability of services to local populations. This is supported by policies to increase choice and to make care more personal. The key elements of the reform agenda are the introduction of independent but publicly owned Foundation Hospitals, which are funded through taxation but with payment based on services provided (known as payment by results), and greater encouragement of private and independently owned providers, which will result in a mixed economy of provision. In addition, GPs are being encouraged to take greater responsibility for determining the type of services available to their patients through a policy known as practice-based commissioning.2
To support the reform agenda the regulatory environment, in which these new relationships of commissioning and providing will be conducted, is also being reformed to create the appropriate incentives for providers to innovate service design and delivery and to improve quality. …