Caught between two Regulators? The NHS, cost and quality...

The scale of the financial challenge currently enveloping the NHS has been well documented. Throughout the summer politicians, policy think tanks and healthcare professionals have indulged in a national debate about a solution to the crisis. Much attention has focused on Jeremy Hunt’s post election vision for the NHS, containing as it did a raft of further reforms designed to improve the patient experience and reduce costs. However, lost amongst the noise has been the consequence of delivering this change agenda for healthcare regulation.

 In April 2013, Monitor and the Care Quality Commission (CQC) signed a Memorandum of Understanding (MoU) detailing the way the two regulators would work together in the future. The document stressed that both were “committed to working together to encourage improvements in the quality of care”. The MoU also stated that the two regulators would “promote economic, efficient and effective services” thereby anticipating Jeremy Hunt’s promises. The compact also emphasised “We will do this by delivering new ways of working that reflect our interdependent relationship”. So, just over two years on, how has this ambitious protocol fared?

In June, Monitor wrote to chairs and chief executives highlighting the fact that 77 of the 152 foundation trusts had ended 2014-2015 in deficit and bluntly advised the sector that “put simply, this is unaffordable”. Monitor indicated an intention ramp up its regulatory activity and the imposition of enforced administration regimes where necessary. By early August it had advised the sector to fill vacancies “only where essential”, follow guidelines on safe staffing in a way that was “proportionate and appropriate”, and “rigorously manage” evening and weekend rosters.

Meanwhile, CQC adopted a more robust approach to trusts failing to meet its Fundamental Standards framework. This was evidenced by NHS hospital trusts in England being placed in special measures due to an array of serious problems including: lack of staff, over reliance on agency workers, inadequate priority for patient safety risks, poor staff morale and the prevalence of bullying target based cultures.

 The conundrum for NHS executives is how best to square these manifestly competing demands. The cliché that quality doesn’t have to cost is often rolled out as a seemingly unchallengeable response to the immense task of delivering healthcare that meets the Secretary of State’s aspirations. However, the reality now for NHS boards is how to comply with the expectations of one regulator whilst not falling foul of the other. The tension is palpable and I see it on a regular basis in my work with NHS trusts. The situation is likely to get worse with the NHS being asked to make £22bn in efficiency savings to plug a predicted shortfall of £30bn by 2020.

 The MoU between Monitor and CQC was inked in 2013, and whilst it contains some admirable sentiments, it now reads more as a creaky statement of fine words and intentions significantly at odds with the apocalyptic assessment of NHS finances in 2015. The roles of the two regulators as expressed in the document say much about why we find ourselves in this place. In a perfect world these objectives are not necessarily incompatible, but for those in charge of NHS finances such perfection promises to be as illusive as ever.