An Auditor of One checking on surgical performance

The UK’s coalition government’s reform agenda continues to unfold with the planned scrapping of the Audit Commission. While the Commission has good analytical capacity and did focus on issues of importance, the need to shift the audit function further into systems and out into the community was not one of its core objectives.

In healthcare, I have written and spoken of the patient as the “auditor of one”, as the patient is the only person who has a real experience of the continuum of care, and it is only through the patient that the integration or not of services is achieved. While bureaucratic processes may try to knit systems together at their edges, only users have that ‘joined up experience’, and it is by engaging with them more effectively that radical service improvement will come about (the use is really the most disruptive force for quality improvement we have).

The next test for audit in the UK will be ensuring that all these auditors of one can be effective; rather unfortunately, the government is referring to them as “armchair auditors” a term which tends to describe distant interest, rather than engaged in the critical appraisal of performance. But organised interest groups can emerge, or existing one expand their scope of interest to increase the salience of issues in the delivery of publicly funded services.

I think one auditor is really enough anyway, but the National Audit Office will need to expand its remit in at least two areas if it is to be really worthy of public expectations, to include:

1. value-for-money retrospective audits (and not just of assessing implementation against legislative intent);
2. prospective audits of planned legislation (similar to the US non-partisan Congressional Budget Office).

I might add a third, namely being advised by, and engaging with, the public, perhaps through regional citizen audit advisory groups who can act to bring local concerns together where national concerns, at least, are an issue. There are models for this sort of relationship which would enhance accountability, transparency and visibility with the public.

NHS System Governance

The English NHS is in for further reform as the flurry of consultation documents and the White Paper evidence. Overall, NHS reforms have been generally weak in having a thought-through systems governance approach. I think in part this arises from perceived problems with two areas: the role of the private sector: the systems governance of previous reforms has tried to ignore this sector, and in effect partition the health market certainly in England, with the result that a single playing field for providers couldn’t emerge. This was compounded by the previous government’s views that NHS providers could fail twice before being of public concern (a silly and ideologically driven position). The second problem has always been the purchasing side (a.k.a. commissioning), where there has been over the years feare of ‘letting the market rip’ (as if we somehow markets are generally regulated anyway), anxiety about purchaser impact on provider viability (again an ideological position on the how to deal with failing public institutions — the usual response it to prop them up with more money). or more generally a plethora of initiatives (such as World Class Commissioning — I wonder when this one gets buried?), whieh exuded more style than substance.

And so it continues with a failure, I think, once again to get the commissioning side of the health system balance sheet cleaned up.  One of the key things that needs to be central to systems governance is clarity of mission of the various bits that make it go, and how conflict is managed, mainly for systems-level problems that need to be resolved within the system, rather than constantly being taken back into the political machinery for resolution. Given that the coalition government wants to create some distance between the Department of Health and the regulatory oversight structures themselves (Monitor, CQC, NHS Commissioning Board seem the main statutory bodies here plus the GP Consortia and providers as agents), the possibility of conflict emerging between the Board and the other two regulators is real.

The NHS Commissioning Board will have oversight of GP Consortia, and in effect givea them a licence of fitness to practice; though this isn’t the exact terminology used, the Board does decide if GP Consortia are handling financial risk well, within the overall clinical frameworks and other guidance. And what of failing GP Consortia?

I am troubled in particular that the Board will be commissioning services for primary care and for national and specialist services. This is where the core problem for system governance lies, as the Board has a potential serious governance conflict between its oversight and regulatory role and its activities as a purchaser (sorry, commissioner…).

Who oversees the NHS Commissioning Board’s commissioning and why should anyone trust them to do a good job in absence of suitable oversight — are they not both poacher and gamekeeper? Since the Board will be commissioning, and also overseeing commissioning by GP Consortia who must commission within the any willing provider framework, will the Board be similarly constrained? While GP Consortia’s behaviour is subject to oversight by the Board in respect of commissioning decisions, the Board appears not to have any oversight in this respect (apart from the usual warm words that folks will consult and work in partnership, etc.) My worry is that the collective effect of GP Consortia commissioning may have some relationship with the desirability or not of specific national or specialist service commissioning. I am also worried about the logic underpinning what national and specialist in fact are, as this type of thinking is really ‘old school’, and is a remnant of centrist thinking. The epidemiology and service logic at work here could also find itself at odds with the possibility of unbundling and decentralising or otherwise restructuring such services (where capabilities, technologies, and opportunities present themselves), a possibility that innovation might unleash, but which cannot be anticipated by this particular solution. As well, we are too aware of the failure of prestigious providers to fail in their quality (do we need to mention neonatal heart surgery?)  So the assumptions underpinning the centrist logic of national and specialist commissioning should fall both within the remit of CQC and Monitor and under the wing of GP Consortia.

The proposed NHS System Governance System, 2014

Apart from all the other things that the Board will do (a very long list) adding into this mix managing commissioning relationships with providers seems not just a task too far but a source of considerable and likely conflict. This is to say absolutely nothing about how they will handle the commissioning of GP and other primary care services, which entails commissioning services from people that, in an different guise as GP Consortia, they in effect regulate.

How to do that? Well… Critical to effective commissioning is ensuring that adequate analytical capacity exists at the levels at which decisions are being made. If, and I see no reason to doubt this, GP Consortia do their jobs well with excellent analytical capacity to inform their decisions, they can, in some collective form, create an appropriate structure to handle the commissioning of national and specialist services. This will ensure the better integration of commissioning decisions, smooth the flow of patients and resources across the borders of GP Consortia, and clarify referral protocols. It will ensure that these national services are really national or specialist and are governed by common standards of regulatory oversight. Importantly, it avoids the potential for gaming the system, as it removes an incentive for providers to lobby for the creation of national or specialist services as a way of protecting their service infrastructure, and ensures that any complacency in service quality improvement is avoided by being able to for specialist providers to forum-shop for a regulator.

Visualising Influence

The Policy Cognologist also maintains a European policy blog, Euro-Sante/Euro-Health. Waggener-Edstrom Worldwide conducted a study of the most influential policy oriented blogs in Europe and I am delighted that my blog was rated amongst the most influential specialist blogs.

There is also activity on Twitter about the influence of the blogs in the study in the EU at #bbs10. You can also request a copy of the report with ratings of all the blogs, specialist and general at Waggener-Edstrom.

The report makes for interesting reading. One observation is the relative greater influence of generalist policy blogs over specialist ones; the highest rated is written by someone from the BBC. Others by folk with less illustrious affiliations, but no less important things to say.

I am pleased though to be counted amongst such company.

Overall, the blogs represent efforts by many people across Europe to put ideas forward with varying degrees of success or recognition. The world wide web creates amazing opportunities for fresh ideas to be presented in easy and accessible forms. Blogs can be updated quickly and with RSS feeds, interested individuals can receive notifications of new posts. Whether internet search engines effectively identify blog entries is another matter. Blogs operate in the real world in real time and with rankings such as Waggener-Edstrom’s, the task is much easier for bloggers with important things to say to be heard.

On a cautionary note, policy processes within the EU and government depend on having accessing to fresh ideas and knowledgable people. But in my experience, they can fail to engage with emerging influencers, as well as with individuals who lack official, recognised or organisational positions to give them ‘organisational cover’ as it were. Influence and quality of thinking depends more on the cogency of the writer’s knowledge and ability to craft succinct argument, than the reputation of their employer (and perhaps the EU puts too much emphasis on the latter).

Daily we read of the debts that governments have run up, whether Greece, Hungary, UK or elsewhere. How has this come to pass will require all of us to reflect on what we expect from government and indeed what is government for. Folks such as Robert Nozick argued for the minimal state, all the way over to the bankrupted ideology of the collectivist state. In between lies reality.

Therefore, in the spirit of redefining the purpose and function of the modern state, I am asking this question:

what are the Grand Challenges for modern government?

In effect, what is the purpose of government? What is on the list will reflect the current priorities, but also an effort to anticipate the consequences of current actions by public bodies — if governments stop doing some things, what will happen down the road.

Here is some to get us going. I think we need 10 at the most as they must in the be both grand and challenges; my list may in the end be neither, but let’s see.

Like any good challenge, one needs to know what is in the problem, what is outside the problem and line that demarcates the two

1. A challenge is to ensure that governments are subjected to the same rules and regulations as everyone else.  Someone said, it would be a shame to waste a good crisis, so many governments find themselves in a crisis, and in many cases they are part of the problem, not part of the solution. Governments have some role to pay in aligning efforts to solve the crisis, but they are not exempt from the solutions.
2. A challenge is to design a simple tax system. We don’t need governments to create complex, full of exceptions tax systems. We have complex tax systems that have becomes ends in themselves, inscrutable and reflecting overly bureaucratic approaches. Rebooting our logic of taxation is a non-trivial challenge. The problem though is that governments use financial instruments as carrots and sticks to alter behaviour, whether of individuals or corporations. We need to rethink our use of financial instruments as tools of policy and that these financial instruments must deliver social outcomes, not just be used to fund government programmes.
3. A challenge is to better control adventuresome, rent-seeking behaviour of civil servants.  Too often, hyperactive civil servants follow a logic of state intervention because in the end it may be easier to do and please political masters, than to do the harder, consultative and more developmental approach which will produce the best outcomes, but with the least amount of government. The problem is that civil servants are rent-seeking, and are rewarded for expansionist activities. We see this with regulators who either do their jobs badly (regulators are after all monopoly suppliers of regulation, so if they do a bad job, we the regulated have little choice), or seek to expand the scope of their mandates, like a gas (there is always some reason to expand a mandate, when there is no one to say no). To be fair, the private sector also has adventuresome corporate executives who need to prove themselves through adventuresome corporate mergers and acquisitions — fortunately they don’t always get their way, such as the shareholder response to the plans of the relatively new CEO at Prudential (on the job only 5 months and he thought this made sense). The challenge here is a general problem, but acute in government.
4. A challenge is for governments need to know how to recognise market failure, and having identified this, decide what they should do it anything. Is there market failure in funding medical research, is there market failure in higher education? Understanding this will help define the boundaries of the government role, and importantly define the boundary conditions that tell us that different logic and problem solving is needed. At the root, we need to  first decide what the role of government should really be. Integral to this is determining a proportional response — in other words, there is identifying the need for intervention, and there is separately deciding what to do, how much to do, and importantly when to stop.