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The Box That Ticked Itself

24 May 2019
 

A little note for regular readers from Andy B - You may notice that the layout of this blog has changed a little. In fact, the whole website has. That's not all that's changed though. The Easier Inc. team has been growing and it's my pleasure today to be able to welcome Jeremy Cox as an Easier Inc. Partner and author for this blog. Over to Jeremy.

I'm delighted to introduce myself via this blog as I join Easier Inc. as a Partner, and I’ll kick off with the thorny topic of regulation - no point paddling in the shallow end...  

The topic resonates because I've recently completed a fixed-term contract with The Care Quality Commission (CQC, England's health and social care regulator) as their first Director of Quality Improvement, establishing an internal quality improvement strategy. It means I'm in the happy position of having seen regulation from all three ends of the telescope (I’m not a fan of dichotomies, especially false ones):

  • I have been a Regulator (at CQC)
  • I have been a Provider (as a school governor and leader in financial services)
  • I have spent many years working for clients in regulated services as a consultant/expert advisor

My most important insight is this - both providers and regulators want to do good work and make services to customers and citizens better, but the relationship is usually pathological rather than generative. Providers fear regulation (which usually manifests itself as inspection and rating) and end up damaging services by spending time and effort on compliance. Here's an example, picked from LinkedIn, of consulting services that feed on and reinforce this pathology: 

“Are you Inspection ready? Want to feel more confident and relaxed when CQC or the Local Authority walk through your service door? With bespoke monitoring tools, inspections, repeated success and proven results let us support you with all your care, quality and compliance needs.” 

The challenge for providers 

As a school governor, I would regularly challenge the “what will Ofsted look for?” mantra from staff, governors and external educational consultants alike - constantly searching for information from other schools on what Ofsted asked and observed on recent inspections. All this seems plausible, but my question is whether the purpose of a school to keep Ofsted happy, or to concentrate on teaching and learning; helping children to become skilful and enthusiastic learners, good citizens, and well-balanced, empathetic human beings? If you do the latter, you will smash the inspection, no matter what specific criteria are applied. If you focus on 'inspection-ready' then teaching and learning ALWAYS suffer. 

The challenge for providers is to find ways to deliberately shift away from this pathological "face to the inspector, backside to the customer" stance. The way to do this is to understand and design for the real needs of customers. The logic is: 

Easier -> Better -> Faster -> Cheaper -> Regulator

...in that order (I've tweaked Shingo here).

You must keep track of compliance with the regulations in the background, whilst engaging proactively and purposefully with your local inspection teams and national leadership to ask them to help you to learn and improve.

I know this sounds like rainbows and unicorns, the world just isn't like that is it? This is easy in principle, difficult in practice, but it most definitely can be done. Helen Sanderson and her great people at Wellbeing Teams have proved it with an unprecedented 'Outstanding' rating on their first inspection for a new home care service. It was achieved first and foremost with a relentless focus on doing what mattered for their clients, building a systematic self-management culture of responsible practice, and putting in a big effort to engage up and down the CQC hierarchy to explore the innovative model of care that was being created. Easy in principle, difficult in practice - not rainbows and unicorns but clarity of purpose and principles, service design anchored in the real needs and strengths of clients, and not least a lot of hard work. 

The challenge for regulators

Regulators for their part tend to rely on methods that reinforce the power imbalance with providers, perpetuating the pathological dynamic. Inspection and rating is the most obvious example. Senior and front-line staff in the regulator can rationalise "make the inspector happy" behaviour as bad people doing the wrong thing. This cognitive shortcut is easier than working through the counter-intuitive truth that a pathological response to inspection is a predictable human response and thus a systemic problem. The challenge for regulators is summed up by Peter Senge:  

"Structure produces behaviour, & changing underlying structures can produce different patterns of behaviour.” 

I know from personal experience that there are good people in CQC who see this problem and are working hard on relationship management and encouraging improvement - the problem is structural.

Don't take my word for it...

In 2018 The King's Fund published Impact of the Care Quality Commission on provider performance: Room for improvement?. The report described eight methods for regulatory influence:  

  1. Anticipatory - Regulator sets quality expectations, provider seeks to comply in advance of regulatory interaction e.g. clarify strategy before inspection visit
  2. Directive - Providers take actions directed or guided to take by regulator, including enforcement, restriction, cancellatione.g. regulator closes GP practice
  3. Organisational - Regulatory interactions lead to internal organisational developments e.g. QI capability building programme initiated
  4. Relational - Informal, soft relationships between provider & regulator e.g. ‘engagement meetings’ to discuss challenges & plans
  5. Informational - Regulator collates intelligence & places in public domain e.g. independent voice publications, public review ratings & inspection reports
  6. Stakeholder - Regulatory actions encourage other stake holders to take action e.g. NHSI support for improvement after CQC interaction with provider
  7. Lateral - Providers stimulated to work with peers e.g. provider staff encouraged to take on inspector roles, collaboration between providers to share learning
  8. Systemic - Systemic / inter-organisational issues identified & acted on mental health legislation changed, place-based inspections tested

When we look at regulation through this lens, inspection and rating starts to look like a blunt instrument indeed. Some quotes from the King's Fund report:

“Between 2015 and 2018 we examined how CQC’s inspection and rating model was working in four sectors (acute care, mental health care, general practice and adult social care) in six areas of England. We found examples of all eight types of impact in our framework, although some were more prevalent than others and there were differences between sectors.

"We also tried to measure the impact of CQC inspections and ratings quantitatively and identified only small and mixed effects.”

“We found that CQC’s approach works in different ways in different parts of the health and care system. When CQC identifies a problem in a large hospital there is a team of people who can help the organisation respond, but for a small GP surgery or care home the situation is very different. We recommend that CQC develops its approach in different ways in different parts of the health system with a focus on how it can have the biggest impact on quality.”

The research highlighted the importance of CQC investing to equip the workforce with the credibility and skills necessary to “foster improvement through close relationships, while maintaining consistency and objectivity". The report also warned that the focus on inspection and rating could have crowded out other activity which could have a greater impact, and recommended that the CQC focus on regular, less formal contact with providers. 

Rainbows and unicorns? Not if regulators grasp the nettle of moving from pathological to generative. Not if providers design from the customer back. Not if provider and regulator decide to work together with the 'Pathological to Purposeful' model as a framework to drive sense-making, learning and improvement. 

What Now?

Here are some simple, practical suggestions for moving from pathological to purposeful (or as we would say, from Harder Inc to Easier Inc): 

  • Take Responsibility - whether you are a provider or a regulator, reach out and work with your opposite number to correct the power imbalance, make it a joint endeavour, at whatever level of influence you can exert.
  • Be Pragmatic - the regulator will be stronger & slower than the provider, don't expect miracles, but do demand engagement.
  • Stay Principled  - use ‘pathological to purposeful’ & the Eight mechanisms as a frame for conversation, sense-making and exploration.
  • Innovate  ‘inspect & rate providers’ won’t cut it any more - find and connect with the people in your regulators who are interested in regulatory innovation and provider innovation. 

To summarise, regulation has a big effect on our public services. When we focus on keeping the inspector happy,  pathological relationships result and 'inspection-ready' consultants feed off the fear and stress that abounds. When we design services to meet the real needs of customers, and regulators engage generatively to encourage improvement, it turns out that the boxes tick themselves, and services improve.

If you want to find out more about the issues explored in this blog, and what it means to approach regulation with a generative mindset here are a few things you can do:

  • Read the Health Foundation report mentioned above.
  • Go deeper into the reasons complex organisational systems require flexible and collaborative regulation. Start with this report Toby Lowe has just published on practical insights for funding, commissioning and managing in complexity - it's just as relevant to regulation.
  • Consider reading our earlier blog on the subject of accountability. It contains a couple of resources that are useful for engaging others in thinking about this issue and which are also useful as a framework for marshalling our own actions. You can find the blog here.

And last but definitely not least, if you are thinking of picking up the phone and calling in the 'inspection ready' experts please don't. Take a deep breath and call me instead, and we'll talk about easier ways of organising so that the boxes tick themselves. 

Thanks for reading!


Comments

Mark Cannon

24/05/2019, 09:05 am

For yur first blog, Jeremy, you have set the bar very high.  Excellent, thought provoking read. I look forward to reading the others.  Easier Inc have added a major asset in you.  Congratulations and good luck to all of you.

Jeremy

24/05/2019, 10:05 pm

Many thanks Mark, I'll try to keep the level up!

Reply to this comment

Mark Smith

24/05/2019, 11:05 am

There I was, merrily blogging away and then Jeremy comes along and shows me how to do it properly. This isn’t diverting and affirming, it’s really bloody useful. Well done and good luck in your new role.

Jeremy Cox

24/05/2019, 10:05 pm

That's v. kind Mark - much appreciated!

Reply to this comment

Stuart Bullock

24/05/2019, 12:05 pm

A well written and thought-through blog Jeremy. Content rich and useful take always for all.

Jeremy Cox

24/05/2019, 10:05 pm

Thanks Stuart - think the issues apply across many sectors - health & social care, housing, police, schools, utilities, financial services... hope people can see the relevance to their world.

Reply to this comment

Harry Longman

24/05/2019, 05:05 pm

Great blog Jeremy and does help to humanise regulators.

But there are very big if's.  If the regulators... and I'm afraid they have to change first, as they have the power.

I've come across two cases in the last week where CQC has in one case destroyed and another case demoralised two very good GP practices.  One of them the best I've ever analysed in terms of access, continuity, patient satisfaction and leadership.  But then, CQC had other things to measure.

Jeremy Cox

24/05/2019, 10:05 pm

That's definitely an issue Harry for sure - you are dead right about the power imbalance - it's incumbent on regulators to honestly understand this issue & their impact, and take the lead in improving effectiveness.

Reply to this comment

Peter W

26/05/2019, 08:05 am

I was a Health and Safety inspector between the 80s and 00s.  We had immediate prohibition powers and unlimited fines plus 2 years imprisonment as our ultimate sanction.

Around 1993, after we went further into Europe, some enlightened souls at the top realised that the 'faults' inspectors were trained to find were manifestation of managerial and organisational failings, so sending a list to fix never changed the underlying problems that caused them in the first place.

We were trained to reframe 'this floor is slippery and dangerous, fix it' to 'why has the management here created a culture where a dangerous floor isnt reported and resolved automatically? Fix the management failings'

We had to learn to reassess how to inspect, but most of us realised that the old way was futile and counterproductive. 

Jeremy Cox

27/05/2019, 06:05 pm

Peter, thanks for posting your comment. That's an interesting reflection -  a reminder that we must treat inspection as just one of any number of methods that regulators have at their disposal, Critical evaluation of our methods of regulation, in partnership with the public, providers, academics et al is what really matters.

Is regulation effective? What can we do to make it more effective?

Peter W

31/05/2019, 04:05 pm

Hi Jeremy.  In relation to the question 'is regulation effective?' there are different perspectives on what 'regulation' is that makes it a hard one to answer.

We're all regulated, by the police, HMRC, TV Licensing people etc, and life goes on.

The regulation that I've done during my career is effective against people who are a danger to the public through either their ignorance or, more usually, deliberate taking of shortcuts or outright criminality. 

Outside of this pointy bit at the top of the pyramid occupied by dodgy people, regulation has little impact and isn't the right approach. Even before I qualified in 1984 we Environmental Health Officers had been schooled to help or train willing people to improve their business practices and reserve the big stick for the occasional badly run business that came along.

As a regulator, and as someone who provides services to the public that are externally regulated, I do find the awe in which some regulators of services are help a bit odd.  

Most of us don't fear the police or HMRC, so it seems strange that CQC and Ofsted are so revered. 

My own services are regulated by FSA, HSC and EA, and we have a grown-up relationship, warn them in advance if we're going to fail a target, and ask for their help and advice when we need it.  Regulators do get to see a load of good and great practice and are normally willing to point you in the direction of where this is to be found.

22 years ago I inherited a service that was massively underperforming and received a warning letter from the regulator (The Food Standards Agency in that case).  I’d been in post for 2 and a half hours when the letter was given to me.  Despite threatening to take the service off the council and surcharge us to get someone else to deliver it, they also offered help and support to get things back on track.  We cooperated and used their support, and things were soon back on track.

I think all regulators (should) just want things to be better, and only the dodgy and the criminal should fear them.

I haven’t seen any real evidence that CQC or Ofsted deserve their fearsome reputations, but perhaps more experienced folk can comment on that?

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