Thursday, 17 July 2014

Ofpiss- the role of inspectors in the public sector

There was yet another item on the Today programme this morning about the CQC (Care Quality Commission). Presumably it detailed more "worrying findings" about the nation's healthcare system- I wasn't really listening. Instead I got to thinking about the similarities and differences between Ofsted, CQC and the like and organisations like Ofwat, Ofgem, Ofcom and the FSA.

On the face of it the two groups of bodies perform the same function: ensuring consistently high standards in the area of their remit. However the differences are actually quite significant. Let's start (appropriately) at a linguistic level: Ofsted and CQC inspect, the others regulate- quite different words. "Regulate" implies a far higher degree of intervention than "inspect" since, etymologically, regulation imposes "regulae" or laws whereas inspection merely involves looking in. The implication is of course that regulation is an end in itself whereas an inspection is a precursor to some other action. Except that that isn't quite how it works any more.

To understand the similarities and differences better perhaps it would be useful to draw an analogy. Consider all of the bodies listed as medical professionals who carry out diagnostic tests. However they would have to be very different sorts of tests in very different contexts. Ofwat, Ofgem and the like seem most like the dope-testing officials who accompany the Tour de France. Their job is to ensure that there is a level playing field between competitors and that no one gains unfair advantage through dubious or underhand tactics. The analogy is actually quite a good one in many ways: like the financial bodies regulated by the FSA cycling teams are always one step ahead of the testers in finding new and sophisticated ways to beat the system. Like them too they are prepared to sacrifice any notion of honesty, ethics or fairness in pursuit of a competitive advantage. If Lance Armstrong hadn't been a professional cyclist he would probably have been a derivatives trader.

Once the regulators have identified misconduct there are a range of sanctions they can apply. Here of course the analogy does not hold so strongly: no lifetime bans from Ofgem or the FSA. Rather it is as if Lance Armstrong had been told to pay back 25% of his winner's fees and asked to try not to cheat quite so much in future.There are other ways in which the analogy is not perfect: The anti-doping doctors in the Tour de France don't work as cosily with the cyclists as UK regulators seem to with the industry bodies they regulate.However for the purposes of this post the analogy will do.

Ofsted, CQC and the other inspection bodies that work with public services would be a different set of medical professionals entirely. They would be more like the staff who carry out universal breast cancer screenings on middle aged women. Again, the analogy fits well in places: the process, which takes place every few years, is unpleasant, occasionally painful and involves exposing ones intimate secrets in front of strangers. When it works it identifies problems buried deep within the body politic that have the potential for catastrophic effect. However the process can also over-diagnose and doctors can identify as cancerous, cells which were actually growing healthily.

Like women facing breast cancer screening, schools and healthcare trusts engage with the process surprisingly willingly, being polite and well-mannered as the staff involved place their tits in a vice. The analogy isn't perfect, mind. I have yet to hear of a woman recalled for a second mammogram before then being told, "You know those cells that we said weren't cancerous? Well they're not, but my boss thinks they might be a bit Muslim."

However the biggest area in which the analogy falls down is in terms of what happens when the process is complete. Following a mammogram the patient will be offered a range of treatments, from watchful waiting to full mastectomy, radiotherapy and chemotherapy. In enlightened GP practices they will be offered counselling too, pointed to a range of support groups and given a host of useful literature. This will all be done in an atmosphere of professional discretion. It will be up to the patient who they do or do not tell that they may have breast cancer.

Not so the school or healthcare trust. Their "failure" will be broadcast far and wide for all to see, and in particular any existing or potential staff or students/patients. They will be asked to come up with their own "recovery plan", which is like a cancer patient being given a kitchen knife and a self-help book on breast surgery, or be paired up with a more "successful" school or trust. That is rather like the GP taking the patient into the waiting room and saying, "See that woman over there? She looks pretty healthy. Why don't you ask if she's got any tips?"

It didn't used to be like this of course. I can only talk about what education used to be like, but I am sure healthcare was similar. There used to be HMIs, highly skilled and experienced professionals who would work with schools in difficulties without pre-judgment. Local Education Authorities had teams of advisory teachers who could go into schools and there were a variety of LEA-run centres where teachers could go for support and interaction with their peers. These systems were very variable in quality of course, and no doubt some were pretty useless, but now there is absolutely nothing. It is as if, because some treatments for breast surgery had poor results the NHS just decided to pull them all. Leaving the patient, whose (possible) cancer has just been broadcast to the world, twisting in the wind.

Partly this is down to cuts at all levels of the civil service, both nationally and locally. Partly though it seems to be recommended neo-con policy. The state, it appears, is the problem and therefore cannot be the solution. Even were the staff there to carry it out neo-cons seem to argue that State bodies (like HMI and LEA advisory teams) are by definition incapable of improving public services. Only the market is capable of doing that. Where a public service institution has failed or is failing, the neo-cons believe, instead of the heavy hand of the State intervening and making things worse with standard and unresponsive interventions the institution itself should be free to access the support it deems most appropriate itself.

There is a strange logic behind this argument, or might be if things were done rather differently following "failure" in an inspection. In fact, far from being free to access the support it requires, the "failing" institution will suddenly find its freedom to do anything much drastically curtailed. Its head may well be summarily dismissed, as may its whole governing body (or equivalent). Furthermore, it may well (in the case of a school) be compulsorily converted into an academy, with or without the support of its staff or users. There will be little or no additional funding available to finance additional support (because that would be seen as rewarding failure) and any distinctive character the institution might have had prior to its "failure" will be seen as fair game- renaming is, for instance, often a favoured option. And if none of that leads to improvement there is always enforced closure- the institutional equivalent of euthanasia.

Is it any wonder that, far from swallowing the line that inspection by Ofsted or the CQC is the key to driving success in education and health, many professionals in those sectors simply want their inspectors to piss off? It is not that they are afraid of scrutiny, or oblivious to the need to ensure good and consistent standards. It is simply the feeling that if a medical test doesn't lead to the offer of any treatment, what is the point of enduring it in the first place?

By coincidence, later in the same edition of the Today programme there was an item about Switzerland stopping its universal breast-screening programme. Doctors there have concluded that, whilst the screening might allow early intervention that may save some patients' lives, the cost in terms of anxiety, stress and unnecessary treatment arising from over-diagnosis is too high. A doctor interviewed on the programme reminded listeners that they can choose to opt out of breast cancer screening should they so wish.

The problem for public service institutions like schools or hospitals is that they do not have that choice.

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