The I in the new CHAI

The Secretary of State for Health of the United Kingdom has issued a rallying call to “unleash the spirit of public sector enterprise.”¹ The problem, however, is that the current regulatory environment tends to reinforce a culture of compliance rather than enterprise. This risks a vicious cycle in which trust is undermined through an overbearing approach to accountability.² This month the Commission for Health Improvement (CHI) published its corporate strategy for itself and its transformation into a new super-regulator of health care.³ But behind the fine words of the strategy lie major obstacles.

The NHS Reform and Health Care Professions Act 2002 expanded the remit of the commission and gave it more “teeth.”⁴ It requires the commission to publish information on performance and a revised star ratings system (from next year). It also gives the commission new powers to recommend franchised management, suspension, or closure of any service found wanting. In April 2002, the government announced plans for a new Commission for Healthcare Audit and Inspection (CHAI) to subsume the existing Commission for Health Improvement and incorporate the audit commission's value for money studies in health and responsibilities for inspecting and licensing private health care.³ The new commission is likely to take shape in all but name in April 2003.⁵

If this is the start of a process of rationalisation and consolidation in the crowded regulatory field it is to be welcomed. The opportunities for linking performance data to a more tailored and targeted programme of inspections are notable, and it is good to see the regulation of the private and public sectors being tackled together. But rationalisation is not just about redrawing organisational boundaries to create an impression of common purpose. Underneath the new corporate wrapping there needs to be a simple and clear new whole. For the new commission, achieving this will mean overcoming confusion on three counts over its purpose, approach, and place in the wider regulatory and political systems.

Firstly, confusion may arise about the new commission's purpose. It will have four roles: setting standards (with the Department of Health), audit and inspection (of performance, clinical governance, and finance), improvement (alongside the Modernisation Agency), and enforcement (working with strategic health authorities). There are tensions here—setting standards, auditing compliance, ensuring improvement, and enforcing remedial action mean acting as lawmaker, prosecutor, judge, jury, and probation officer. The new commission is on its own in being asked to combine these roles, whereas other bodies (such as the regulators of healthcare professionals) are separating and clarifying the boundaries between these tasks.⁶

Secondly, these multiple roles require the new commission to adopt different and contradictory approaches, which in turn imply different and competing conceptualisations of effective regulation. For example, the process of auditing organisations' compliance with government targets implies one style of regulation—summative, quantitative, punitive, and centrally driven. It places the locus of accountability on individuals (usually managers) and views change as a managerially driven process. Alternatively, to look at the quality of care across whole health systems, or to hold a mirror up to healthcare organisations, suggests a different style—formative and qualitative.⁷ It places the regulator within a local process of enabling and facilitating improvement.

Thirdly, the new commission's place in the wider regulatory and political system may lead to confusion. However successfully it manages to resolve internal tensions, it also needs to locate itself clearly amid a still confusing array of different bodies with different underlying approaches to regulation.⁸ Here the new commission (like the healthcare organisations that it visits) shares responsibility with others, including government, for seeing things through the eyes of consumers rather than advocating responsibility at the organisational boundary.

Consequently, the new commission is faced with three challenges: clarity of purpose, coherence of approach, and independence from government. Achieving clarity means that “CHAI” has to choose a conceptual focus for its activities. The “I” in old “CHI” stood for improvement; in the new commission it currently stands for inspection. An emphasis on inspection implies a harder edged and more bounded identity. This is a misguided emphasis; inspection is just one element of a more developmental and holistic approach to improvement.⁹ CHI needs to do battle over the “I” in the new CHAI.

To achieve coherence the new commission will have to dovetail potentially contradictory roles and approaches. If it wins the day over ensuring that improvement remains its characteristic stripe then coherence may be within its grasp. This will, however, entail casting off some of the regulatory burden that has already accrued over the Commission for Health Improvement's short life and radically changing the way in which it undertakes some of its new obligations, such as the star ratings system.

The third challenge, which underpins attempts to meet the first two, is for the new commission to achieve meaningful independence. As in the rest of the NHS the independence on offer is a deal that emphasises central control over direction in return for the lesser freedom over how to travel. For example, the government will pick the targets used to determine star ratings while allowing the new commission the freedom to adjust the methodology.¹⁰ The political attraction of such a position is that it will allow the government to present the new commission by turns as evidence of government toughness as well as testimony to its new devolution of power.

The secretary of state argues that there is no contradiction in this sort of third way stance: “Where there are persistent problems we will step in—where there is progress we will step back.”¹ But does this simply hide a central uncertainty at the heart of New Labour's mindset? Does the government have a sound model for thinking about how change happens and who should be responsible for ensuring its achievement?

The new proposals for the Commission for Healthcare Audit and Inspection mix up independence and developmental intent with a limited and tightly controlled political mandate. The danger is that healthcare professionals will experience this type of regulatory hybrid as a bewildering set of contradictory messages. Processes that inconsistently redefine the relationship between professionals and government risk paralysing rather than unleashing the “modernisation” of both the service and its professional ethos.