Editorial

Those of our readership above a certain age may recall a terrifying scene in the film Marathon Man, where Laurence Olivier, playing an ex Nazi dentist, was torturing an American student, played by Dustin Hoffman. He was probing his teeth and touching nerves, without any anaesthesia, while repeating the question “Is it safe?” Part of the horror of the scene was that the helpless victim had not the slightest idea what the question meant and was thus unable to satisfy his tormentor. This scene (inappropriately, I am sure) came to mind when I read the proposal for the new inspection regime by the Care Quality Commission. ¹ It will build the new system for inspection around five questions about care:

Is it safe?

Is it effective?

Is it caring?

Is it responsive to people’s needs?

Is it well-led?

While previous systems and standards have genuinely sought to answer these questions, the problem is essentially the Marathon Man problem – what do the questions actually mean? What should inspectors expect to see, read and hear of the care they review and how can they assure themselves that the evidence they use is reliable? Confidence that the new approach to regulation will crack this particular nut is based largely on two changes: the deployment in inspection teams of clinical and specialist expertise (rather than generalists) and the development of standards measuring the “fundamentals of care”, as recommended by Robert Francis QC in his inquiry into care at Mid Staffordshire NHS Foundation Trust. ² Getting the balance right between a rigid system of standards and compliance and a more laissez-faire approach, allowing local interpretation, has challenged the search for an effective quality inspection system for years. Perhaps the mantra of “we must move from the tickbox mentality” has contributed to a lack of rigour in defining the essentials of care and how they can be recognised and measured by staff and patients, as well as through outcomes and process data.

At the time of writing, there is outrage at the alleged suppression and deletion of a critical report into events at Morecambe Bay NHS Foundation Trust. ³ The furore around the role of the regulator and its relationship with the Department of Health is an unwelcome and potentially costly distraction from what matters to patients. We must hope that the new regime delivers a system where we can focus on patient care, what works and what doesn’t and how NHS managers and clinicians can put things right, where necessary. Most importantly, as pointed out by Robert Francis in an interview on the Today programme on BBC Radio 4, we need to ensure that this process occurs in the public domain with full candour to patients, openness with the public, and transparency on the process itself. The consultation on the changes to the inspection regime is open until 12 August 2013. ⁴

In this issue, there are two excellent examples of how NHS services can be responsive to differing needs in complex circumstances and how they might seek to improve those responses. Jim Blair writes about the special circumstances of patients with learning disabilities attending Accident and Emergency departments and the consequences that insufficient attention to these specific needs can have. The niceties of correctly interpreting and communicating laboratory results are explored by Tim Wreghitt. Finally, we have included an overview of the role of the new improvement organisation, hosted by NHS England. An important part of their role is to support change and improvement through working closely with NHS staff.

Perhaps truly proactive approaches to listening to staff and patients, combined with open discussion and attention to the detail of the changes needed, may make it less frightening to hear the question: “is it safe?”.