In a recent radio broadcast Kevin Fong explored how helicopter emergency medical services became the most dangerous occupation in American. Cost, training and safety were implicated in a surge in the number of incidents, but an additional potential cause was regulation: or rather that the emergency helicopter medical service is largely deregulated.
This suggests there might be a link between regulation, or the lack of regulation, and failure in healthcare services. So at first sight it appears that having regulated health services should be a good thing. After all, failure in healthcare can have severe and critical effects on any of us. There are also implications for our attitude to regulation and deregulation. In this article we focus on regulation in healthcare – not just air ambulance safety.
Mention regulation and you are likely to hear cries about it being burdensome and stifling of innovation and enterprise, and being too much red tape. Red tape, in particular, incites emotive negative attitudes; and yet it is crucial to the efficient and popular healthcare system we enjoy in the UK. Our NHS relies on bureaucratic conformity to the small print. However, listening to the arguments about red tape makes it seems that it is a recent innovation. This is far from the truth. Red tape was used in the time of Henry V111; he with the six wives. His petitions to the Pope to have his first marriage annulled were bound in a red ribbon-like tape. Having sent eighty or more red-taped petitions to the Vatican, it is not surprising that red-taped paperwork began to be considered as excessively bureaucratic and burdensome. Whether healthcare regulation is bureaucratic and burdensome is another matter, but it does impact on the success or failure of the care we all expect to receive.
The difference between success and failure in healthcare depends largely on having educated and trained professionals and their co-workers. Modern healthcare also relies on tools, machines and medicines. And of course, healthcare professionals and their co-workers’ scope of practice, their technical gadgetry and medicinal substances are provided within an organisational structure. Each of these three elements is heavily regulated in the UK to ensure that, mostly, healthcare is controlled, efficient and above all safe.
Of course this is not always the case. The Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry chaired by Robert Francis QC (2013) points out that the Healthcare Commission’s system of regulation – and there was a lot of it - failed to detect or prevent the ‘biggest scandal in NHS history’ (Francis, 2013, p. 54). He didn’t call for more regulation or deregulation, but he called for a ‘simpler regime of regulation’.
Regulation in healthcare is essential and has a vital part in ensuring our safety. Like red tape, regulation of healthcare provision is not a modern invention. As far back as the Fifteenth Century Henry V was asked to approve regulation so that only those with medical qualifications could practise as doctors. While the King was sympathetic to this simple attempt at regulating medical practice, a shortage of doctors prevented the implementation of the petition (The Health Foundation, 2016). It seems regulation wasn’t quite so simple after all.
At Mid Staffs regulation was complex and multifaceted and, curiously, systematically unregulated and uncoordinated. The result was a failure to place quality of care and patients at the heart of healthcare. The NHS Foundation trust was at fault, as was the system of regulation. While the senior management and the Department of Health set the culture of the organisation where focus drifted away from the primary purpose of their provision, caring for patients, there were also shortcomings in how healthcare professionals, the doctors and nurses on the ground, were regulated.
Simple regulation would aim to protect patients by providing a register of practitioners who carry out a defined type of work. It would allow information sharing in the public interest. Simple regulation would also ensure that if a practitioner was unfit to carry out their healthcare duties they can be prevented from doing so, or concerns be raised. This would necessitate a register of healthcare practitioners. Yet these conditions mirror closely what already happens.
The General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) have simple regulation in the terms suggested above. The GMC and the NMC govern and regulate how doctors and nurses and midwives respectively practise. The GMC’s role is to protect patients through good medical practice, high standards of medical education and training, registering qualified medical doctors and managing doctor’s fitness to practice. The NMC’s aim is to safeguard the health and wellbeing of people using or needing registered nurses’ services. It too keeps a register, sets standards of education and training and ensures they are met, and investigates allegations made about registered nurses and midwives. Few people would argue that such regulation is unnecessary, while some might argue that it is so self-evidently desirable that regulation is unnecessary. But while it is simple in its aims, implementing such simplicity is a highly complicated process with scope for failings.
Francis addresses many of the concerns. In this article it is suggested that while simple regulation has merits, being uncomplicated and having simple aims: public protection and fit for purpose services, and equipped professionals, in practice what is needed is far from simple. Regulation needs to be more integrated so that healthcare professionals are regulated to:
- Work together, share information and concerns, and address them collectively
- Limit self- assessment and self-declaration, while challenging any claims of compliance
- Vigilance to ensure standards are observed across professions and services
- Give regulation a chance to embed itself
Failings in regulation do occur. While having simple regulation might be desirable it is questionable if it is will do what is expected. Perhaps it is integrated regulation that is required to enable a modern and complicated healthcare to work with us to provide our healthcare needs safely. So whether you are an air ambulance medic, a King seeking a marriage separation or a member of the general public in need of healthcare, regulation is one of your best friends even if it still comes wrapped up in red tape.