The myth that will not die?

I’ve seen Don Berwick speak many times, at the Kings Fund and IHI conferences, and it is always a pleasure to hear his well constructed, intelligent presentations delivered with that uniquely american “folksy” charm he shares with other great communicators from across the Atlantic.

His keynote address (link here) questioned why people (particularly politicians) still believe that it is possible to deliver high quality through “inspection” performed by regulators. It is the stock reaction to every failure in the public sector or any sector that has an impact on the public; how often have you heard “this must never happen again – the regulator has failed and we must” either i) “do a ‘root and branch’ review” or ii) “abolish it and setup a better one”?

Don Berwick argues against reliance regulators on the grounds that they generate fear, control of information and a lack of transparency amongst the regulated. Worse, the over reliance on external control stunts the internal development of quality improvement and innovation.

I would add another reason – because external quality control doesn’t work because of weaknesses intrinsic to every regulator and the organisations they regulate. In “The Challenger Launch Decision” by Diane Vaughan, the author describes the failure of safety regulation which was one of the causes of the Challenger launch decision and subsequent tragedy. The culture within NASA and its subcontractors was open, professional and not one of fear. She suggests that the regulatory system still failed for two reasons :

  • autonomy of the regulator, while giving objectivity, meant that the regulator had limited access to information and often lacked the specialist skills to interpret it.
  • this reinforces interdependence of the regulator and regulated organisations, where there are shared goals and sharing of specialist resources. This led to the regulators becoming a part of the regulated organisations culture resulting in negotiation and management of safety issues rather than discovery and sanctions.

When we look at recent NHS “never again” healthcare disasters (for example Mid-Staffordshire NHS Foundation Trust) we see the same issues in play.

So we must ask, if the definition of insanity is doing the same thing over and over again and expecting different results, why the knee jerk reaction to poor quality of service, or worse, is to setup “better” regulators? It doesn’t work, never has and never will!