As the range and number of service providers increases and Whitehall withdraws top-down controls, the civil service will need new ways to guard against service failures. Stuart Watson reports on a CSW round table.

As public spending cuts bite deeper, the pressure on civil servants to achieve more with less grows ever more acute. Publication of the public services white paper may have been postponed, but the government’s direction of travel is clear: Number 10, the Treasury and the Cabinet Office want to increase the range and number of services delivered by non-governmental organisations, and to develop stronger internal markets within the public sector. As part of this agenda, the coalition is keen to commission more services from voluntary and community organisations, social enterprises, small and medium-sized businesses, and mutually-owned bodies.

Meanwhile, the coalition is dismantling complex top-down controls aimed at ensuring consistency in the provision of services. Ministers hope that by doing so they will be able to harness the creativity and energy of a wider spectrum of providers, and thus deliver services more efficiently and with greater local accountability.

The test for civil service managers will be to put systems in place that can maintain quality as delivery passes to a more diverse set of service providers, while avoiding the excessive bureaucracy that would undermine local autonomy and present a barrier to the involvement of smaller organisations.

A recent CSW round table, organised in association with the UK Accreditation Service (UKAS) – the national accreditation body for organisations that provide certification and inspection services – considered how public service managers can feel confident in choosing service providers, and how they can assure quality of delivery in a world of more diverse public services.

The challenge: a drawer full of standards

The Department of Health has pioneered the creation of mutually-owned service providers, and is a major patron of social enterprises. And the pressure to ensure quality in medicine is particularly acute, as practitioners deal with life-or-death situations on a daily basis. So participants began the discussion by looking at relevant healthcare issues, before branching out to consider the issues raised for government as a whole.

The round table began with civil servants considering the systems currently in place to assess and monitor service providers in the health sector. It quickly became clear that there is an enormous challenge to be overcome in creating a streamlined system that will not overburden small organisations with red tape.

Marlene Winfield of the NHS Informatics Directorate reeled off a list of the bodies assessing NHS activity: organisational regulators like the Care Quality Commission; foundation trust boards; hospital safety professionals; clinicians’ own regulators such as the General Medical Council; the primary care trusts, which oversee commissioning; the NHS Litigation Authority; and the National Patient Safety Agency.

Joan Higgins, chair of the NHS Litigation Authority, added that the NHS Confederation has identified 84 organisations asking for information from NHS trusts for regulatory purposes. “The problem is that many regulatory bodies have grown up to meet a particular need, and it has never been anybody’s job across the piece to see if the need is still there or whether they are meeting the need effectively; if they are duplicating, or leaving gaps,” she said.

This creates confusion, said Mandy Collins, deputy chief executive of the Healthcare Inspectorate Wales: “When I talk to clinicians, they say: ‘What standards do you want me to comply with?’ And they bring out a drawer full of guidance and standards that they have been issued with.”

Higgins responded that some slow progress is being made on reducing the level of duplication, but she reminded the panel that even with all these assessment tools, some failures still slip through the cracks. Last year, she said, an inquiry found that Mid Staffordshire NHS Trust had failed patients in a “shocking” manner, leaving them humiliated and in pain.

As assessment tools are streamlined and reformed, said Nuzhat Ali from NHS South East Coast, civil servants should make sure they keep gathering data through staff surveys as well as other channels. She argued that the degree to which doctors and nurses are satisfied with their work is a key indicator of clinical standards, frequently providing a warning when an organisation is failing.

Reducing the assessment burden

It is against this background of burdensome regulation – some of it effective and some not – that ministers want to introduce a raft of new service providers, many of them without established track records or a demonstrable capacity to meet bureaucratic standards.

If this policy’s aims are not to be undermined, Ali said, “the new system, whatever that looks like, needs to be a light touch system. One of the areas that I am involved in is the approval of groups of professionals who want to set up as a social enterprise. You would think it should be an easy process, but we have to apply the same, very rigorous standards that we do to other providers that are going through our foundation trust pipeline.”

At this Jana Dale, who works on organisational capability at the Department of Health, chipped in: “I think it has to be the ‘right touch’,” she said. “Not [examining] everything, but the things that matter; that will give you that assurance [of quality].”

Pat Kelly, an information assurance specialist at the Home Office, said that all her department’s suppliers have to fill in a questionnaire on their information security policies and procedures. The answers are then risk-assessed, and audits done where potential dangers emerge. However, she added that it becomes increasingly difficult to maintain standards further down the supply chain, among suppliers’ own subcontractors; and she admitted that some government departments see the Home Office’s approach as labour- and cost-intensive.

UKAS chairman Jamie Lindsay summed up the situation: “We find ourselves in a political landscape desperate for solutions that are reliable, both in terms of the user and of the minister,” he said. The solution that he offered was the development of accredited standards. He cited the example of the food industry, which involves long and complex chains of many suppliers. There, he said, a system of accreditation has been set up for organic producers, offering a lighter touch quality assurance process than would be offered by tight regulation and compliance inspections. “For start-ups, accreditation can be more fleet of foot than regulation,” he concluded.

The panel also discussed self-assessment by suppliers as a means of reducing the regulatory workload. There was some scepticism about this approach, however. “Self-assessment didn’t guarantee quality in the Mid Staffordshire case,” said Ali. UKAS chief executive Paul Stennett pointed to a study on self-assessment that found it accurate in 56 per cent of cases. This, he suggested, begged the question of what had happened in the other 44 per cent. “That is a challenge in reducing the burden,” he said.

Data gathering

Civil Service World managing director Kevin Sorkin, who chaired the discussion, asked what kind of data must be gathered to ensure that accounting officers provide accurate information to Parliament.

The Home Office’s Kelly answered that in the case of information security, the Cabinet Office is gradually moving away from demanding highly-detailed information on how the Home Office is ensuring that standards are met. “Last year they would drill quite deep down and ask us how we had done something. This year they have moved away from that approach,” she said. “There is a list of 70 things that organisations must do to meet the minimum requirement for handling government information. Now they’re trying to get to 30, the idea being that they are trying to get our accounting officer to declare that the supplier is assured.”

Winfield argued that one of the outcomes of the information revolution will be to set information free, enabling private and third sector organisations to analyse data on the outcomes of policy in areas in which they specialise, then produce their own reports.

Outcomes versus outputs

Coalition ministers committed to the localism agenda are keen to trust local decision-makers in shaping services, rather than imposing regulations designed to ensure universal quality across the board. They want to focus on a handful of results measures (outcomes) rather than numerous measures of actions performed (outputs). The panel discussed the implications of this approach. Can quality be assured without close examination of suppliers’ processes?

Lindsay said that there are examples of accreditation regimes that are outcomes-driven. He pointed to the certification schemes for gas boiler fitting and maintenance – formerly known as CORGI and now called Gas Safe –which are all accredited by UKAS. “There is an absolutely open field in how you become accredited; there are six different processes,” he said. “What we assure ministers is that those processes will all deliver the desired outcome.”

Higgins spoke up in favour of process, however: “Looking at it from a negative point of view where things have gone wrong and there is a question of compensation, then it’s absolutely critical that we look at process: at who did what and what their liability might be,” he said. “When we look backwards and try to unravel what went wrong, both process and outcome are important.”

Lindsay responded that looking at suppliers’ processes is a key part of determining whether schemes would receive accreditation. “We look at the processes which people propose as being capable of meeting those standards. We make that judgment on behalf of the minister and regulators – whether [processes] are robust,” he said.

There was also debate about how to define desirable outcomes. “A good outcome for the finance director might not be good for the customer service provider,” warned Kelly. “It’s about striking a balance and weighting end user experience a bit more highly when you get into the contract negotiations. If you don’t get the outcomes clearly articulated at that stage, then you are at risk when the service is delivered of those people’s views being under-represented.”

Ali said she has been working on creating a tool looking at a providers’ performance across a range of metrics, aimed at preventing a repeat of the Mid Staffordshire failures. However, she added that she is struggling to integrate the outcomes experienced by patients into the system. “At the moment the data is not there. A whole new piece of work is needed. We are very much driven by process,” she admitted.

A democratised voice

The role of service users in providing information that can help to maintain and improve quality was a further theme of the discussion. Paul Hodgkin, a former GP and now chief executive of the Patient Opinion website – through which NHS users give feedback on their treatment – stated early on that he was present to “bang a drum for a democratised voice”.

“We have spent the last ten years doing accreditation and regulation, but what people are doing out there is having conversations, tweeting and going on Facebook,” he argued. “That is cheap, transparent and has tremendous power. If you assume that the system is better off because it changes and improves something on the basis of a patient story, you don’t need standards.”

Mohammed Muftawu from Holibrook House, which provides residential care services for children, also called for service user experiences to feature prominently in appraisal of service providers. “If no-one is listening to a young person they become like a statistic,” he said. “The provider may achieve a good result, but that isn’t what the service user is receiving.”

Such ideas are not entirely new to the public sector – and two members of the panel came forward with examples of service providers using lay assessors to evaluate their performance. Stennett said that with UKAS’s help, the Imaging Services Accreditation Scheme is providing both patient feedback on service quality and more technical data to the Royal College of Radiologists and the College of Radiographers. And Collins added that in Wales, the NHS is working with mental health charity Mind to improve care evaluation by gathering information from people with learning disabilities on their treatment by doctors and nurses.

Hodgkin added that it is now much less expensive to put users at the heart of assessment processes, because technology makes it easier to identify specific groups and to get in touch with them to receive feedback.

Taking the participants’ views in the round, the group concluded that in a changing landscape of service delivery, quality assurance will rest on a mixed bag of metrics and systems. Some process measures will probably still be required, even as the main focus switches to intelligent systems for assessing outcomes.

There is clearly also a role for accreditation, which can give people procuring services confidence in their contractors – and, perhaps, their subcontractors too. And it began to become clear how the government’s transparency and citizen-empowerment agendas might offer ways of replacing the existing top-down, process-orientated scrutiny systems. A twin-track approach that allies social media, staff surveys and user feedback with public oversight of data on service operations and performance could create powerful tools for testing and profiling service quality. Perhaps, concluded Winfield, service user opinions could even provide the data to underpin accreditation of service providers. “I see the possibility of accreditation built around the world that we are moving to, not the world that we are in now,” she said. “Accreditation starting with the service user, and not with the service.”

Written by Stuart Watson