I don’t know how it goes in education; I imagine that social services are similar to health. It has been this way for a very long time and it continues today.

What I am discussing is the role of inspection in the maintenance of quality.

Below is an excerpt from the book ‘Sans Everything’ by Barbara Robb which I described previously.

It was written in 1965:

To me, what this means is that the role of inspectors in public services, in the UK at least are to maintain standards to a certain level. I’ll explain what I mean.

Today as in the 60’s if the inspectors are coming, there is advance notice. For hospitals, clinics, care homes and GP surgeries, the inspector is the CQC – the Care Quality Commission.

The CQC has multiple teams of inspectors who visit care facilities across the country; inspect books, records, talk with staff, patients or care home residents.

This all sounds great. And, to an extent it is.

Yet, as described above, rarely do the inspectors just pop-in. They aren’t patients or staff of the organisations monitored (although they are all patients and staff within the NHS). And, here is the challenge.

Life is never great all the time, and care, although for the vast majority – in the UK at the very least, is very, very good, it sometimes fails.

It is usually the failures that are noticed by those working in the organisations. The staffing short-falls, the inadequate equipment, capacity and so on.

Now, are these issues important?

Yes. Certainly, to the individual staff member or the patient affected, but, on a larger scheme, not necessarily.

There are truly awful things – called never events in healthcare – where error is always inexcusable; an example being a patient receiving 10 times the dose of a medicine – 100 units of insulin instead of 10, which leads to coma or some other harm. That can never be acceptable or justified.

The events that don’t trigger this threshold are however ten or a hundred-times more common and in general don’t lead to permanent harm and are often unsystematic – moving staff from ward to ward, moving patient from ward to ward, not washing hands, illegibility of handwriting, incomplete tasks, delays in medicines, falls in older people during their time in hospital; the list is very long – possibly limitless (cf the 20 or so never events).

It is this latter group that the inspectors cannot address.

They can check that plans and processes are in place to ensure there is adequate learning and improvement, they can even gather evidence that things aren’t quite right, but this data doesn’t often go very far.

‘Would you be a patient on your own ward?’ is an incredibly salient question with high sensitivity. A negative answer suggesting that the care patients receive is less than you would expect, were you in their place.

And, the thing with humans, is that we are heavily influenced by the type of question and who is asking and when.

Most of us want to portray a façade of competence.

‘Would you be?’ ‘Yes, definitely.’

It depends who is asking – a trusted colleague or an inspector who might report their findings to your boss.

Inspection does not engender a feeling of trust; even when you have little trust in the people in your organisation responsible for your welfare, better usually, the devil you know.

So, if inspectors are not there to smooth over the cracks, what is their purpose?

As I have said, a certain aspect is to audit; look through the records, check processes, ensure that plans are in place. What happens if a patient is harmed? What happens if a member of staff is overly stressed? How do you cope with increasing or unanticipated demands?

Most of this is predictable and this I believe is part of the role of the regulator – to ensure that these plans are in place and to then offer assurance to the public (and health ministers) that everything is OK or if not OK, can be improved.

This is the reason for the advance notice; to allow organisations to get themselves in line, to oil the rusty hinges, to get everyone to a showcase standard.

Those places who can’t or won’t do the necessary – organise committees, polish the silver, brief their staff, are likely those which are in such a state of chaos that the inspector needs to intervene. If you can’t get your act together with a month’s notice, you have a problem.

I don’t know if this explains it;

Inspectors are there to give people an aspirational goal, if they are in a position to achieve excellence; if not, they at least give you time to wash, hang-up and air your laundry.

They are not a panacea.

In some respects, this suggests that their role is less than some might anticipate, i.e. to make everything well.

And I believe that to be the case.

We are humans after all.

We have fragile egos that can be challenged.

‘Are you proud of your organisation?’ Is a little like, ‘Are you proud of yourself, of the work you have done, of the efforts of your colleagues?’

Again, it depends who is asking the question and how.

How then to create change?

This is a different question.

If you are lucky and a visionary leadership team of engaged, enlightened, creative executives descend upon your organisation, practice or care home, you are sitting pretty; sit back, join in, and get going.

If like most people, that team, those leaders are ordinary people like everyone else they will not necessarily succeed without great effort, luck and engagement.

As with a quote I posted on social media yesterday, leaders don’t tell you where to go, they ask you to come with them. They are embedded in the trenches, they taste the same bitter or sour or salty water; they understand the hardships the precarious situations people encounter daily.

They aren’t on the mountaintops, they are in the valleys.

Here is a memory of a leader I used to know: (you can also see it here)

My old headmaster Moshe