The top managers of two flagship NHS hospital trusts resigned last week. They departed, tellingly, only days before big investigations into their organisations are scheduled to be published by the Healthcare Commission, the health service regulator.

Anna Walker, the chief executive of the commission, will also be out of a job on April 1, as the watchdog is dissolved next month in favour of the Care Quality Commission (CQC), the new regulator for health and social care.

Reflecting on five years of naming and shaming in the NHS – as well as giving credit where due – Mrs Walker remains an advocate of the targeted, risk-based regulation that the watchdog pioneered.

“There are real risks attached to poorly performing health and social care organisations,” Mrs Walker says. “The public constantly need assurance, because at the point at which you need care, you’re in someone else’s hands, so you need to know that they are performing well.”

The commission has conducted more than 100 reports and assessments on the NHS, including 17 investigations into specific trusts and annual “health checks” of the whole service. It still has several reports to publish, including inquiries into Mid Staffordshire NHS Foundation Trust and Birmingham Children’s Hospital, which sparked the resignations last week.

But this was not some bloated, public sector inspectorate – it has overseen the activities of 1.5 million NHS employees with a skeleton team of only 750 staff, Mrs Walker points out. “You could go and visit a hospital every week and not find out what the real issues are,” she says.

“We have had to rely on self-declarations from trusts whether they are meeting core standards of care followed up by spot checks or investigations where necessary.

“You need to use the information you have in the right way and use a range of different methods to find that information, which include listening to whistleblowers, patient complaints or ‘suspicious minds’, as we put it. If someone has valid concerns, and if the trust is not communicating properly with us, we will investigate.” Senior staff have resigned in half the cases when the watchdog has investigated a trust, “but we have never considered it our view to tackle the future of individuals”.

She says: “When we go in to investigate, our job is to establish what has gone wrong and it’s usually a systems failure, a whole series of things which aren’t being done or looked after.

“Sometimes there are key individuals who have got key things wrong. But otherwise we’re not singling people out, but we do not hesitate to take them to task if that collective leadership has failed. That’s what we did in Maidstone and Tunbridge Wells [where at least 90 patients died because of Clostridium difficile infection] and some of the other reports.

“That then triggers a discussion about whether anyone should leave.”

The investigation into Mid Staffordshire was prompted by high mortality rates, particularly among emergency admissions.

It is the first time that the commission has raised questions about such “outlier” information, and is expected to highlight key management failings as well as inadequate clinical and nursing care at the trust. Birmingham Children’s Hospital, by contrast, attracted complaints from its own doctors, which prompted ministers to ask for an investigation. “But the issues around this are complicated, the services had experienced a huge surge in demand,” Mrs Walker says.

Working with the Government has been easy compared with working with NHS managers, she adds. “No one likes dealing with regulators if they are on the receiving end, but at times people did not appreciate the role we had to play on behalf of patients. However, there’s a really strong need for an independent regulator to do that job and step in where necessary.”

The CQC is taking on the majority of the Healthcare Commission’s staff and is likely to continue with its working methods. However, despite the potential benefits of being able to regulate health and social care together – and the gaps in between – the new regulator faces a “huge challenge” to meet the expectations of patients, Mrs Walker says.

She believes that her successors must recognise the importance of the patient voice. “At the moment the standards say that health and social care providers have to ‘engage’ with patients or users, but you can engage with people by having a cup of tea with them and not do anything as a result. What we’ve been really passionate about is moving on from that, saying to providers, ‘you really have got to be very receptive to your customers’. You’ve got to behave as though you’re in a fully competitive industry and think about what they want.

“The best health trusts are already doing that but many of them aren’t.”

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