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K Walshe. Glasgow: Open University Press, 2003, £22.50, pp 238. ISBN 0 33521 022 8
Regulation—the application of arm’s length, independent control over performance—is increasingly used in a wide range of commercial and public sector contexts throughout the world. Since coming to power in 1997, the UK’s Labour Government has relied heavily upon regulatory interventions as a mechanism to improve quality and performance in health care.
This book is therefore a highly relevant and timely contribution to the literature. It is a comprehensive and authoritative work which illuminates the “Hydra-esque” nature of regulation in health care. It helps us to make sense of the complex and diffuse nature of regulatory systems, examining the theoretical and conceptual foundations of regulation, it provides an insightful analysis of the systems for provision of health care in the divergent systems of the US and UK, and compares and contrasts the systems of healthcare regulation therein.
Walshe adopts as a definition of regulation “the sustained and focused control exercised by a public agency over activities which are valued by a community”. This inclusive interpretation has resulted in a wide ranging account of the regulatory landscape. In the UK context, organisations such as the National Institute for Clinical Excellence (NICE) and the Modernisation Agency (MA) are discussed even though these organisations arguably fall outside the generally accepted view of regulators. NICE is without any detection, inspection, or enforcement powers and, as the author himself acknowledges, the Modernisation Agency is neither arm’s length nor independent and could be argued to be part of the Department of Health’s internal management structure. In contrast to its inclusiveness in terms of organisational regulation, the book explicitly excludes the subject of the regulation of healthcare professionals. Whilst understandable in the face of time and space constraints, it is regrettable that, as so often happens, the professions are annexed in discussions about performance and quality of care.
The book achieves its stated dual objectives—describing what constitutes effective regulation and illuminating how regulation may optimally contribute to performance improvement in healthcare organisations. It highlights how the potentially powerful tool of regulation is often overused and misused in practice. It makes a strong case for a strategic review of current regulatory regimes, with the development of explicit statements of intent, objectives, assumptions, enforcement powers, and enforcement strategies within the multifaceted regulatory environment. This line of argument is particularly apposite in the UK where the new “super-regulator”, the Commission for Healthcare Audit and Inspection, is currently developing its role, strategy, and approach.
This is a well laid out and informative book which should inform the decisions of policymakers and be of interest to managers and researchers within healthcare organisations that either conduct or are subject to external regulation.