Alandmark report by the health inspectorate today is about to change dramatically the tone and content of debate about the current state of the NHS. Until now, the official line - from ministers, inspectors and managers - has been that the service is steadily improving. Proof came each year in the star ratings, a grading exercise showing how well each trust met government targets. As more gained the maximum three stars and fewer got one or none, it looked as if impressive progress was being made, whatever the doctors, nurses and lobby groups might say.
From today, that entire system of validation becomes extinct. The Healthcare Commission will produce the first in a new series of "annual health checks" on all 570 trusts in England, including ambulance and mental health services, as well as acute hospitals. Meeting government targets will no longer be enough to gain high marks. Now trusts must also run the gauntlet of 44 quality tests and show they are making good use of their resources, avoiding any deficit.
Results are secret until they are released at a press conference this morning, but the flavour of the exercise is already apparent. We will see question marks appearing against the names of famous institutions and their distinguished executives. Many trusts are expected to be graded "weak/weak", showing defects both on quality and financial control. Only a tiny number will emerge as "excellent/excellent".
A ragtag army of trust managers, who may be seeking consolation from grades of "fair", will be told by the commission in no uncertain terms that fair is not good enough. Our sense of steady improvement in the NHS will be interrupted.
The person responsible for introducing this more rigorous system is Anna Walker, the commission's chief executive. She says: "When I arrived at the commission in 2004, a trust chief executive told me: 'You can get three stars by treating performance ratings as a project; you put all your effort into achieving three stars and the rest of the organisation can go hang.' With our new standards we are saying: 'Oh no, you can't do that any more.'" To be successful, trusts will have to achieve exacting professional standards, as well as meeting the targets.
Incredibly positive
The results today will show that trusts had difficulty in delivering about a third of the standards, including important safety issues such as control of patient records and decontamination of medical equipment. Walker says: "At one level, that may sound scary. At another, it is incredibly positive. What matters is that they recognise the problem and do something about it."
Maybe so, but there can be little doubt David Cameron will emphasise the scary side in his campaign to rebrand the Conservatives as champions of NHS improvement. Is the commission not aware that it may be delivering a serious blow to the public perception of Tony Blair's legacy?
Walker says: "There has been absolutely no pressure from government. None. I don't know how they will respond, but we speak as we find. I believe it would be possible for the government to react positively. The standards are the government's, not ours. And they have been put in place on behalf of patients and the public. It is a tougher system, but that is what the government wants for public services. This is the first year of a tougher system. What really counts is whether the NHS shows real improvement next year. If we can encourage that to happen, we'll have something seismic to celebrate."
Meanwhile, Walker reassures herself with a lesson she learned during a career largely devoted to regulation of public services. She says the regulator is seldom popular, and that "when you are, you need to become quite anxious".
That career included working on competition policy under John Redwood during the last Conservative government, when she came to understand the difference between effective regulation and excessive interference. She held a senior post at Oftel, the telecommunications regulator, before heading the energy division at the Department of Trade and Industry (DTI) and then the rural affairs division at the Department for Environment, Food and Rural Affairs (Defra).
These were powerful jobs for a woman who flunked the civil service entry test at the first hurdle after graduating from Oxford University. Walker may derive some of her natural style of unstuffy, relaxed authority from an advantaged background. Her father, Lord (Jack) Butterworth, was an Oxford law don who became the first vice-chancellor of Warwick University. She moved aged 12 from Oxford high school to Benenden, where she was a classmate of Princess Anne in the first year. "She and I were in the same group (the top stream), and we were both at the bottom of it," she recalls. "Her maths and mine were not good."
After the setback of early rejection by the civil service, she worked for the British Council and the Confederation of British Industry. That qualified her for subsequent fast-streaming at the DTI.
Walker says there were points in her career when being a woman was advantageous. One of them came in 1997 when Whitehall chiefs looked at the picture of "Blair's babes" showing the incoming prime minister surrounded by a phalanx of women Labour MPs. Apparently, the mandarins became anxious about the lack of an equivalent pool of female talent at the top of the civil service. "Being a woman was helpful at that point - if you did as well as the men," she says.
The civil service had been progressive enough to allow her the flexibility to bring up her three "fiercely independent" daughters. She worked part-time for 10 years and was shooed out of the office by bosses who appreciated her need to be at the school gate on time. "I don't think the DTI did it for the sake of my blue eyes," she says. "They looked across at their fast-streamers, saw that a third were women, and realised they needed a system in place to suit them."
It was her husband, Tim Walker, director-general of the Health and Safety Executive, who encouraged her to take the NHS inspection job. Her first instinct, when approached by headhunters, was to stay at Defra. But he said her experience prepared her well for a job at the cutting edge of regulation that could make a real difference for the benefit of patients.
Sophisticated system
The paradox of the system she is introducing is that it combines toughness and a lighter touch. "We are not interested in inspection to catch people out," she says. "We want a series of prompts to get trusts to ask themselves the difficult questions." So the new gradings are based on self-assessments by trust boards, backed up by a sophisticated system of information gathering to detect when they may be glossing over the truth. "We still visit trusts [to inspect], but only when there is cause for concern. Then we only look into the matter causing concern. It's not like the old clinical audits, when inspectors went in and asked about everything across the board." The gradings will for the first time incorporate a systematic assessment of patients' experiences of each trust, and a new website will make the results accessible to help other patients decide where to go for treatment.
In many public bodies these days, the chief executive plays second fiddle to a more visible chairman. At the commission, that pecking order is less obvious. Sir Ian Kennedy, head of the inquiry into the Bristol babies scandal, is the chairman and takes the lead on subjects close to his heart, such as maternity services and the safety of children. Walker fields the rest.
She has achieved an armistice in the turf war that appeared to be brewing with William Moyes, chairman of Monitor, the regulator of foundation trusts. The future of all the health and social care regulators are under review by ministers, but Walker meets Moyes every six weeks for a coffee to keep relations cordial.
She confesses to sounding like a masochist when she says she likes attending meetings where people berate the commission for doing a poor job: "If I can't answer their criticisms, I know we need to go back and rethink what we are doing."
But as she cycles to work as usual this morning, she must surely wonder whether ministers think the commission has become too critical for its own good. "That would not deter us," she insists. "If we find poor practice, we will not hesitate to say so on behalf of patients and the public. But we must always have the evidence."
· Curriculum vitae
Age 55.
Status Married, with three adult children.
Lives Balham, south London.
Education Oxford high school; Benenden school, Kent; Bryn Mawr College, US; Lady Margaret Hall, Oxford (MA History).
Career 2004-present: chief executive, Healthcare Commission; 2001-03: director-general for rural affairs, Defra; 1998-2001: director general for energy, DTI; 1994-97: deputy director-general, Oftel; 1975-94: civil servant, mostly at DTI; 1973-74: CBI; 1972-73: British Council.
Awards 2003: CB.
Interests Cycling and walking (member of health inspectorate's "commission expedition" cycling team for London-Brighton bike ride, 2006).
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