Are we expecting too much from the Care Quality Commission?

It has been open season on the Care Quality Commission (CQC) for some time now. The Panorama exposé into the abuse of patients at Winterbourne View, a private hospital for people with learning difficulties in Bristol, triggered a wave of criticism culminating in a highly critical report from the Public Accounts Committee last week.

The Committee went well beyond its value for money remit, criticising the CQC’s lack of strategic focus and leadership, inconsistency of its inspection regime, failure to strike the right balance between registration and inspection, and the lack of measures of performance or impact of its own work. The Department of Health has also recently published the findings of its own Capability Review, setting out 23 recommendations which it expects the Commission to address focused on strategy and performance, accountability and governance, and the regulatory model.

The early reports into the events at Mid Staffordshire hospital also questioned the CQC’s predecessor – the Healthcare Commission – which gave the trust a clean bill of health at the time it was responsible for some serious failings in the quality of care. The full public inquiry, led by Robert Francis QC, is yet to report. However, from the evidence presented, the early indications are that it will have something to say about the role of the quality regulator and the strategic health authority which was led at the time by Cynthia Bower, currently Chief Executive of CQC. Given this, it is perhaps of little surprise that she has decided to step down later this year in a managed transition.

These reports all highlight some of the challenges the Care Quality Commission has faced since it was set up in 2009. But are we expecting too much from a quality regulator?

The Commission had a troubled beginning, exacerbated by a lack of clarity about its role. Politicians must bear some responsibility for this – it is no good preaching the virtues of light touch regulation, and then blaming the regulator for not taking a more interventionist approach when problems emerge. They are also responsible for giving it such an enormous and complex task. As well as undertaking inspections, the Commission has registered 23,000 organisations in 40,000 locations since it was established and will embark on registering 10,000 GP practices later this year. Only last week, it emerged that it had been asked by the Secretary of State to inspect more than 300 abortion clinics at short notice. As the Commission’s Chair, Jo Williams, pointed out in correspondence obtained by the BBC, this will necessarily reduce its capacity to inspect hospitals and social care providers.

There are somewhere in the region of 1 million patient contacts every day in the NHS. Add to this the fact that approximately 1.7 million adults received social care services following a local authority assessment and the scale of the challenge for CQC is clear. It is impossible to expect a regulator to prevent the incidence of poor quality care and yet it often appears it is the first to be blamed.

Frontline workers are the first line of defence against poor quality care – it is the responsibility of every clinician and care giver to speak up when they see care that is below acceptable standards and to act to remedy this. But we know that staff often find this difficult. They may work in organisations that are disempowering, that alienate them from the people they are caring for, or where there is a blame culture that discourages them from speaking up.

It is vital that the boards and senior managers of provider organisations create an open culture of reporting and are held accountable for the quality of care. In the nuclear industry the senior person responsible for safety is able to report issues ‘outside the line’, that is outside their direct line management, to the Chair of the board or equivalent. Do we need to identify someone in every hospital who can go outside the line if they have significant concerns about the quality or safety of care without fears of repercussions?

While the CQC must address its shortcomings, it is time to move on to a wider debate about how to design a system of quality assurance that patients and service-users can have confidence in.

Comments

Dear Andy, I fully support your view regarding a change in culture and values within the NHS and more emphasis being placed on compassion. Having worked for the NHS for over 14 years a lack of compassion and blame culture rather than more deeper reflection is something that I have also observed. I would like to this opportunity to wish you every success with your study regarding compassion, culture and values within the NHS workforce.

My wife is in a Care Home which has two section, a residential and an EMI. There is a marked difference in the dress code of the units, the residential unit 's staff are well dressed in coloured three quarter coats indicating their role,while in the EMI unit staff wear what they like (even a rugby shirt!). Do you think this is acceptable,and does it suggest a differential attitude towards the EMI residents? I would value your opinion before I proceed further. Many thanks.

i have to complain about the unjust article in the Rotherham Advertiser on 11th May 2012, regarding the Abbey Care Home in Rotherham. I went on a 40 minute inspection tour of this care home before placing my Mum in their care.. I know a great deal about care homes in the Rotherham area, as I researched 20 of them when looking for one for my Nan back in 2005. She had been in Park Lea residential home since 2003, but the council in it's wisdom decided to close it down as the building had become unsuitable, what a load of tosh. It was a perfectly suited to it's task with the most wonderful care staff I have ever met. So in 2005 after 2 years of being there she was forced to move, which broke her heart, we all felt it would be the ending of her. But luckily she made it to her 100th birthday. while looking for a new care home for her, I visited 20 in the Rotherham area and quite honestly I wouldn't have put a pet, in 90 percent of them, for respite never mind long term. I hasten to add I would have cared for my Nan myself, unfortunately I lived in a one bedroom flat on the third floor at the time. Again unfortunately for some unknown reason I didn't visit the Abbey Care Home, I wish I had because I would have placed her there without reservation.

The abbey Care Home is one of the best I have ever come across.

The accommodation is second to none, the staff are superb, understanding to each persons needs, friendly and kind. My Mum who had a really bad experience at a Sheffield care home in 2009, stayed there for 3 days this Easter and absolutely loved it.

This is extremely fortunate for me to get the well earned break as a carer I need from time to time.

Adam Brown from the CQC and every person that works for them, needs to spend a week as a full time carer and a week in a care home. Then tell it like it is. Have the CQC seen what goes on in hospitals. When my Mum had her stroke in 2008, it started at 10p.m. at her home, my Dad phoned the ambulance, they arrived very quickly and confirmed they thought it was a stroke. Dad phoned me, we left her home at 11p.m, went to Rotherham District General Hospital and were not seen to until 4a.m. the following morning. I didn't know at the time about the 3 hour rule concerning strokes, I wish i had because I feel sure if I had my Mum's speech would have been saved. Unfortunately, she now has aphasia which is the most debilitating, frustrating and soul destroying outcome of a stroke. Because of this I was determined my Mum would never go into a home full time. I gave up work in order to provide my Mum with the best possible care I can give, but do have to use care homes for respite, which brings me back to the Abbey. The article in the paper was totally out of order. The CQC needs to get out there and find the homes that are abusing the most vulnerable of our society. Get in the real world and do the job they are being paid highly for. My disparity regarding this countries treatment of the old and vulnerable grows daily in what is reported in the news. Get real, CQC for heavens sake!!!!!!!!!!!!!!!!!

Every healthcare outlet should find amongst its patient base those willing to sit on committees to discuss the complaints of other patients from geographically distant clinics. It's done by email, and you just have to read the complaint and then answer a few questions.

The results have no legal standing of course, but a corporate that is truly interested in how its staff are performing at the clinical level (as opposed to billable throughput) will find this data essential in the final push to administrative nirvana. Where every crack in the pavement has an administrator waiting at the bottom to catch anything that might fall through. Nothing could ever possibly go wrong.

Like the world on a turtles back it'll never happen. There just isn't enough money. But administrators do like to dream of the day when they can put their feet up and finally stop grinding their teeth.

Will a change come? The boat is already leaking. Rocking it too much is bound to bring a whole new set of problems. What we need is a quiet change, but one that will succeed eventually.

At the moment, every setback brings a new bill. To analyse the setback down to the n'th degree so as to be seen to be taking the proper steps costs a fortune, and as Ed said, it just makes more work for more administrators. It could very well be that the changes made were right, but does that help the man on the street?

I don't think so. Every change is just going to be another leech on the NHS with less money for the frontline staff who actually have to delve into the disease just to earn their daily crust.

A new approach is needed, and I think the failings of the NHS fall squarely on the shoulders of all of us.

The problem is not so much the expectations we have of the CQC itself, but rather the expectations that we (especially politicians) have of the whole concept of organisational regulation.

Every time there is a failure, an additional layer of organisational assurance or regulation is added (once again locking the stable door after the particular horse involved in the particular failure has bolted).

In my view, we are well past the point where an additional amount of organisational regulation produces an equivalent amount of added value. Of course, it's easy to say, after a failure, "well, we have to do something..." and rightly so, but why another layer of organisational regulation?

We set up quasi-autonomous organisations so that they can be accountable, and then we undermine that accountability by adding layers of regulation. If an organisation fails, it needs to be held to account, not cocooned in regulation. And if organisations were able to devote at least some of the resources they currently use to provide external assurance, and apply it to internal quality improvement instead, who knows what level of benefit might be added?

But the focus on organisational regulation also diminishes the responsibility of individuals for their actions and for their colleagues actions. The professional regulation function is perhaps where much more attention should be focussed. Getting organisations such as the NMC to operate effectively and to develop a culture of professional accountability is likely to have much greater benefits than more organisational regulation.

And by the way, every NHS organisation should already have a NED who acts as the Whisleblowing Champion, the point of last resort for staff with concerns. And any Chief Executive worth their salt will make sure that their staff know that their door is always open to genuine concerns.

Anna is right to question some of the criticism facing the CQC and to point to the key role played by Ministers and others who still believe in light touch regulation. For me the rot starts at the top and the top must take responsibility for the regime that allowed the Staffordshire situation to arise.

Many insiders will agree that iatrogenic disease is rife, quality is mixed and many patients receive late, wrong and damaging treatment causing real and permanent loss. The only reason there are not greater costs to the NHS is that compensation is only given if the patient can prove negligence. I have heard it said several times that no fault compensation schemes are impossible because of the costs involved.

Unfortunately it would seem the main function of the CQC has been to accept uncritically the role given by government of providing false reassurance on the generality while identifying a few outliers. Add to this the severe cuts in the CQC’s budget and the extra work piled upon it, and we have a tragedy – or scandal, call it what you may – waiting to happen. Who will be willing to pick up the poisoned chalice from the recently resigned CEO, Cynthia Bower?

The CQC should not be giving false reassurance. It must honestly reflect the true position to managers and politicians rather than the ambiguous "health improvement" role so readily adopted. Matters will only get worse as the government’s cuts to the NHS budget force hospitals to take dangerous cost-cutting measures. Take a look at how nursing loads on hospital wards have increased over the last two years, and tell me this is a sign of improvement.

What is required is:
• better quality comparisons with other countries using more up-to-date and meaningful data on mortality, outcomes and serious untoward incidents;
• licensing hospitals for clinical case mix;
• accurate reporting and decisive action regarding serious untoward incidents;
• clear and transparent financial incentives and penalties for quality.

‘It is vital that the boards and senior managers of provider organisations create an open culture of reporting and are held accountable for the quality of care.’
Exactly Anna but how will this be achieved? Without these conditions it is not safe for staff to report concerns. They will be silenced by being suspended and dealt with very slowly and unjustly, very often disappearing without trace, too ill to work anymore.
We at CAUSE (Campaign Against Unnecessary Suspensions and Exclusions in the NHS UK) know these scenarios too well, from personal experience and through providing information and support for the last 9 years.
With the present management lack of accountability and lack of scrutiny of employment practices, we despair of seeing any improvements.
Julie Fagan, founder member of CAUSE (suspension-nhs.org)

Thank you Anna,
A balanced and thoughtful article in what often appears an unbalanced and over-reactive world. Undoubtedly the vast majority of us share the view that poor standards must never be tolerated, least of all for our vulnerable citizens. Often it seems that some believe quality can be regulated into a service, but in reality Quality comes from within the service - with the right leadership, incentives and a culture of transparency and openness. Services where people are central, and where everyone involved is proactivley encouraged and committed to constantly discussing what is working well and what isn't working well - and where raising concerns is encouraged and celebrated. This together with commitment and resource to deliver consistent high quality services and to take appropriate and timely action to put right anything that goes wrong and adapt to prevent reocurrence.

Moreover, perhaps we should better recognise and appreciate core values more than some of the measures typically used? Firstly, staff who have the essential but often overlooked core values including kindness, compassion, dignity and respect. Then of course the qualifications, skills and knowledge. This is what vulnerable people say is important to them.

Perhaps all of us working in health & social care and support, could assist by working more closely together to develop approaches that seek out and celebrate such qualities in action?

Thanks Anna
On the frontline of care my partner witnesses and is passionate about providing high quality care for cancer patients. What he frequently highlights is that in his depth they are under staffed and under pressure to complete treatments at speed. The situation for staff is clear. They strive for good quality but managers see patients as targets. Some nurses on radio 4 were being criticised for a lack of compassion when dealing with the elderly. I would argue that when staff are under pressure, under valued and under funded then quality slides. The regulator is there purely to measure but measuring alone does not make something grow! The responsibility lies with departments and quality assurance needs to be rigorous and accountability should lie with the people working in the service.

It is heartening to read this view Anna. I had a role in the design and implementation of the new regulatory system at CQC. Having been a doctor in frontline services prior to joining CQC, I was acutely aware that the responsibility for quality is firmly with staff and the provider itself – a view shared commonly in CQC. Adding to Rob’s comment, it would also be sad if an impending CQC inspection was the only reason that a provider or staff member wanted to do all they can to provide a service that meets essential standards.

The time to design and implement a completely new regulatory system was very short and the volumes of new registrations in 2010 and early 2011 enormous. Getting the tools refined, adapting to the different contexts and creating the most effective steady state operational aspects were always going to take time. From the outset, we described the change programme as a 5 year one - CQC is only now just ending its third year. An enormous amount has been achieved but there will always be a lot more to do.