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7 Dec 2011
John Adams, VODG general secretary, and Martin Green, chief executive, ECCA

Quality care falls victim to regulation

Rarely have standards and quality in health and social care commanded such public, political and media attention. In the last few months alone, the Winterbourne View scandal, the Dilnot commission report on social care reform and the recent damning Stafford Hospital inquiry are among the issues that have catapulted care to the top of the national agenda.

Martin GreenJohn AdamsPity then, that the organisation charged with inspection and improvement of health and social care appears to be at its most embattled since its launch in 2009.

The Care Quality Commission (CQC), the independent regulator of health and adult social care services has come under fire in recent weeks. A damning National Audit Office (NAO) report has outlined how the CQC faces serious difficulties thanks to staff vacancies and a lack of time to test new procedures. The NAO stated the regulator has missed deadlines for registering providers and suffers from falling levels of compliance and inspection. But successive governments and the Department of Health (DH) must also share responsibility for the current lack of vision for driving-up quality.

The commission is also facing condemnation after a public inquiry into the Mid Staffordshire hospital trust scandal questioned its leadership and “unhealthy organisational culture” (regulation failures had meant avoidable patient deaths were not identified or prevented). Meanwhile CQC board member Kay Sheldon has candidly told the public inquiry that the CQC’s leaders “lack the necessary skills”.

In a recent CQC consultation on the proposed changes to the regulator’s judgement framework and enforcement policy, both ECCA and VODG reach similar conclusions on the regulator’s approach to quality in social care.

We have serious concerns about the lack of vision regarding quality improvement and regulation. In a nutshell, providers face increasing costs and red tape and the public are poorly served by the current system. Until there is a stable, coherent vision, and a regulator that is fit-for-purpose, the scandals will continue. Even now we are unclear about what will replace the defunct star rating system; the public is being let down by a lack of leadership.

CQC’s single essential standards framework across health and social care does not serve social care well and there has been little or no useful progress in driving-up the overall quality of care since the organisation was established.

To be more specific, the regulator’s focus on providers failure to comply with essential standards needs to be balanced with recognising and publicising good practice. Both VODG and ECCA feel that inspectors’ presumption of culpability - which could result from the proposed judgement framework - is not a constructive way to engage with managers and core staff. In addition, it’s worth noting that among CQC’s stated aims is celebrating and sharing good practice.

To put it another way, we need to balance the regular diet of bad news from CQC with a recognition of provider performance that goes the extra mile. Building on good practice is far more likely to improve practice rather than simply focusing on concerns.

While the proposed changes to the model claim to be more effective and efficient – and there are indeed some aspects we support - taken overall, they are likely to add burden to providers and to CQC itself. Our fear is that the changes – essentially a shift from a carrot to a stick approach - will result in more judgements about non-compliance, an increase in enforcement for minor improvement areas and little impact on people themselves. This is the worst of both worlds and will do very little to usefully inform the public about the relative merits of different services.

Responsibility for delivering quality results rests with providers, but with no focus on quality improvement in the inspection process, there will be an unhelpful distinction between the essential standards and quality itself.

Inspection is of course an intrusive process, but the majority of providers welcome it as currently it makes a judgement about how far they meet essential standards, recognises good practice and offers feedback how to improve. But the proposed ‘non compliance’ model could increase anxiety, foster a feeling that the regulator only looks for failings and prevent an open and transparent provider/regulator relationship.

What’s more, finding and accessing good quality information about care services can also be extremely difficult. It is crucial that people who use, or are about to begin using, a care service have access to good information that will help them decide which service to use.

We do not believe that a focus solely on non-compliance will:

  • ensure that people who use, or intend to begin to use a service, have the information they need to make informed choices about which service to use
  • foster a positive relationship between providers and CQC
  • incentivise the sector to strive for improvement achieve improved outcomes for people
  • reduce the regulatory burden for providers
  • represent good value for money for tax-payers

It is also imperative that no changes are made ahead of the social care white paper next year or before a successor to quality ratings is established. Whilst we supported the principles put forward by the CQC of its now failed excellence award scheme, we believed the framework of the proposed scheme was completely flawed. We need urgent discussions with providers to develop a fair and transparent award scheme and a recognition that the drive for continuous quality can include provider peer-style reviews and audits.

We support a return to the star rating system as a regulatory system based solely on non-compliance fails to offer people the information they need to make informed choices about their care. It will do little to drive improvement and nothing to reassure the very people – those in receipt of social care and their families - whose confidence in the sector has been shaken by a string of woeful and high-profile failings.

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