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1 Mar 2012
John Adams, VODG general secretary

Who really cares about quality?

We all expected it, but none of us derived any pleasure from having our expectations met; the resignation of Cynthia Bower, chief executive of the Care Quality Commission last week was the latest in a litany of problems surrounding the health and social care watchdog.

John AdamsCQC is barely yet three years old, and news of Bower’s resignation came on the same day as the Department of Health’s (DH) capability review was published. The creation of the watchdog as the unified regulator of health and social care in England came with the merger of the earlier Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission. The merger was the inspiration of Gordon Brown, who wanted to reduce the costs of regulation, by giving the new agency less funding than the combined funding of its three predecessors.

But it was a flawed model, with too broad a remit; sooner or later the wheels were bound to come off.

From the too-broad brief to several damning reports that seemed tantamount to nails in CQC’s coffin, the commission’s catalogue of problems, which the VODG has long raised concerns about, have included:

Official nails in the coffin too with criticisms from The National Audit Office and the health select committee and we’ve still got the report from the public accounts committee to come, the Mid-Staffs report and the report into CQC’s leadership by former Cabinet Office civil servant Gill Rider, president of the Chartered Institute of Personnel and Development.

The problems are too numerous to detail in full, but let’s just take one – the issue of the CQC’s broad remit. The VODG has always maintained that a dedicated inspectorate for social care is essential - we recognise that is very unlikely now – because of the fundamental differences between a short hospital stay for treatment and living in a care home or being supported in a domiciliary service, perhaps for one’s whole life.

The commission’s mind-boggling remit includes regulating treatment, care and support provided by hospitals, dentists, ambulances and mental health services, treatment, care and support services for adults in care homes and in people’s own homes (both personal and nursing care) and services for people whose rights are restricted under the Mental Health Act.

Supporters of this broad inspection horizon suggest that by sharing a common set of essential standards the likelihood and opportunities for integration – between the NHS and social care are that much greater.

This argument may have some relevance to better supporting older people but on the whole is largely irrelevant to many disabled working age adults. Integration is not going to happen simply because we have a single set of standards across the health and social care divide.

Things are only set to get worse with the regulation of primary medical services from April 2012, the regulation of GPs in 2013 and the addition of Healthwatch England the new independent consumer champion later this year. How on earth can anyone make a success of a job with such a sweeping range of responsibilities? The department’s second stage review of the regulations as a whole, which they propose consulting on later in the year, offers a glimmer of hope that we might yet see a regulator that’s fit for purpose.

As sparks are still flying over the “what went wrong” at CQC, there is as yet little debate on the “why” and the “what next” – both issues that are of huge concern to VODG.

As for “why?” this is not solely the failure of CQC – other than perhaps its board might have required stronger performance measures regarding its own progress and stood-up bettter to the government. We lay much responsibility at the door of the DH and the people who designed this unfortunate commission.

This – in an unprecedented move - is acknowledged in a letter from Una O’Brien, DH permanent secretary, to CQC’s respected and popular chair, Jo Williams, and Cynthia Bower, following the department’s unprecedented, performance and capability review of CQC. O’Brien writes, “in hindsight, the scale of the task facing CQC was underestimated.” The question now is, what will the department do about it?

The DH shares responsibility for these failures. Its lamentable failure in respect of quality improvement is astounding. It might have been reasonable for CQC to retreat from the wider, more strategic quality improvement agenda, given its remit and depleted resources, but where is the vision and leadership from the department?

The public and taxpayers have been let down, ratings websites are not the whole answer. They have their place and may prove useful to inform some potential customers but alone will not address the need for an agreed national framework to drive-up standards everywhere.

No, the CQC failure relates to the lack of a “quality improvement” vision and leadership from the DH. Many of us advised and warned of difficulties ahead as the commission was launched – some providers we know suggested it was a “train crash waiting to happen” - but it was only with Winterbourne View, a huge and damaging failure of the regulatory machine, and the damning National Audit Office report that the department finally took notice. The “regulatory pigeons” are it seems at last coming home to roost, but at what cost?

So what next? No one wants another new regulator. We want an effective agency that offers protection to those who use regulated services and fair and proportionate regulation to those who provide services. We would like to be genuinely listened to this time around as part of the department’s wider review.

We want to see better value for money for tax payers and providers and a regulator held to account for its own performance – particularly with regards to inspection consistency. Currently there is a virtual post-code inspection lottery with massive inconsistency in judging performance.

The less informed might be forgiven for thinking that the resignation of Cynthia Bower - effectively a figurehead surely jumping before she was pushed - paves the way for a bright new chapter for the regulation of health and social care. The truth, of course, is that there is nothing to celebrate here and no suggestion of a clear way forward.

The fact is that, thanks to the inadequacies of the regulatory system and its impossible remit, the focus is stuck firmly on the failing inspection regime itself, on its organisational and procedural crises, rather than on its raison d’etre: the improvement of care for those who need it most.

As this lumbering machine limps on, the people in need of safeguarding are lacking a champion in the form of a reassuring, strident and fit for purpose social care regulator. The department needs to get this right.

For the DH and its Care Quality Commission a question: who really cares about quality?

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