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.
CQC 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:
- the impracticality of having a unified regulator for health and social care
- the appointment of Bowers given her direct connection with the Mid-Staffs NHS scandal; she was formerly chief executive of the NHS West Midlands’ strategic health authority, responsible for supervising Stafford hospital
- the use of a “light-touch” regulatory regime based on a quality risk model – lacking the necessary useful data for social care
- the lack of an effective care rating system
- the early resignation of CQC chair Barbara Young
- the confusion and disorganisation providers experienced in registering with the new agency
- the falling number of inspections carried-out by the agency, which somehow they managed to over-report to Parliament by an astonishing, 7,852 inspections
- the well documented Winterbourne View whistleblowing failures
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?
Comments ...
John, a very succinct article. You have boldly stated the concerns of many.
There is one fundamental flaw in the current regulatory system that troubles me most and it is the inconsistency of CQC in measuring quality:
Measuring the quality of a service requires skills which are very different from the skills of inspectors who in the past, just enforced regulations. Enforcement could be done by finding some weaknesses and making a requirement to put them right. Although it would appear to the lay person that finding a number of weaknesses must mean that a service is poor, measuring quality accurately and consistently is a bit more complicated than that.
The 'Judgement Framework' should provide some consistency but it is no substitute for training inspectors in the principles of measuring quality. Although it is only a guess, from the evidence that I see in Compliance Assessments, inspectors and managers in the Care Quality Commission are not trained specifically to measure quality, but to enforce the regulations. They should either be trained appropriately or the value of quality marks such as Investors In People and ISO 9001 should be formally recognised by CQC.
Mike Neilens
Quality & Safety Manager
Brandon Trust
Thanks very much Sarah and Mike for your comments.
To what extent the current regulatory system can be described as 'national', when there is local variation and inconsistency is an interesting point.
Lately the VODG has had an avalanche of emails from providers about reporting safeguarding concerns and the (sometimes) wildly varying attitudes of inspectors, local government and across different locations.
It's just this sort of issue that we'd like to see the DH take responsibility for. As for the VODG it will try to work with Adass and CQC to develop a national protocol in an attempt to improve matters.
Unfortunately there seems to be little appetite for a policy-level debate on regulation. No-one is that keen on going back to the drawing board yet again but that doesn't mean there's not room to manoeuvre. It may be that the Government wants the regulator to stop scandals, take the blame if it fails to do this and very little else. In any case the 'improvement role' is pretty much off the agenda. Or is it?
I don't see a strong imperative from the DH for the elected compliance-enforcement model of CQC. In fact I see a desire for the regulator to exercise some leadership, setting the agenda rather than simply responding. The Capability Review report holds some important findings/recommendations. We're getting a new CEO and changes to the board are afoot (I suspect my days are numbered - but hey, at least I had my say!). This could be an opportunity - we just need a few folk who willing and able to be bold and visionary.
Having been on the receiving end of negligent care and subject to abuse by a care professional, I want regulators to protect and safeguard. But I also want there to be a robust and sensitive system with joined up levers that supports, and when necessary insists on, high quality care based on individual circumstances (albeit within resource constraints). I don't believe regulation is THE silver bullet, but it should be A silver bullet alongside others.
But how do we achieve this? We need to talk about regulation...
Excellent blog- which takes us to the heart of the issue.
I think that fundamental thinking is needed about three different things:
- (i) what can and cannot realistically (and yes cost- effectively) be achieved ever by regulation and inspection,
- (ii) what the current arrangements do and have the potential to do
- (iii) most importantly, what people using health and support services want and need, how far this can be achieved by (i) or (ii) and what else is needed.
The CQC has failed in many ways- some of which have been catastrophic for people. But it has faced an impossible task. Your piece sketches out many of the reasons for this. It is impossible to regulate and inspect even serious risk out of a system, and utterly impossible to inject real quality, personalisation, protection of rights and genuine autonomy into it. Indeed the CQC focus is increasingly on compliance not quality.
Yet people using services and those who love them need all of these things.
So alongside getting real about what regulation and inspection can achieve - redesigning and integrating this across different regimes (e.g. CQC and Supporting People) there is an urgent need to consider it alongside much more person centred approaches, including independent advocacy.
It might just be the optimism of a sunny Saturday working its magic on me, but I believe that, if the political will can be generated, there potential to develop from the current sad state of affairs a new, vibrant and powerful citizen led approach to safeguarding rights and quality, which sat alongside a refreshed approach to regulation and inspection, might begin to offer what is needed.
It seems to me that - at least in social care - there is a common vision for regulation along the lines so encouragingly described by Jonathan. The key issue is how to generate the 'political will'. I'm certain that this will not come from or via CQC (at least not until there is sufficient impetus behind it). My recent interactions with Government and DH, suggest that the regulatory doors are not fully closed - that is there are chinks left open and the chinks may be large enough to get a foot in.
However the nature of the mechanisms available for influencing regulation in recent times have simply served to feed the 'lumbering machine'. It is a fact that the current regulatory approach has not been subject to a full and transparent consultation. There are some great pieces of work taking place in CQC and elsewhere but they are 'pieces' and not part of a coherent and joined up (internal & external)framework.
Is it enough to wait for the new CQC CEO and refreshed board - a lot can happen between now and the autumn? Given the lack of enthusiasm for starting from scratch again, can 'another way' be created without going back to the drawing board? Is it possible to stimulate a 'big conversation' without frightening off the DH & Government?
Thanks very much Jonathan and Kay for really interesting comments - and Jonathan for spending part of a sunny Saturday afternoon writing them, good man!
The insights you offer Kay, about what may or may not be possible are fascinating. I believe the sector is willing to take the quality question forward and I agree Jonathan that no single approach is going to offer everything that's needed. That's why I say in the blog that ratings websites also have their place, alongside other tools and approaches, including advocacy.
But what I want to see is greater coherence; why do we have the essential standards; providers own quality systems (some of which are extensive and impressive); NICE developing quality standards and Monitor's reach being extended to social care? Nothing seems to be joined-up; this is the lack of a vision.
Kay do you know anything about the DH second stage review of the regulations, which they propose consulting on later in the year. Is it correct, or not, to speculate that this may offer a glimmer of hope?
Hi John
I don't know how or if the review of regulations will facilitate change (other than strengthening the CQC board which is supposed to set the strategic direction of the organisation). I was particularly thinking of the recent DH Capability Review of CQC which indicated the desire for CQC to take more of a leadership role. The report also said that the DH needed to clarify/establish how different quality initiatives fit together. At the moment I feel that CQC is part of - and even contributes to - the general incoherence. Whilst it is good that the organisation is listening and learning, this has to be viewed as part of a coherent regulatory framework which we don't have. The increase in inspections and inspectors is a case in point. There is general agreement that the regulator needs to 'go and have a look' but there is no evidence to indicate how often this should be and/or how this fits with other measures/mechanisms. The decision around this was not taken by the board and was not part of an overall strategy but a response to some external influence. The latest reactive response (to concerns about the negative/punitive nature of the compliance-enforcement approach) is that CQC inspectors can 'describe compliance' and 'highlight good practice' when they see them but what does this mean and who decides what's good practice & how? What I don't know is how to influence real change and progress - CQC is not really willing and/or able to engage in this kind of discussion (I know that sounds disloyal & inappropriate from a board member but I believe these issues need to be aired - and CQC will read them as they have alerts out for every time my name is mentioned on the net, & no, I'm not paranoid - it's true!).
I believe your blog does get to the heart of the issues. Maybe VODG could get together with other social care networks/groups and write a letter to David Behan (and Una O'Brien?) asking for a dialogue and offering to help establish a more joined up and coherent framework that deliver benefits for people using services?
On the move at present so briefly, this is v. helpful, thanks Kay.
The answer to the question posed, 'who really cares about quality?' has to be 'all of us'. For the Skills Academy, conveniently blaming the ills of the sector on one organisation is a way of avoiding responsibility.
The way you do this is by engendering leadership confidence and behaviours at all levels of the workforce, and we will be looking for our Leadership Qualities Framework, due out shortly, to provide employers and employees with clear guidance as to what this looks like in practice and how to attain it.
Great blog John - we need measured responses like yours to what can feel like a crisis in regulation and inspection. Here's a link to the Care Provider Alliance vision for regulation and inspection, to which John/ VODG and others contributed and which readers might find of interest:
http://www.ukhca.co.uk/pdfs/CPAvisionforinspectionfinal2011.pdf (PDF on external website, size not known)
I wonder if I could pose some key questions that are floating around (at least in my head). Any thoughts on any of the questions would be helpful (I ask these as an individual):
- What would represent 'success' for regulation and how would you know it had been achieved?
- How important is leadership & influencing policy for the regulator? What should characterise the relationship between the ALB regulator and Government/Gov depts?
- How important is the participation of people who use services (& family members/carers) in regulation: that is both getting views/experiences of people using services in inspections and more widely e.g. in policy, regulatory development, inspections?
- What are the differences between stakeholder engagement and 'user' involvement/participation? Is there a level playing between these 2 (broad) areas?
- What values are important for a health and social care quality regulator?
Hi Kay – my response (R) – my 'starter for ten,' to your questions would be as follows:
- Q. What would represent 'success' for regulation and how would you know it had been achieved?
- R. In addition to all of the usual caveats about regulation processes needing to be smart and efficient and provide value for money – the regulatory system must be able to give confident assurance about quality and be able to show (over time) that more services are meeting the required standards; with fewer safeguarding incidents; greater customer/client satisfaction levels; with evidence of more services 'going beyond' the minimum standards. The essential or minimum standards should in my view be capable of driving improvement. Regular inspections are a fundamental requirement.
- Q. How important is leadership & influencing policy for the regulator? What should characterise the relationship between the ALB regulator and Government/Gov depts?
- R. Leadership is critical – how could it not be? The relationship question depends on what role Government want to play; up-until-now they've 'set the framework,’ and the budget, but clearly the regulator needs to be independent and honest about what it can do well within the given resources.
- Q. How important is the participation of people who use services (& family members/carers) in regulation: that is both getting views/experiences of people using services in inspections and more widely e.g. in policy, regulatory development, inspections?
- R. Again it seems to me that it's vital, but the 'engagement' needs to be with a broad section of people, not just the usual 'activists.'
- Q. What are the differences between stakeholder engagement and 'user' involvement/participation? Is there a level playing between these 2 (broad) areas?
- R. My elderly Mum (92) has lived in a nursing home for the past 6 years. I visit her there most days so would claim to be a stakeholder with some useful insights to offer. Stakeholders in my book are a wider group. In this example my Mum is obviously the 'user' but due to her advanced dementia she is unable to be 'involved' or participate in any meaningful way. However in the 6 years I’ve been visiting I've only once been asked (by CSCI) for my views. Whether there's a level playing field or not will I suspect depend very much on the type of service.
- Q. What values are important for a health and social care quality regulator?
- R. Fairness/rigour/evidence based judgements/consistency/honesty/relentless focus on service users
Let's see what others think!
Some thoughts on this:
- 1) Success = improvements in measures Joe Public would expect, so reductions in SUIs, increase in patient satisfaction etc. Also leading indicators about regulatory activity, e.g. numbers of inspections, amount of enforcement activity etc.
- 2) A credible regulator is involved in research > developing published standards > measuring performance against same standards > enforcement > feedback loop to improve standards
- 3) Patient involvement essential. However start with the basics - a credible complaints system. Currently a member of the public who complains about wrong site surgery is likely to have their complaint added to the intelligence file ...
- 4) CQC needs to become a regulator with teeth, following the 'values' of other regulators - e.g. targeting, proportionality, consistency, accountability etc.
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