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Monitor should toughen assessments following scandal - Bennett

Monitor’s executive chair has admitted it is “very likely” University Hospitals of Morecambe Bay had “deep-seated problems” at the time his organisation granted the trust foundation status.

David Bennett told HSJ the regulator needed to further toughen its assessment process after major failings in the trust’s management and maternity services came to light within 12 months of its authorisation.

Mr Bennett is both chair and chief executive of the regulator. He is leading Monitor at a time when it must accelerate its authorisation work to meet the government’s 2014 expectation for all NHS trusts to become foundations, and months before its regulatory remit is extended to the whole healthcare sector.

The Care Quality Commission sent inspectors into Morecambe Bay in July 2011, nine months after it was granted foundation status. In September, the quality regulator reported “major concerns” about the maternity unit at the trust’s Furness General Hospital.

Monitor placed the trust in significant breach of its terms of authorisation, and commissioned in-depth reviews of its governance and maternity services. The reviews found a catalogue of governance failures and continued risks to patient care.

Mr Bennett told HSJ: “I accept that it’s very possible, very likely even, that there were issues – deeper issues – at the time of assessment.”

An independent review Mr Bennett subsequently commissioned from KPMG concluded there was “strong circumstantial evidence that deep-seated problems were probably there”, he added.

Mr Bennett said Monitor now had to ask itself whether it should “take steps to further reduce the risk that we miss something” in future assessments.

“Ultimately it’s a decision for the Monitor board. My personal view is, in simple terms, yes. Where there are specific indications of possible problems we should dig somewhat deeper, to reduce the likelihood that we’re missing something.”

In August 2010, Monitor reported on its response to the care quality scandal at Mid Staffordshire Foundation Trust, which also erupted shortly after the trust attained FT status.

The regulator said it would introduce a detailed “quality governance” assessment for applicants, to ensure, in part, that they were identifying and managing care quality risks, and taking action on substandard performance.

But asked if Monitor had applied these checks at Morecambe Bay, Mr Bennett replied: “The simple answer is no.”

Monitor had held “a discussion” internally about whether to conduct a quality governance review at Morecambe Bay but decided against it.

The trust was already most of the way through assessment when the new checks were introduced, he explained. Monitor did “take a limited look at quality governance” at the trust, but recognised it “would effectively be the last trust we didn’t do this procedure on”.

He added, however, that even if the checks had been in place he could not say “with certainty” that they would have picked up deeper problems that may have been present at the trust.

He suggested Monitor could strengthen its assessments by commissioning in-depth reviews – similar to the investigation it commissioned into the trust’s maternity services – when it had “specific indications” there might be problems at an applicant trust. He had “started the conversation with the CQC” about the two regulators working jointly on these reviews.

CQC director of operations Amanda Sherlock said she now believed there were underlying problems at Morecambe Bay in 2010.

“If the provider isn’t able to identify risk and take steps to mitigate those risks it is unlikely to be able to respond proactively to developing concerns, and I think that would be our view of where Morecambe Bay was at,” she said. “It didn’t know what it didn’t know.”

In June 2010 the CQC had carried out a responsive review of the Furness maternity unit, which identified no major concerns. But Ms Sherlock said she was confident the work the CQC had subsequently done to “refine” its assessments “would lead us to a different conclusion were we looking at the same circumstances today”. She added that the proposals outlined by Mr Bennett would be considered by the CQC board in April.

She acknowledged that, as with Mid Staffordshire, the drive for foundation status could have been “a distraction” for the Morecambe Bay board “when they should have been focusing on core elements of the quality of their services”. But since April 2010 “ourselves and Monitor are always mindful of understanding where there may be an over-focus on the attainment of foundation trust status”.

Readers' comments (4)

  • Heads should role at Monitor for this incompetence. Perhaps they should be investigated by an FT?

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  • I can't see how every Trust will be an FT by end of 2014, and I can see a number of FTs falling over. This is going to be a major embaressment. Circle and the private sector have no capacity and capability to fix this.

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  • I'm on a different track to comments above. I know there is no love lost between many Trusts and Monitor but I for one find it refreshing that someone is prepared to admit they (or at least their organisation) got it wrong and have work to do.

    There have been many sad stories in the HSJ about people doing their best in tough situations being held to account for situations at least partly outside their control in brutal fashion. This has to change.

    All I ask on behalf of the rest of the NHS is that Monitor take the same approach when faced with an NHS Trust trying to do the right thing, not quite getting there but putting it right!


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  • Dr Suparna Das

    It's good to read that clinical quality might be given more weighting, than it currently is, for the FT authorisation process. If I understand correctly, the authorisation process is prinicipally weighted in favour of financial metrics and am perplexed as to how a performance scorecard for a hospital can be so unbalanced. The post-authorisation compliance framework does indeed look at clinical quality governance but these are, by and large, process measures such as waiting times. There seem to be no outcome measures listed. Let's hope the NHS Outcomes Framework and NICE Quality Standards will change this.

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