Monitor executive chair Bill Moyes believes the deaths at Mid Staffordshire must lead to system wide change for how quality is regulated - but the scandal should not be allowed to compromise the foundation model, he tells Dave West
The appalling care standards at Mid Staffordshire Foundation Trust, revealed by the Healthcare Commission in March, raised questions over Monitor’s ability to ensure patients were safe and receiving good care in foundation trusts.
The case shone a spotlight on the regulator’s own procedures, NHS regulation and performance management in general, and the freedoms given to foundations.
Not just the CQC but also the DH. All parts of the system are saying, “Actually we got a bit sloppy”
The regulator has attempted to allay concerns this week by proposing across-the-board changes to how quality of care is regulated and managed. It also defends its own role and the idea that independently regulated hospitals are safe enough to keep their freedoms.
The proposals are in a report, published today, based on recommendations made in a review by consultants KPMG, commissioned by Monitor.
One of the areas highlighted as in need of change is how organisations worked together - particularly Monitor, the Department of Health and the Care Quality Commission, which took over from the Healthcare Commission two weeks after it published its report into Mid Staffs.
The KPMG review says: “Monitor will not receive a high degree of assurance over quality performance… until the potential gaps, overlaps and uncertainties in roles, responsibilities and ways of working across the stakeholders have been resolved.”
In an interview with HSJ about the report, Monitor executive chair Bill Moyes says the new powers of the CQC to register and deregister services or entire hospitals have complicated the situation further.
He says: “It is an area the legislation has caused to be more complicated than it used to be.
“Parliament didn’t describe how it wanted these two bodies to exercise their powers [in relation to each other], so the two bodies have got to decide.”
One way towards improving this situation is already under way - the drawing up of a memorandum of understanding between the CQC and Monitor setting out, for example, how often they meet and when they exchange certain information. It is expected to be agreed imminently.
Mr Moyes is confident a clearer system is being established although it will depend on development of the registration system, and further government decisions on how quality will be performance managed.
“The [memorandum of understanding] will start the process of prescribing. There’s a little bit of working it out as we go along. I’m not going to conceal that.
“We can only really work it out sensibly when registration is fully developed, and we understand exactly how regulation is going to operate, and probably we have one or two cases,” he says.
Asked who foundations can expect to intervene on quality matters - and when - Mr Moyes says he thinks there will never be a set formula. He says: “We will decide on a case by case basis. In some cases it will be the CQC, in some cases it will be us, in some cases it will be one after the other.
He adds: “They [the CQC] will intervene to sort out clinical problems and we’ll be coming in to say to the board, ‘What can you do to make sure you don’t get yourself into this situation again?’”
Mr Moyes’ call for system wide change follows concern about it “sharp elbowing” the CQC to allow it to move into quality territory. For example, Monitor had looked at CHKS providing it with information.
Mr Moyes says he cannot “devolve” responsibility for regulating foundations, and the option to go to other “specialists” for help remains. But he is clear that inspecting care quality is the CQC’s domain.
“Clinical quality is the CQC’s job, that’s not our job. I do not see Monitor ever having a clinical team,” he says.
“The fact is there was a gap in the way the bodies worked. I think the solution is to say we now recognise we do need to ask certain questions and other bodies now recognise they do need to give us certain information,” he says.
“Not just the CQC but also the Department of Health. All parts of the system are saying, ‘Actually we got a bit sloppy’,” he adds.
CQC chief executive Cynthia Bower welcomes Monitor’s reports. She says: “It is absolutely clear we are the source of advice for Monitor, both in authorisation and ongoing compliance. It is clear the CQC will make the definitive judgement.”
The reports also propose that a new “quality bar” for the authorisation of foundation trusts be agreed. The previously clear standard of three stars from the Commission for Health Improvement, and its successor the Healthcare Commission, was lost when the latter changed its annual health check standards.
Mr Moyes says the new “bar” will again depend on how the CQC develops its regulation and how the Department of Health decides to manage quality in future, which he thinks is likely to become clearer in the operating framework.
Ms Bower says the CQC has consulted on its registration requirements and is clear these will form new standards for quality.
The main task for Monitor set out in the reports is to improve its regulation of clinical governance at board level. It is considering more regular reviews of how foundations check, manage and improve quality of care.
The dilemma here is the lack of an agreed definition of good clinical governance. As a result Monitor is working on one.
Mr Moyes says: “Our job is to ask the questions: ‘Does this board know what it’s doing? Does it get the right information? Does it ask the right questions? Or is it a passive board?”
Foundations are likely to welcome greater clarity and alignment of the system. However, ideas like new checks on clinical governance and moving the quality bar may prompt concern about a greater burden of central control and regulation.
Many quality and safety experts say improvement is hindered if driven by top-down performance management or regulation.
Mr Moyes says establishing terms with the CQC and the DH will avoid this. He expects performance management to be increasingly local, but adds that it is “entirely legitimate” for the DH to set national standards.
Avoiding perceptions of top-down compulsion was a reason given by former health minister Lord Darzi for not requiring external audit of quality accounts. However, Monitor is planning to require external audit, starting in some capacity next year.
Mr Moyes says: “I want people reading quality reports to be assured by someone reliable that the data is sound and the description offered of quality is a reasonable description - [so] they don’t just pick the things that put them in a good light but they give a rounded picture.”
The Mid Staffs effect
The degree to which Mid Staffordshire has damaged the cause of foundation independence and independent regulation still remains unclear - although ministers have already mooted changes.
The government set out proposals in July - which it linked to the care scandal - to give the health secretary new powers to request Monitor intervenes in a foundation trust and potentially de-authorise it. If the regulator decides no action is needed, it would have to “justify its position” within seven days.
Mr Moyes has strongly opposed the plan and believes it will compromise Monitor and foundations’ freedom from political interference. But he has yet to be assured the proposal will be changed.
He says: “We are having lots of discussions with the department but we are certainly ready to respond and make clear what we think. I’m not sure the department really thought out what it was saying when it talked about writing to require intervention. That would be a huge step for us.”
Some have asked why, in light of Mid Staffs, foundations’ freedom should continue. In response, Mr Moyes highlights similar cases that occurred in NHS trusts. For example, Maidstone and Tunbridge Wells where the Healthcare Commission concluded in 2007 that C difficile had killed at least 90 patients. “The department was overseeing that hospital and exactly the same kind of things happened there.”
Mr Moyes argues: “I don’t think there’s any evidence that bringing [regulation and performance management] back into government would produce a better result.
“It didn’t in Maidstone and Tunbridge Wells and there’s no reason think that would [prevent] other cases in the future.”
After the Mid Staffs storm
Changes already put in place by Monitor in response to Mid Staffs
- Seeks written confirmation on quality from CQC and DH
- Regular meetings at senior and staff levels between Monitor and CQC
- Seeks more information from DH specialists
- “Memorandum of understanding” with CQC on roles at authorisation, compliance and intervention
- Asks for more evidence on clinical risks of cost improvement plans
- Better documentation of actions, including decisions not to intervene
Changes in the pipeline
- Discussion on new “quality bar”
- Commissioned study on clinical governance
- Agree memorandum of understanding with Department of Health
- Review of involving quality in business plans
- Seek more clinical management expertise, possibly by hiring
- Examine quality metrics, with possibility of using for compliance
- Consider periodic “in depth reviews” of foundations
- Develop and publish intervention manual
- Better communication with foundation governors
- Clarify CQC role as it develops registration system
- Acute care
- Annual health check
- Ara Darzi
- Bill Moyes
- Board Talk/governance/assurance
- C difficile
- Care Quality Commission (CQC)
- Cynthia Bower
- Department of Health and Social Care (DHSC)
- Foundation trusts
- Infection control
- MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST
- MID STAFFORDSHIRE NHS FOUNDATION TRUST
- Patient safety
- Quality accounts