Cynthia Bower interview: replacing the 'light touch' with a firm grip

Care Quality Commission chief executive Cynthia Bower pauses when asked what external factors are behind the regulator’s plan to annually inspect each NHS and independent provider. It is a long pause - not exactly Murdoch-esque, but not entirely comfortable either.

The plan, reported in last week’s HSJ, would see providers, including those in adult social care, subject to unannounced inspections at least once a year. It is a substantial change: in the past year, the CQC’s “light touch” approach has meant only around 174 NHS trusts have been inspected by the regulator, letting about a third off the hook.

The subtext seems obvious: struggling regulator takes a tougher approach ahead of criticism from the public inquiry into Mid Staffordshire Foundation Trust and following a shocking care scandal. Throw in a mauling by health committee MPs and outraged patient groups and it is easy to reach a cynical conclusion about the rationale for its announcement.

Ms Bower is not legally permitted to talk about the Mid Staffordshire inquiry but she acknowledges that the Winterbourne View exposé last month, which revealed routine abuse at a care home for people with learning disabilities, has demonstrated the need to “cross the threshold” when assessing care.

However, the decision has also been largely inspired by the disappointing findings of the regulator’s reviews into dignity and nutrition in hospital trusts. Observations from the reviews, carried out in light of the health ombudsman’s damning February report into poor care of the elderly are being written into an overarching document.

But Ms Bower reveals, ahead of the document’s publication, that 18 per cent of trusts inspected were not compliant with standards related to older people’s care – a worse than expected result.

People power

“These are basic standards, we’re not asking for anything over and above what represents safe care for people,” Ms Bower stresses.

Elaborating on what inspectors discovered, she continues: “The biggest problem is about staffing. Sometimes it’s about numbers or skill mix but sometimes you have extremely well staffed organisations and it’s about how they recruit, train and support the people they have in place.”

She adds: “Some hospitals have absolutely got that nailed. And some just didn’t do that.”

Another problem cropping up in the reviews, as well as other NHS inspections, is safeguarding – a worrying area of weakness that is “undoubtedly” linked to the “training problem”, says Ms Bower.

She says the fact the findings were uncovered only after going into hospitals proved that “in the end there’s no substitute for getting onto the wards and seeing what’s going on, talking to patients, talking to clinical staff, and that’s really what the public wants us to do.”

It is this, added to feedback from patients and staff, that has convinced her of the need for more frequent inspections, she says. “It’s certainly not coming from political pressure at all, or the department [Department of Health],” she says. “We’ve been listening to what people have been saying about what they want the regulator to spend time doing.

“We came in with a very light touch, risk-based notion of regulation and I think that one of the things we’ve heard – both from our own staff but also from the public – is that they want inspectors on wards, greeting patients, talking to frontline staff, observing care.”

A short consultation is intended for the autumn, setting out the plans in more detail.

Although several senior NHS managers approached by HSJ welcomed the principle of unannounced inspections carried out “at least annually”, the Foundation Trust Network made its feelings known to the contrary within 24 hours of HSJ publishing its story last week.

Network chief executive Sue Slipman issued a statement questioning whether it was the “right way to use scarce resources when some places need more attention than others”. The statement added: “The value of being a risk regulator is that you identify the places you might need to inspect more regularly rather than spreading scarce resources more thinly.”

Ms Bower understands some will take this view, but stands firm. “Where people’s lives and wellbeing are at stake, [the public] don’t want to hear about light-touch regulation,” she asserts. “They want to believe that, informed by the best professional practice, and by patients and service users, [we are] getting out there and playing a very effective part in that system of assurance.

“That’s what the public want and actually a lot of the time that’s what the sector wants from us as well.”

She admits that the “punishing” task of registering 22,000 registered providers running out of 37,000 locations meant that “the number of inspections we did completely collapsed”.

But without financial assistance, it is unlikely the plans will come to anything. The CQC has asked the Department of Health for £15m to fund the new regime, including a 15 per cent boost to its 800-strong inspection workforce, and is developing a detailed business plan. As HSJ has previously revealed, the regulator has flagged its lack of resources as a major risk (news, page 9, 26 May).

This is one of the reasons it has already had to request that GP registration is delayed by a year to 2013. The delay is subject to a government consultation and will need to be voted on by both houses of parliament, but the DH is sympathetic to the move and the CQC is proceeding as if it were official. Ms Bower said this would provide time to make the registration process “slicker” before it applies to GPs. Resources have also been blamed for delays to “provider profiles”, the scaled down, publicly available version of quality risk profiles containing all the CQC’s information on each organisation. These are due to be ready by September, along with a general upgrade to make the regulator’s website more public friendly.

As part of its proposal to the DH, the CQC will emphasise the internal efficiencies it is making. Several people, including former Healthcare Commission chair Sir Ian Kennedy, have suggested the regulator could save money by merging with Monitor. The idea has gained extra ground due to the Southern Cross crisis, which commentators have argued might have been picked up sooner had the CQC been able to tackle poor financial performance in addition to its quality brief.

Unheeded calls

Monitor chair David Bennett rejected the concept of a single quality and economic NHS regulator at a health committee hearing earlier this month, and Ms Bower shares his sense of caution.

“Having a quality regulator that doesn’t have to be troubled by the money is enormously advantageous to the system,” she says, adding that this prevents trusts using financial problems as a “mitigation plea”.

“We don’t think about the money,” she insists. “We absolutely are focused on registering people, ensuring they’re compliant with essential standards, and if they’re not, taking action and publishing that. That’s a fine thing to be doing.”

She adds: “We’d welcome the economic regulator getting involved in adult social care.” This is a scheme reportedly being worked up by the DH.

Any savings that the CQC does make are aimed at freeing resources for a “massive increase” in clinical inspectors. At the moment only around 20 clinicians are used regularly, though as very specialist staff are often required this is not a static pool. A separate internal review into how the regulator uses clinical staff is being drafted with input from the Royal College of Nursing, and is expected in September.

Calls from professional regulators such as the Nursing and Midwifery Council for the CQC to go even further are likely to go unheeded.

Ms Bower justifies this: “We can play our part but the best chance of excellent care is the quality of the person sitting in front of you. We had lots of volunteers to do the [dignity and nutrition] work but we can only do so much. We need commissioners to play their part, professional regulation to play their part – and that’s a point Bruce Keogh [NHS medical director] has been making a lot – we need the providers and their boards to play their part.” The importance of professional regulation is a point she makes more than once during HSJ’s interview.

“We can step up to the mark… we’re a small but very significant cog in a large and very complex machine,” she says.