Too many trust challenges will undermine CQC inspections

“It is a very, very big jigsaw”, claimed Sir Mike Richards, the chief inspector of hospitals, in his exclusive interview ahead of Thursday’s publication of the first trust ratings produced under the Care Quality Commission’s new inspection regime.

‘The CQC will have to travel quickly if it is to achieve its goal of credibly rating all 141 acute trusts by December 2015’

Sir Mike’s approach to completing that jigsaw – consisting of assessing performance across eight services judged on five criteria for each of a trust’s individual sites before issuing one of four ratings – is to combine data with the judgement of inspectors. This approach will reassure many, who feared the tick-box approach of old. It also tallies with reports the new inspection process is more informed and thorough.

• First three trusts rated in new-style CQC regime

However, the same trust leaders who speak positively of the inspection process say the reviews it produces still often fail to give an accurate picture of performance. We report how one leading trust successfully challenged the CQC’s decision to issue a warning notice; HSJ understands others have secured significant changes to inspection reports by challenging CQC findings.

This is, of course, before the inspections have begun to be translated into ratings. The stakes will be even higher then and the incentive to challenge greater.

Steep learning curve

By Sir Mike’s own admission, he and his inspection teams have to take account of “multiple different things” when deciding each individual service rating and are on a steep “learning curve” about how to translate that into a meaningful overall rating and to achieve greater consistency. It is a learning curve the CQC will have to travel quickly if it is to achieve its goal of credibly rating all 141 acute trusts by December 2015.

The difficulty will be exacerbated by the context within which the inspections will be taking place. It is reasonable, for example, to expect the CQC to pay greater attention to cost improvement plans to check if they are undermining care as financial constraints grow tighter.

‘Trust leadership will be partly judged on its willingness to be transparent about problems before an inspection even begins’

Those putting together these plans now face the devil’s own job determining how the CQC’s inspectors will apply their “judgement” to any decision they might make. They may understandably decide to err on the side of caution - and find themselves out of the CQC frying pan and into the Monitor or Trust Development Authority fire.

The challenge for chief executives is just as sharp-edged. Sir Mike states trust leadership will be partly judged on its willingness to be transparent about problems before an inspection even begins, saying: “If we find problems in maternity… and they haven’t mentioned them to us, then either they were trying to pull the wool over our eyes, or they don’t know about it themselves, and they should do.”

Second guess the inspectors

This is sensible and appropriate, but once again chief executives will be left to second guess how inspectors will exercise judgement in determining which problems needed to be flagged up in advance.

‘Tension between the inspector and the inspected is to be expected and too little challenge would suggest an overly cosy relationship’

As the number of trusts with ratings grows, the way the CQC exercises its judgement in certain circumstances will be carefully examined - and any inconsistency will be robustly challenged, especially by those who feel hard done by.

This, in turn, will put pressure back on the inspectors, who – not wanting their judgements to be challenged – will want to cross reference decisions made about other organisations, creating another layer of complexity.

Tension between the inspector and the inspected is to be expected and too little challenge would suggest an overly cosy relationship. But too many successful challenges will undermine the credibility of the process and the confidence of inspectors. Sir Mike claims the new inspection system is “more robust and reliable and fair than anything we’ve had before”. Most would agree, which would make any serious problems it encounters so damaging to the growing reliance on quality regulation