It has been open season on the Care Quality Commission for some time now. The Panorama exposé into the abuse of patients at Winterbourne View, a private hospital for people with learning difficulties in Bristol, triggered a wave of criticism culminating in a highly critical report from the Public Accounts Committee last week.
The Committee went well beyond its value for money remit, criticising the CQC’s lack of strategic focus and leadership, inconsistency of its inspection regime, failure to strike the right balance between registration and inspection, and the lack of measures of performance or impact of its own work. The Department of Health has also recently published the findings of its own Capability Review, setting out 23 recommendations which it expects the Commission to address focused on strategy and performance, accountability and governance, and the regulatory model.
The early reports into the events at Mid Staffordshire hospital also questioned the CQC’s predecessor – the Healthcare Commission – which gave the trust a clean bill of health at the time it was responsible for some serious failings in the quality of care. The full public inquiry, led by Robert Francis QC, is yet to report. However, from the evidence presented, the early indications are that it will have something to say about the role of the quality regulator and the strategic health authority which was led at the time by Cynthia Bower, currently chief executive of CQC. Given this, it is perhaps of little surprise that she has decided to step down later this year in a managed transition.
These reports all highlight some of the challenges the Care Quality Commission has faced since it was set up in 2009. But are we expecting too much from a quality regulator?
The Commission had a troubled beginning, exacerbated by a lack of clarity about its role. Politicians must bear some responsibility for this – it is no good preaching the virtues of light touch regulation, and then blaming the regulator for not taking a more interventionist approach when problems emerge. They are also responsible for giving it such an enormous and complex task. As well as undertaking inspections, the Commission has registered 23,000 organisations in 40,000 locations since it was established and will embark on registering 10,000 GP practices later this year. Only last week, it emerged that it had been asked by the Secretary of State to inspect more than 300 abortion clinics at short notice. As the Commission’s chair Jo Williams pointed out in correspondence obtained by the BBC, this will necessarily reduce its capacity to inspect hospitals and social care providers.
There are somewhere in the region of 1 million patient contacts every day in the NHS. Add to this the fact that approximately 1.7 million adults received social care services following a local authority assessment and the scale of the challenge for CQC is clear. It is impossible to expect a regulator to prevent the incidence of poor quality care and yet it often appears it is the first to be blamed.
Frontline workers are the first line of defence against poor quality care – it is the responsibility of every clinician and care giver to speak up when they see care that is below acceptable standards and to act to remedy this. But we know that staff often find this difficult. They may work in organisations that are disempowering, that alienate them from the people they are caring for, or where there is a blame culture that discourages them from speaking up.
It is vital that the boards and senior managers of provider organisations create an open culture of reporting and are held accountable for the quality of care. In the nuclear industry the senior person responsible for safety is able to report issues ‘outside the line’, that is outside their direct line management, to the Chair of the board or equivalent. Do we need to identify someone in every hospital who can go outside the line if they have significant concerns about the quality or safety of care without fears of repercussions?
While the CQC must address its shortcomings, it is time to move on to a wider debate about how to design a system of quality assurance that patients and service-users can have confidence in.