A new start for the Care Quality Commission?

Today we publish our response to the Care Quality Commission’s (CQC) consultation on changes to the way it inspects, regulates and monitors care services: A New Start.

Our response builds on the findings from our review of provider ratings, commissioned by the Secretary of State for Health, as well as drawing on the expertise of various members of our team with a past in regulation.

Back in November 2012 when work started on the ratings review, we could not have predicted the 290 recommendations cited by Robert Francis QC in response to the failings in Mid-Staffordshire NHS Foundation Trust, nor the extensive regulatory changes that were to follow.

An aggregate rating could hide pockets of poor performance within an organisation as trusts are large and complex institutions

Set against the changing policy landscape and the high-profile internal challenges faced by CQC, A New Start offers a glimmer of optimism for the future; something that is badly needed.

Throughout the engagement process on ratings, we gathered a lot of intelligence about the broader role of inspection and surveillance that didn’t make it into the final report. We heard plenty of grievances about the problems associated with generalist inspection.

I certainly don’t recall any strong advocates for generalist inspection and many social care providers spoke nostalgically about the specialist inspections of the Commission for Social Care Inspection.

CQC’s proposal to move towards a more specialist form of inspection is to be welcomed as are the appointments of Professor Sir Mike Richards as the Chief Inspector of Hospitals and Andrea Sutcliffe (who was a member of our ratings review working group) as the Chief Inspector of Social Care.

In Rating providers for quality: a policy worth pursuing? we concluded that the benefits of implementing a ratings system would be more favourable for providers of social care and for general practice.

On this basis, we suggested that ratings should be developed first for social care. Such providers tend to be more homogeneous and during our engagement exercise, there was strong stakeholder support for re-introducing ratings for social care providers.

Given the recent drive by the Secretary of State to tackle failure in the NHS, and recent press headlines, it is perhaps unsurprising that CQC will launch its new inspection regime in acute trusts first. However, this will not be an easy task.

An aggregate rating could hide pockets of poor performance within an organisation as trusts are large and complex institutions. Instead, the goal for hospitals should be to introduce ratings that drill down to a departmental or service level.

During the engagement exercise, some stakeholders expressed considerable anxiety about the introduction of single ratings for hospital providers. The fast pace of implementation proposed by CQC will do little to lesson those concerns.

In mid-July, 18 chief executives received letters explaining that between August and December 2013 their trusts would be inspected and awarded shadow ratings under the new regime.

Six of those 18 trusts were identified as ‘high risk’ under CQC’s new surveillance methodology. One of the trusts, The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust issued a press release questioning the interpretation of the mortality data cited by CQC.

The chief executive explained that the trust had a specialist palliative care unit (unlike most acute hospitals) and that community provision for end-of-life care in the area was poor.

This demonstrates the difficulty of relying on mortality rates in isolation. Robust inspection has a vital role to play in examining an organisation and its local context in detail. However, the consultation document is rather vague about the standards that will underpin the inspection judgements.

Shadow ratings are expected to be published in December 2013 but further detail is not expected until the autumn when the Department of Health will issue draft regulations alongside draft guidance published by CQC on the Fundamentals of Care and Expected Standards.

Our review received many comments highlighting the dangers of placing too much significance on a single rating. Yet in the context of a new single failure regime, the consequences for trusts judged ‘inadequate’ may be severe.

Given the tendency for autumn publications to slip to January, inspections for the 18 trusts could happen before any further information is published. In an adversarial situation, this risks a protracted debate about the validity of the methodology and may prove to be a distraction from any serious issues identified through the inspection process.

In the interest of fairness, there should be an opportunity for stakeholders to craft and comment on inspection standards before providers are issued with ratings (albeit shadow ones) that could unduly influence their reputation for years to come.

In her recent blog Dr Jennifer Dixon CBE noted a number of barriers to good decision-making in Whitehall. One of the hurdles was the pressure to show results in a short period of time. CQC’s timetable for implementation is not just quick, it is utterly ferocious.