Working at change: responding to the Francis Inquiry

MBA students in the United States are now taught about the Mid Staffordshire NHS Foundation Trust Public Inquiry as a case study of institutional behaviour when leaders lose sight of their values. Will they one day also use the Care Quality Commission (CQC), as a case study of just how fundamentally a failing institution has to change?

I know it’s stating the obvious, but I’m still amazed at how wrong decisions about the direction of an organisation (that are often relatively quick to make) can take literally years to turn around.

Last week the CQC completed the exercise of matching our inspectors to sectors of health and social care. This is a major change of principle: the end of a generic workforce is within sight. No-one is happier about this than inspectors themselves.

But inspectors coming to my bit of CQC – acute hospitals and ambulances – will find it’s not a case of them returning to their comfort zone. I’m asking them to join us in working at change, and then working at the next stage of change.

People struggle to understand how CQC, Monitor and the Trust Development Authority (TDA) fit together

We spent a full nine months consulting and engaging, internally and externally, on the values and purpose of CQC after Francis. We’re currently focusing on our culture. Helene Donnelly – the whistleblower from Mid-Staffordshire – and Emma Pullar – the sister of a man who was abused at Winterbourne View and abused again at the next hospital he went to – both recently came to CQC’s leadership team to tell us about the reality of what they experienced.

We’re trying to keep reflecting on our values and purpose, and how they translate to culture and behaviour. They are the anchors that enable us to contain uncertainty, keep focused and make change happen.

Because our change programme does, of course, involve uncertainty. To accelerate it, we introduced the new approach when we felt it was ‘good enough’. That’s code for some bits being missing initially, other incomplete, and some as yet untested. It means there’s pretty much on-going change at CQC until we reach what we hope will be a steady state in the spring.

Since January, our inspections now rate acute trusts – an assessment of quality overall and in individual services, made by teams of specialists, rather than generic inspectors looking for non-compliance with regulations. This hasn’t touched all sectors yet, or all our staff, and we’re learning as we go. It is a massive change, with layers of system and culture change behind it in CQC. For a national body, it’s a rapid change too.

I want to end on an issue that came up in questions at the Nuffield Trust event: The Francis Inquiry: the impact one year on. It seems that people struggle to understand how CQC, Monitor and the Trust Development Authority (TDA) fit together. I think this is because Monitor and the TDA need to know about quality of care and CQC wasn’t competent to comment on it in the past. As a result each agency developed different ways of commenting on quality.

Our new CQC ratings will be the single, authoritative voice on quality. We will also be authoritative on clinical sustainability. It’s a measure of how much better we are working together now that I know Monitor and TDA are up for that – although we have only started doing so in one sector so far and we need to demonstrate that we can do it reliably in all.

That will clarify at least one aspect of the debate about how the regulators all fit together…

Alex Baylis is Interim Head of Better Regulation at the Care Quality Commission. Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors’ own.