Time to scrap the Care Quality Commission

The only thing the social-care monitoring quango has done is nourish tick-box culture at the expense of patient care.
The 2011/12 Care Quality Commission (CQC) report on the state of health and social care in 13,000 services in England has just been published. It focuses specifically on whether health and social care services are meeting some of the essential standards by treating people with respect and dignity and involving them in decisions about their care. These care aspects were chosen because ‘our inspectors are seeing a growth in services that are struggling to cope with the pressures on them. Most of all, this affects those who are unable to speak up for themselves.’ Negative headlines from the report’s findings were widely quoted in the media with one source, the Guardian, reporting ‘one in 10 patients are denied respect and dignity, 15 per cent are not fed properly and 20 per cent have their care and welfare neglected’.

While exposing neglectful care may win it plaudits, the CQC is unable to comprehend that the task-oriented approach to care which is now so commonplace has culminated in the tick-box culture the CQC has helped to foster. The CQC (and its predecessors) have been developing this watchdog role since 2004 and it’s worth asking what, if anything, these state-appointed monitors have contributed to health and social care during that time - apart from undermining leadership, interrupting healthcare delivery, holding organisations to ransom and becoming a massive policing industry.

Three regulators were merged in 2009 to establish the CQC. It is a quango with a brief to regulate for health and social care services in England. It checks that care providers such as hospitals, dental practices, ambulances, care homes, even people’s own homes comply with 16 essential government standards. Providers must produce evidence that they meet these standards.

Some of the standards - like the clinical ones - appear more justifiable than others, but all are bureaucratic, onerous and burdensome. Other standards are viewed with scepticism, even cynicism, by staff. For example, there are standards relating to treating patients with dignity and respect and involving people in decisions about their care. What constitutes ‘evidence’ in these areas is subjective – for patients, service users and CQC inspectors (despite protestations and denials to the contrary). Evidence has to be gathered and appended to support elements.  This has to be corroborated by patients and service users. A small backroom industry is needed in each organisation to gather, receive, process, verify, consider, seek amendments, reconsider and approve evidence before a self-declaration is made to the CQC stating that the organisation considers that it meets the standards. If the organisation does not think it is meeting the standards then it must explain why not, detailing the measures it will undertake to address the deficits.

The CQC’s reputation took a nosedive after an estimated 1,200 patients died at Stafford Hospital between 2005 and 2009 having suffering neglect, indignity and shoddy care. Counsel for the public inquiry into the Mid Staffs hospital scandal called into question the CQC’s leadership then and its ‘unhealthy organisational culture’, while the National Audit Office said its failures had risked ‘unsafe or poor quality (patient) care’.

Then in 2011, there was the horrendous Panorama exposé of the abuse that vulnerable residents at Winterbourne View care home were subjected to. The CQC was accused of ignoring a whistleblower’s information about the sub-optimal care provided to residents there. The CQC’s knuckles were severely rapped, forcing it to admit to an ‘unforgivable error of judgment’ and to reconsider its care-review system.

In February 2012, Cynthia Bower, the chief executive of the CQC, announced her resignation amid widespread criticism of the organisation. And in March 2012, the Commons Public Accounts Committee reported the CQC still had a ‘long way to go’ to become an effective regulator.  Under David Behan, who replaced Cynthia Bowe, the quango has gone into overdrive in an attempt to re-establish its legitimacy and to regain public trust, so it is throwing its weight around and showing its teeth by identifying poor care in services that might have previously have passed its inspections.

The stultifying effect that these inspections have on staff, whether delivering care or collecting and processing the ‘evidence’ needed for the regulator, is palpable. Governance and its imperatives dominate work life. In fact, the CQC is just one of the many organisations that scrutinise aspects of the NHS and Social Care. Others include:
Monitor - the regulator for foundation trusts
NHS Litigation Authority – risk management standards
NICE (National Institute for Health & Clinical Excellence) - guidance and quality standards
Connecting for Health – information governance and records management
MHRA (Medicine and Health Care Products Regulatory Agency) – for patient safety and medical devices alerts
HQIP (Healthcare Quality Improvement Partnership) – clinical audit
OfSTED – for child safeguarding
NHS Employers – for NHS employment check standards

This is a huge and heavy burden on the NHS and social care, which limps from one inspection to another with barely room to breathe in between, let alone do any work.

Service managers (on the whole) and most frontline staff have little confidence in these inspection processes and many privately consider them a complete waste of their time because they demonstrate nothing useful apart from the fact that they can produce ‘evidence’ to feed the beast. For social-care departments and institutions, getting a positive CQC report means getting the organisation off their backs (even if they play the game and flaunt positive findings) while getting on with the real job. If savvy, they remember to collect and store ‘evidence’ for the next year to help make the process less tedious and onerous.

Meanwhile, the CQC focuses on services that don’t do well enough. The result is that the service in question ties itself in knots while attempting to correct its failings to the CQC’s satisfaction, producing mountains of evidence to demonstrate how problems have been rectified. Nobody can ever relax, however, because spot checks can be made with little notice on any service provider. All this scrutiny has become such a burden on care providers that specialist advisers now offer to help them meet the CQC requirements - yet another expense to bear.

However difficult it is to collect factual evidence to demonstrate that a standard is being met, it is the intangible aspects of the CQC standards that prove most difficult and a huge amount of creative brain power is needed to produce the ‘right’ kind of evidence.

Take the engagement and involvement agenda as an example, the work area I was involved as member of staff at an NHS trust over a number of years. Putting patients at the heart of the NHS was the mantra before the current ‘no decision about me without me’ political catchphrase was adopted in the Liberating the NHS 2012 document. We had to demonstrate that we had invited patients’ views, had systems in place to do this, considered what they said, took their views into account and then let them know what difference (always reported positively) their views made. We were expected to demonstrate to the CQC that patient input was making a difference.

The feeling among many staff and some patients that this was a complete waste of time was fuelled by the fact that many people who had the time and energy to get involved were derogatively called ‘the usual suspects’: well-meaning, unrepresentative people (despite being called patient representatives or representative patients as we deftly learnt to call them), who were mostly elderly and some of whom had an axe to grind. Understandably, it took many years to understand the complexity of NHS and social care in order to begin to play a semi-useful role. It was effectively a charade; the Emperor’s New Clothes phenomenon. Who could criticise the sacred cow that was patients’ views? So a whole industry grew up around it and staff went along with it because they had to be seen to.

So around the country, yet another industry developed to make this ‘involvement’ happen. Some initiatives were centrally directed, some were developed by consultants and advisors, while managers like me were recruited specifically to push and steer the agenda. Finding creative ways of collecting patient views dominated our working lives. How could we find people willing and able to sit on committees, to wade through reams of boring reports, often at short notice and then participate in important decision-making meetings? We all played the game until some of us could tolerate it no longer and left.

Now the new health secretary Jeremy Hunt has said that he’s unhappy with the CQC system and is asking the Nuffield Trust to recommend how the NHS could use a grading system similar to what Ofsted does in schools. Somehow, I can’t see Nuffield taking the radical approach that’s needed and recommending an end to audits, inspections and regulation so as to enable managers and staff to do the job they’re employed to do. Nor do I envy general practices who are to be ‘welcomed’ into the bosom of the CQC regulatory family in April 2013. The best way to improve patient care would be to scrap the CQC.

First published here Jan 2013