Care Quality Commission: a case study in poor regulation – an MP agrees

From Steve Barclay’s blog, Steve is the Conservative MP for NE Cambridgeshire.

Yesterday’s Public Accounts Committee hearing was on the Care Quality Commission, the regulator for the National Health Service set up in April 2009 bringing three predecessor organisations together: the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission.  It has a budget of £139 million.

The hearing was like a case study in what went wrong in the last Government’s approach to regulation. The Care Quality Commission is an organisation that the National Audit Office concludes does not provide value for money; diverted huge resource to registration (yet failed to complete this on time); and did not undertake a single new investigation between May 2009 and June 2011 (its first two years). It has not launched a single prosecution because the hospitals it regulates are too big to fail and it has no audit system to ensure that there is consistency in the inspections it undertakes.

It also has no effective controls regarding the training of its inspectors, many of whom are reviewing clinical areas without any clinical qualification. It remains unclear exactly how many inspectors working for the Care Quality Commission have a clinical background and the Chief Executive has agreed to send the Committee a note providing a detailed breakdown. Given that just ten days of training was provided to inspectors in 2009/10 (some of which was e-learning) and that many inspectors work from home, I remain concerned as to whether inspectors are largely reviewing processes rather than having the expertise to question clinical staff. Where clinical staff are working for the CQC, there was no evidence to confirm that their clinical discipline relates to the issues they are inspecting.  For example, a dentist has a clinical qualification but will be less effective, I suspect, in inspecting the deaths of babies on a maternity unit than someone with clinical experience of working on such a unit.

One of the most glaring faults with the Care Quality Commission which I highlighted yesterday is the conflict between its role as a regulator that promotes whistleblowing and a culture of openness within the NHS, and the gagging clauses imposed on departing CQC staff by its own Chief Executive. It is quite remarkable that a distinguished member of the CQC’s own board, who has 11 years experience as a Mental Health Commissioner, stated “My endeavours to provide robust scrutiny and challenge led to my professionalism being challenged.  Doubt was cast on my mental health and my performance.”

Another of yesterday’s remarkable revelations was that a regulator responsible for improving the quality of healthcare nationally has, in the view of the Permanent Secretary of the Department of Health, a flawed strategy: the management information provided of its own board is solely quantitative, not qualitative. In short, they are simply measuring how many boxes they tick rather than the quality of the work they do. If they cannot get their own strategy and management information right, what authority do they have when telling those they regulate how to do things?

Another disturbing revelation was that senior management, in order to protect their own reputation, changed the regulator’s approach to news management by ensuring information was circulated on a local and regional basis rather than nationally.  This had the effect of playing down problems, when wider circulation of the lessons to be learned could have helped patients in other areas of the country.

Yet another failure was the decision by the Chief Executive of the CQC Cynthia Bowers to scrap the dedicated whistleblower line, previously manned by investigators.  Instead, whistleblowers were put through to a general helpline where we know that calls were missed. One such case led to the Panorama investigation of Winterbourne View where abuse was taking place and CQC ignored more than one call from a whistleblower. We do not know how many other scandals were missed where abuse might still be continuing.

As readers of my blog will know, I have been campaigning for some time for a change in the Department of Health policy as it applies to whistleblowers. At yesterday’s hearing, the Permanent Secretary at the Department of Health, Una O’Brien, agreed to look again at the circulars sent out by her department in 2004 which allows health bodies to sign gagging clauses to silence staff.  She has agreed to send a note to the Committee within the next week and I hope she will take the opportunity to finally change their policy

It was also far from impressive to hear – from the Chief Executive of the CQC – that Parliament had been misled when it was told in the Annual Report that twice as many inspections had been carried out as was in fact the case. The Chief Executive of the CQC suggested that this was a typo. Yet, she was still unable to say when Parliament was informed of the correct information. An error relating to an additional 7,500 inspections is sufficiently large that it is reasonable to expect that it would be spotted. She has said that she will write to clarify the chain of events.

In short, the registration process applied by CQC was flawed. Not a single major investigation was undertaken in the first two years. By contrast, one of their precursor organisations, the Healthcare Commission, undertook 16 major investigations in 5 years identifying significant issues such as the importance of C-difficil. The number of inspections was half the actual number claimed and no prosecutions have been undertaken. The dedicated whistleblower line was scrapped and the news management has sought to play down issues, in order to avoid bad publicity for the NHS. Despite its evident problems, the CQC management underspent against its budget in 2009/10.

For providing leadership to this organisation, Cynthia Bowers is paid £198,000 annually in salary and currently has a pension pot of £1.35m which, bizarrely, has gone up by £421,000 in real terms in the last two years. Ms Bowers suggested this was another typo or error in the Annual Report.

The Monday Morning Quote #152

“Man is made by his belief. As he believes, so he is.”
Johann Wolfgang von Goethe

Ever wondered what Bridge2Aid does?

I met Jem Patel of JSP at Manchester Airport Hilton on Thursday where we were both part of the BKH meeting. He was telling me about the film that he has produced for Bridge2Aid about what actually goes on in Tanzania. I recommend it to you and hope that it might well encourage you to take the step to support Bridge2Aid.

For more on Bridge2Aid take a look here.

GDC updates advertising regulations

The General Dental Council has updated its rules on advertising, I wonder how many websites will need to be amended to comply?

Please don’t shoot the messenger.


Guidance on ethical advertising

All information or publicity material regarding dental services should be legal, decent, honest and truthful.

Advertising by dental professionals can be a source of information to help patients make informed choices about their dental care. But advertising that is false, misleading or has the potential to mislead patients is unprofessional, may lead to referral to fitness to practise proceedings and can be a criminal offence.

Patients may be confused and uncertain about dental treatment so you should take special care when explaining your services to them. This includes providing balanced, factual information enabling them to make an informed choice about their treatment. Do not exploit the trust, vulnerability or relative lack of knowledge of your patients.

Misleading claims can make it more difficult for patients to choose a dental professional or dental services and this can lead to expectations which cannot be fulfilled and, in more serious cases, can put patients at risk of harm from an inappropriate choice.

Patients can check with us that their dental professional is registered and whether they are on a specialist list, but they are more likely to rely on information that you provide such as practice leaflets or certificates on the practice wall.

The onus is on you to be honest in your presentation of your skills and qualifications. If you make misleading claims, you may have to justify your decisions to the GDC through our fitness to practise procedures.

Advertising services

Whenever you, your practice, or any place where you work as a registrant, produce any information containing your name, you are responsible for checking that it is correct.

You must:
i) ensure information is current and accurate;

ii) make sure that your GDC registration number is included;

iii) use clear language that patients are likely to understand;

iv) back up claims with facts;

v) avoid ambiguous statements; and

vi) avoid statements or claims intended or likely to create an unjustified expectation about the results you can achieve.

Advertisements and other practice publicity must make clear whether the practice is NHS, mixed or wholly private.

Only recommend products if they are the best way to meet a patient’s needs.

If you wish to offer services which your training as a dental professional does not qualify you to provide, make sure you undertake appropriate additional training to attain the necessary competence. Do not mislead patients into believing that you are trained and competent to provide other services purely by virtue of your primary qualification as a healthcare professional, but make clear that you have undertaken extra training to achieve competence.


In line with European guidance(1), for all dental professionals providing dental care mentioned on the site the following information must be displayed:
i) their professional qualification and the country from which that qualification is derived; and

ii) their GDC registration number.

Dental practice websites must display the following information:
i) the name and geographic address at which the dental service is established;

ii) contact details of the dental service, including e-mail address and telephone number;

iii) the GDC’s address and other contact details, or a link to the GDC website;

iv) details of the practice’s complaints procedure and information of who patients may contact if they are not satisfied with the response (namely the relevant NHS body for NHS treatment and the Dental Complaints Service for private treatment) and

v) the date the website was last updated.

Update the information showing on your website regularly so that it accurately reflects the personnel at the practice and the service offered.

A dental practice website must not display information comparing the skills or qualifications of any dental professional providing any service with the skills and qualifications of other dental professionals.

Specialist titles

Only dentists who are on a GDC specialist list may use the title ‘Specialist’ or describe themselves as a ‘specialist in….’

Dentists who are not on a GDC specialist list should not use titles which may imply specialist status such as Orthodontist, Periodontist, Endodontist etc.

There are no specialist lists for dental care professionals. Dental care professionals should ensure that they do not mislead patients by using titles which could imply specialist status, such as ‘Smile specialist’ or ‘Denture specialist’.

Registrants who are not on a specialist list should not describe themselves as ‘specialising in…’ a particular form of treatment but may use the terms ‘special interest in..’, ‘experienced in..’ or ‘practice limited to..’.

Honorary degrees and memberships

Patients may reasonably believe that if you put a qualification after your name, it has been ‘earned’, that is, it represents a particular level of academic achievement. This may not be the case where a degree is honorary. Listing memberships or fellowships of professional associations or societies can also mislead. The letters may imply to the public that a registrant has attained a certain level of skill which in fact may not be the case.

(1) The Council of European Dentists’ (CED) EU Manual of Dental Practice contains extensive information on oral health systems as well as legal and ethical regulations across the EU. In particular this includes the Code of Ethics for Dentists in the EU for Electronic Commerce which covers the content of websites
General Dental Council 37 Wimpole Street London W1G 8DQ T +44 (0)845 222 4141 F +44 (0)20 7224 3294 E W

Exciting Opportunities in Mwanza!

From those great people at Bridge2Aid

Exciting Opportunities in Mwanza!

As you may know, we run a Dental Clinic in Mwanza, Hope Dental Centre (HDC). The profits of the Clinic help to fund the work we do in training medical officers in Emergency Dentistry in Tanzania.

It’s becoming very clear early into this new year that our work here in Tanzania is growing at an exciting pace. To help with these changes, we require more people to join our team and we have 2 exciting opportunities available.

HDC Business Manager – to enhance the clinic systems and processes ensuring the clinic is running efficiently and effectively, giving the patients a positive experience.

HDC Principal – to promote efficiency and quality within HDC and ensure all clinical procedures are delivered to a high standard.

Both roles are for 12 – 18 months and would be ideal for a married couple or 2 individuals. Assistance with living expenses will be available.

If you are interested or would like more information, please contact before 10th February 2012. We are looking for these positions to begin in September 2012 or before if possible.

We look forward to hearing from you!

“COPDEND claims success despite widespread concerns” says GDPUK

The new system for recruiting Dental Foundation Trainees is a disgrace, putting final year students through examinations that are without test and trial is at best ill judged. Yet again a patrician attitude of “we know best” is obvious to see. For one sixth of all final year students to be put in a position that they will not be able to get a post for at least a year and will this have to twiddle their thumbs before joining the cattle market again in 12 months.

The final year of a dental course is stressful enough with the Beecher’s Brook of finals looming, now this fiasco has added to the worry for undergraduates and their families. Put yourself in the position of the parents who cannot understand how their son or daughter has spent 5 years studying, may well have never failed an examination and been a model student yet will not be able to work as a dentist on graduation. “So you’re good enough to graduate, good enough to be FULLY registered with the GDC, but not good enough to treat patients for the NHS?”

Adding insult to injury is the rule that a dental graduate must commence Foundation Training within 18 months of graduation in order to work in the NHS. Yet another bit of dabbling by academics and DoH that further reduce their credibility. Perhaps the next stage will be for the corporates to take new graduates straight in to the UDA sausage machine and brainwash them that this is the only way of working. How long before a university accepts sponsorship so that we see the ADP/IDH school of “NHS” dentistry?

Everyone involved with this from the CDO “down” should, in the words of Mark Kermode, “be thoroughly ashamed of themselves”.

Here’s the article from GDPUK,

Despite widespread criticism of the new dental foundation recruitment exercise, Chris Franklin Professor COPDEND Chair says he was very pleased with how well the process had gone. Of the 1109 students who attended interviews, 182 (16.4%) were unsuccessful and even if they graduate this year, may never be able to work as a dentist in the NHS. Professor Franklin said he understood that the uncertainty caused may be ‘unsettling’.

GDPUK understands that the DF year is also viewed internationally as part of the qualification process for UK dental graduates, and the lack of this training place will affect the long term careers of young unemployed graduates.

At the end of the first phase of nationally co-ordinated recruitment to Dental Foundation (Vocational) Training in England and Wales, 83% of candidates have already been offered places on training schemes commencing in 2012.

There were 1,190 applications made online and of these, 1,145 eligible candidates, including 97 from European Dental Schools were invited to one of five selection centres held across England. In November 2011, 1,109 candidates attended these assessments and interviews.

There were 927 places available and all were allocated within a week of offers being made. Individual Deaneries will be allocating these successful applicants to individual training practices over the next few months. Further training places are expected to become available later in the year and 133 candidates on a reserve list will be notified about these after 2012 BDS final examinations are concluded. This leaves 49 with no hope of being placed this year.

Professor Chris Franklin Chair of COPDEND said, “I am very pleased with how well this process has gone and would like to congratulate all those who have been offered a place in the first round. I do understand that the uncertainty may be unsettling for those who are still waiting to hear about a training place and would encourage those at Dental School to concentrate now on preparing for final examinations. In previous years, most students didn’t know where they would be training until much nearer the start of the programme”.

Recently, Chief Dental Officer at the Department of Health Dr Barry Cockcroft assured GDPUK there would be no newly qualified dentists unemployed after the 2012 final exams.
However, this whole selection process has been widely condemned among dentists and students, not least through the GDPUK forums and the Facebook group.

Amongst reports to GDPUK are that, for example, 20 final year students at Cardiff Dental School, about 30% of the final year, have not been allocated places in this scheme. These students have already passed the written part of their final examinations. Their university has already started to advise them as to how to spend the next year before re-applying again for the 2013 process. Under present regulations, these graduates may only re-apply one more time.

Questions asked include what will happen to unemployed future graduates, who because the system has not provided enough places, may have their careers affected immensely.
Other issues raised concern the number of EU applicants (97applied) and how many of these were given places, at the expense of English graduates, who have been trained at the expense of the UK taxpayer. Many have asked for an analysis of EU applicants, where they were from and how many were given places. It has also been noted that EU graduates can work in NHS without a VT number, but English graduates cannot, so there is therefore discrimination by our own authorities against our own dental graduates.

Such rules were described by Michel Barnier, the EU Commissioner for the internal market and services as a myth. He said that EU rules required the UK to employ European doctors and nurses without proof that their medical skills and English are up to scratch. ‘This is not the case and never has been’, he declared. Although his article was concerned with the reading skills of EU medical practitioners it could equally apply to the suitability of EU dentists.





The Monday Morning Quote #151

“On some positions, Cowardice asks the question, “Is it safe?” Expediency asks the question, “Is it politic?” And Vanity comes along and asks the question, “Is it popular?” But Conscience asks the question “Is it right?” And there comes a time when one must take a position that is neither safe, nor politic, nor popular, but he must do it because Conscience tells him it is right.”

Martin Luther King Jr

Revealed: How CQC registration is running over budget and has failed dozens of dental practices

From The Pulse

Revealed: How CQC registration is running over budget and has failed dozens of dental practices
By Andrew McNicoll | 20 Jan 2012

Exclusive: More than 30 dental practices and an unknown number of private GP practices have failed to secure registration with the Care Quality Commission, in the first sign that regulation by the new body is prompting some providers to shut down.

The figures for those failing to register, revealed to Pulse under the Freedom of Information Act, come as the regulator also admitted that shifting registration to a new online system will push the total cost £5.5m beyond its initial budget.

The CQC has previously played down fears that its registration process would lead to the closure of providers, publically stating last June that ‘we have not closed down any dental practices’ and reassuring GPs earlier this month that surgeries would not be closed over not having disabled access.

But the regulator disclosed this week that 36 of the country’s 8,232 dental providers have not completed registration, with some subsequently closing. A further 68 dentists have been identified as ‘potentially unregistered providers’ by the CQC and could face prosecution if they are found to continue operating.

The CQC said: ’27 providers have not secured registration with the Commission and have either ceased providing a service or are subject to our unregistered services policy. The remaining nine require specific information to allow their registration to be concluded.’

However the CQC was unable to say how many private GP practices had failed registration because of a ‘temporary technical problem’.
Dr Jack Edmonds, chair of the Independent Doctors Federation and a GP in Harley Street, London, said the IDF had held ‘amicable talks’ with the CQC but warned that the regulator’s inability to provide data on the number of private practices failing registration was symptomatic of a wider issue.

He said: ‘The law requires us doctors to be open, transparent and have evidence that backs up what we tell the CQC. We have to jump through a number of hoops.’ ‘You want us to be transparent? Well, you should be transparent. It is a matter of fairness. The IDF would like to help the CQC if they are having problems – we don’t know if they are as they have not shared any information with us.’

The CQC also revealed for the first time the likely cost of the registration process, which was budgeted at £29.1m. It has spent £25m on registration of all providers so far, and expects to spend a further £3m on NHS GP registration – but also now expects to plough a further £6.5m into IT to support its registration programme that it did not originally budget for.

Dr Peter Swinyard, chair of the Family Doctor Association and a GP in Swindon, expressed concern at the overspend and insisted any additional costs run up by the CQC should not be passed on to GPs.‘The cost of CQC is a very sensitive issue for GPs. To be asked for a lot of money for something with no merit in it for general practice is a big ask.’

A CQC spokesperson said: ‘We are projected to be within budget for initial registration of all providers, with a projected spend of £28 million against a budget of £29.1 million. The additional £6 million is for the development of an online service that will simplify ‘business as usual’ processes for all providers – for example applying to change the status of their registration. GPs will also benefit from this as they will be able to carry out their initial registration online.’

The cost of the CQC
£29.1m – Original CQC budget for registration
£25m – Cost of registering dentists, social care providers, private GPs and others so far
£3m – Estimated cost of registering NHS GPs
£6.5m – Additional unbudgeted cost of shifting ‘registration and regulation’ to an online system.

Bringing premises up to scratch
Hundreds of GP practices sign-up for software to prepare for CQC registration

The Monday Morning Quote #149

“Your ability to adapt, be flexible and deal with the unexpected is one of the most powerful assets you possess.”

David Bowie

The Monday Morning Quote #150

“The value of a thing sometimes lies not in what one attains with it, but in what pays for it – what it costs us.”

Friedrich Nietzsche

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