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.

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