Regulators like the status quo. Any large changes or upheavals present challenges and potential overhauls to long established processes and procedures that they would rather do without. The Care Quality Commission (CQC), the regulator of health and social care in England, is no exception to this.
However of all the bodies involved in the transition to the Government’s new world of health and social care delivery, the CQC is arguably undertaking some of the most radical changes to its operation. This was not supposed to happen. When the Government published its White Paper Equity and excellence: liberating the NHS it said that it would: “strengthen the role of the Care Quality Commission as an effective quality inspectorate across both health and social care.” This mainly involved giving the CQC a broader remit, covering its existing responsibilities of secondary care and residential care providers, but also including dentists, and GPs in the longer term.
The vision for the CQC was two-fold: the regulator was to operate a joint licensing regime with Monitor to register providers of health and social care services against essential safety and quality standards, and also to inspect providers against those standards. As I have previously blogged, inspections were to be “targeted and risk based.”
The scandal of poor care at Winterbourne View coupled with the revelation that the CQC had reduced inspections by 70% in order to focus on registering all the new provider groups under its jurisdiction destroyed this new framework in its infancy. As my colleague, Rupert Gowrley, recently wrote, the backlash against the regulator from politicians has been fierce and unremitting.
To stem the tide, the regulator has postponed the registration of GP practices to April 2013 and announced a new inspection regime which is designed to fight back against accusations that it is weak and ineffective in enforcing minimum standards.
This new framework is a complete turnaround from existing CQC process and is much more stringent in its tone. The main changes are as follows:
There will no longer be any middle ground on the issue of compliance – providers will either be compliant or non-compliant
A provider’s capability to address an area of identified non-compliance will not be taken into account when judgements on compliance are made
The escalation system for enforcement will be transparent and deadlines for improvement will be enforced rigorously
The level of concern and the impact of the failure to be compliant will take place after judgment is passed on compliance with a regulation, rather than before as currently takes place
The level of impact on people who use the service will take place for each individual regulation where the CQC has identified non-compliance
Warning notices on a provider will be published and mentioned in compliance reports
These changes represent the start of a new inspection regime, which the CQC hopes will show that it has learnt its lesson from Winterbourne View.
However, whilst well intended, the new framework will not work in practice without some fundamental changes.
Firstly, the CQC needs to develop robust safety and quality standards for different types of providers. For example, the quality and safety metrics for providing high quality dementia care will differ greatly from those needed to provide safe and high class dentistry care. The CQC needs to address this by developing subgroups of metrics for the different types of organisations and patients in its remit.
A ‘one-size fits all’ policy will not provide the right indicators against which different providers should be assessed. The CQC should work with providers already providing high quality care to develop these metrics and use these to raise standards.
Secondly, the CQC needs to ensure it has an adequate number of inspectors in each discipline in order to provide the high quality inspections needed. In an environment of spending cuts, this is unlikely to be easy but the regulator needs to ensure that its inspectorate is well balanced. This is particularly the case for inspections of specialist services such as mental health care.
Thirdly, there is a concern that in taking a much tougher line the CQC may go after headlines relating to enforcement rather than working with providers to address poor areas of patient care. Whilst headlines of enforcement will win short term plaudits, longer term they could damage relations with providers and even result in providers pulling out of care provision altogether if they feel victimised and unfairly targeted. As has been demonstrated with the collapse of Southern Cross, such failure or market exit can result in huge pressures being put on the existing level of service provision.
The CQC has announced that its consultation on its new inspection regime will close in early December. The message is clear – it is fighting back, but it does need to ensure that its new framework balances the needs of patients, commissioners and providers who rely on it in order to be truly effective.