A few days ago, I wrote about the train-wreck that is Southern Cross and used it as an example of the serious damage that is being inflicted on some of Britain’s essential services – and the taxpayers’ pockets – by corporate greed.
There is another – largely unreported – aspect to the Southern Cross story that has wider ramifications and which chimes with BBC Panorama’s recent exposure of abuse at Castlebeck’s Winterbourne View residential home in Gloucestershire. Putting aside the depressing fact that both have shared the distinction of quickly falling off the news agenda after their allotted day of ritual breast-beating, they also enjoy a commonality in the extent to which they are failures of the regulatory system that is supposed to safeguard the quality and continuity of care for hospital patients and residents of our numerous care and nursing homes.
The details of these failures are not the concern of this article; my interest here is the regulatory system itself – specifically, the role of the Care Quality Commission (CQC) – and its impact on care services with particular respect to care homes. There are many other bodies that monitor aspects of care provision, examples being the Audit Commission and local authorities but they impact in a relatively minor way.
(By the way, Foundation Hospitals have an additional regulatory body called Monitor which initially authorises any new Foundation Trust and continues to regulate it thereafter. If you can stomach it, Monitor’s current compliance framework document is here but be warned – it runs to 82 turgid pages of the sort of corporate drivel favoured by the bureaucratic class. Its practical usefulness can, perhaps, be judged by the fact that Monitor approved and regulated the Mid Staffordshire NHS Foundation Trust where a lack of competency resulted in the unnecessary deaths of at least 400 patients. Monitor’s ‘it weren’t me guv’ evidence to the current Mid Staffs inquiry is available here but again, unless you are especially interested or you’re a singularly odd masochist, you’re better off taking my word that it is more interested in robotically maintaining Monitor’s reputation and lucrative government funding than in offering contrition for failures of regulation).
The CQC was formed in April 2009 to replace the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission. Its first Chief Executive was Cynthia Bower who remains in place. For those of us critical of the backroom deals that give plum jobs to incompetents, apparatchiks or, indeed, anybody – provided they are not in possession of a white skin, a fully functioning set of physical/mental attributes and a penis used exclusively in heterosexual pursuits – there is a sorry irony in the fact that Cynthia Bower was previously Chief Executive of the Strategic Health Authority responsible for the aforementioned Mid Staffordshire NHS Foundation Trust… precisely at the time that many of the unnecessary deaths occurred.
The initial inquiry into the deaths – which was published in March 2009, after Ms Bower’s appointment to the CQC – criticised her for having “accepted without detailed scrutiny” Mid Staff’s assurances that it was suitably responding to its high mortality figures. Some evidence was given to suggest that Ms Bower was too preoccupied with the Trust’s reorganisation to take note of the mere details of patient care. Subsequent calls for her appointment to the CQC to be reviewed appear to have gone unheeded.
Interestingly, Ms Bower has been busy reorganising the CQC as well – no fewer than three reorganisations are mentioned on page three of this document: not bad for a body that, at the time, had only been in existence for a little over a year under its first and only Chief Executive.
Interestingly, too, both the Mid Staffs mortality rates and the Winterbourne View abuse were first drawn to Cynthia Bower’s attention by whistleblowers. In both instances, their concerns were ignored.
(Even more interestingly for conspiracy theorists like me, not long before Andrew Lansley initiated the latest Mid Staffs inquiry, Nursing Times announced that many records of staff complaints had disappeared).
The CQC’s publication “Essential standards of Quality and Safety” runs to 278 life-sapping pages only 24 of which are taken up by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. There are numerous other publications from the CQC who clearly have a penchant for dotting i’s and crossing t’s but to get a flavour of their role, the ‘quick guide to essential standards’ can be found by following this link. The guide is a relatively brief document itemising the provisions of the Act.
I think few of us would argue with the tenor of the Regulations or the CQC’s definitions of the standards we would want applied to the care of vulnerable people. But there is one sentence that sums up the enervating micromanagement culture that has developed in recent years; “Providers must have evidence that they meet the outcomes.”
Therein lies a problem.
The way that the CQC has interpreted the Act has been to opt for self-assessment with an insistence on proof of outcomes rather than permitting outcomes to speak for themselves (GPs – who have to register into the system by April 2012 – have described CQC’s system as a “creative writing exercise that will cost money and take GPs away from patient care.” Dentists have argued that it “provide[s] no significant benefit to patients”. Hospitals have been obliged to take on more administrative staff to cope with the additional workload).
Once upon a time, a care home manager would be expected to take it upon themselves to constantly monitor the wellbeing of their clients and the effectiveness of their staff. There would have been a limited amount of recording but by and large, an appropriately capable manager was entrusted with using their skills and intuition to assess and correct any failings before those failings developed into matters that could threaten the health and welfare of the home’s clients. Such a system was known as taking responsibility and it was probably as effective as any system could hope to be given that we live in a less than perfect world. It bore comparison with the way in which we all look after the health and welfare of our partners, children and parents in our own family homes: it’s part of what makes a home a home.
Under the CQC regime, it is no longer sufficient for a manager to assess the home’s running by exercising the responsibility for which he is paid to satisfy himself that all is well; now, the manager is obliged to provide evidence that he has satisfied himself that all is well. Inevitably (and not surprisingly given the huge array of stick-bashing penalties involved), this involves managers and their staffs in vast quantities of ultimately meaningless record-keeping but note – especially given that the CQC effectively gives advance notice of its inspections (it will write to ask for certain outcomes by a particular date and visit shortly afterwards) – it appears to be the quality of the recording rather than the quality of the care that CQC’s system regulates. And, of course, political correctness is the overarching requirement that trumps all real quality considerations: this paragraph appears as CQC’s first key definition:
Equality, diversity and
Providers must consider equality, diversity and
human rights in every aspect of their work. You
should consider the needs of each person using a
service against six key strands of diversity:
●● Sexual orientation
●● Religion or belief.
(Some idea of how all-encompassing and demanding CQC’s system is can be gained by looking at this which is the information required to monitor one outcome. It runs to 12 pages – there are 16 of these outcomes altogether, some of which demand answers and evidence for considerably more questions; I’ve not looked at them all but I can vouch for one running to 17 pages. Imagine this level of monitoring being introduced to the domestic home – how on earth would anybody find the time to go to work? And the costs to the service provider must be enormous, quite apart from the astronomic fees being charged to (compulsorily) register with the CQC. These registration fees have to pay for the CQC and its ivory towers – just for the CQC to rubber-stamp – or ‘inspect’ in CQC parlance – the homes’ self-monitoring records costs £140 million p.a. The CQC is a very expensive job-creation scheme).
To most intents and purposes, the regulatory system has usurped the manager’s responsibility and judgement, creating a culture in which the management of the care home is effectively transferred to the anonymity of the regulating body while the home manager becomes a glorified box-ticker. The personal interactions that make the establishment a home are codified to such an extent that the humanity disappears and staff members become little more than automatons. (Some idea of how the senior staff of the CQC regard people can be gleaned from a look at their corporate risk register where the need for extra staff is couched in not in terms of ‘staff’ or ‘people’ but ‘people resources’).
The effect of this degree of regulation has a parallel with that of the Criminal Records Bureau (CRB) checks in terms of disengaging staff from their primary objectives. In what we might call the compliance mentality, there is a plausible argument that by arming a prospective employee with a clean CRB check, there arises a false sense of security in which an employer may suspend their own critical judgement when deciding upon a candidate’s suitability. The very existence of a statutory checking system may lead to a tendency to diminish warning signs of a potential problem where, previously, they would have caused suspicion; the regulatory system acquires the status of a faith.
It would be virtually impossible to prove how corrosive the CQC and its targets have been on our health and care providers and how ineffectual they are in improving the lot of service users but I can provide some anecdotal evidence that demonstrates the burden placed upon employers and the degree to which the focus of workers’ priorities has been shifted from care to compliance.
Until a little over a year ago, my wife worked for the NHS in a small unit that offered specialist welfare support to families of patients with long-term, demanding conditions. The nature of the work and the circumstances of the families dictated considerable flexibility in approach and hours. My wife loved her job and forged strong and lasting relationships with her colleagues and her client group: the unit as a whole had an impressive record and was only ever threatened by the annual budget rounds when the Trust juggled with frontline service budgets to find the necessary savings to enable them to pay for all the sustainability officers and carbon footprint analysts that the NHS considers it essential to employ. The integrity of the unit was maintained by a system of written reports and weekly case conferences until at some point during 2009/2010, a demand for some superfluous box-checking came from some previously unheard-of department. What began as a minor irritation rapidly grew to become a major exercise in bureaucratic futility, so demanding that the unit – already constrained by a tight budget – was placed in the position of significantly reducing its front-line commitments in order to meet compliance requirements. Breaking point came when compliance – or the Trust’s perception of it – meant an introduction of targets that the unit could not possibly meet if it was to properly satisfy its client objectives. No longer able to provide adequate care to her client group and driven to the point of compliance insanity, my wife chose to leave the NHS.
To summarise, the emphasis of CQC’s regulatory scheme is bureaucracy rather than care. Its demands – particularly in cost-sensitive environments – can adversely impact on care levels: it sucks money from frontline care. It centralises some key management functions, diminishing flexibility and increasing the sense of institutionalising care – particularly in homes. The scheme encourages staff to think in terms of targets rather than the needs of individuals – and managers may be inclined to entrust issues to determination by state regulation rather than by using their own judgement. The scheme is horrendously expensive (as it needs to be with the senior management team alone costing in excess of £1.4 million p.a. in salaries) but achieves nothing that could not be done by responsible management at the local level. Above all, the events at Winterbourne View prove that the scheme does not work: the CQC’s ‘inspection regime’ found the home to be compliant with essential standards of quality and safety – not once but three times in the past two years.
We have lost sight of the fact that first and foremost, care homes need to be homes. Of course, there are bad homes run by unscrupulous companies such as Southern Cross and Castlebeck: this has long been the case and no amount of regulation will eliminate the rogue operators completely. But the best way of keeping them to a minimum is by the use of professionally competent and responsible home managers with functional responsibilities to competent and responsible senior management teams and suitably qualified inspectors – probably attached to one or more of the bodies funding care places. These inspectors should randomly visit homes on an unannounced basis and possess the authority to act upon complaints from residents, their families and whistleblowers.
Put the money back into care services: dispense with the grandiose CQC, its self-serving senior management team and its futile exercises in furniture moving. The CQC is complicit in diverting resources from frontline care and is nothing but a dire reminder of the very worst of the New Labour years when our government was obsessed with regulation, centralising power, infantilising the population and diminishing individual autonomy and responsibility.
It must go – and soon.
As a footnote, here are a couple of entries from the CQC’s website which further demonstrate the organisation’s priorities. First, there is the response to the Panorama programme. Note that it essentially amounts to a ‘shutting the stable door’ exercise with no acknowledgement that their scheme is not fit for purpose:
31 May 2011
Tuesday night’s BBC Panorama programme highlighted serious abuse and appalling standards of care at Winterbourne View, a private hospital for people with learning disabilities.
Following an internal review, we recognise that there were indications of problems at this hospital which should have led to us taking action sooner. We apologise to those who have been let down by our failure to act more swiftly to address the appalling treatment that people at this hospital were subjected to.
In response to the serious issues uncovered by Panorama, CQC has taken the following action:
- carried out three unannounced inspection visits of the hospital and taken steps to ensure the hospital will not admit any new patients. We are working with the primary care trusts and councils who pay for the care of people at the hospital to secure the best outcomes for those people
- started an immediate review of all services run by this provider
- written to Care Services Minister Paul Burstow MP proposing that we launch a programme of risk-based and random unannounced inspections of a sample of the 150 hospitals providing care for people with learning disabilities. The Minister supports this proposal.
- launched a detailed internal review of our actions in relation to Winterbourne View
- spoken to the former member of the hospital staff, apologised for not contacting him earlier and offered to discuss his concerns.
And secondly, page 4 of this document will show you the Executive Team. For some reason, the CQC feels the need for a Strategic Marketing and Communications Directorate. Despite it having a staff of just 49 (!), this particular Director earns more than the Directors for Governance and Regulatory Development.