Session 2010-11
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Evidence heard in Public

Questions 1 - 47



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Oral Evidence

Taken before the Health Committee

on Thursday 9 September 2010

Members present:

Mr Stephen Dorrell (Chair)

Nadine Dorries

Fiona Mactaggart

Grahame M. Morris

Chris Skidmore

David Tredinnick

Valerie Vaz

Dr Sarah Wollaston

Examination of Witnesses

Witnesses: Dame Jo Williams, acting Chair of the Care Quality Commission, gave evidence.

Q1 Chair: Dame Jo, thank you very much for coming to see us this morning. Congratulations on securing the recommendation, or intention to appoint, of the Secretary of State, subject to any advice that he may receive following this session.

I would like to start with a fairly general question asking you to reflect on the time since the Care Quality Commission was formally established. You have been involved with it as a member of the board from the date of its establishment. Will you reflect on what has happened since that time, particularly since you took over as acting Chair in January this year? Will you reflect on where you think you’ve got to, how successful you’ve been at integrating the three predecessor institutions and what key challenges you face now to deliver your objectives for the organisation?

Dame Jo Williams: Thank you very much, and thank you everyone for seeing me so quickly. I appreciate that.

Reflecting back, I think that, first of all in shadow form, we worked very hard to clarify what our strategy would be. We determined that we very much wanted to make sure that people who received services were central to everything that we were doing, and we also put some infrastructure in place. When we became operational, of course there was the challenge of trying to integrate the work force and create a new culture. I will say a little more about that, and then go on some of our other objectives.

I think it’s fair to say that we are still going through a period of change. We have needed to think very carefully about how we use our resources. We have £60 million less than our three predecessor organisations, so we have had to prioritise. We wanted to make sure that we put our efforts into creating front-line staff who may be visible, but have the back-up and support to do their jobs.

Putting the three organisations together has been quite painful for the work force, and people have said that they have a sense of loss of what went before. I think we are on the way, but my experience to date tells me that to say that we truly have a new culture that represents the Care Quality Commission will probably take about three years, but we are well on. Over the last few weeks, staff have been very tired and somewhat pressed because we’ve been focused on a huge process of registration for the social care sector.

So in terms of pulling the three organisations together, my reflection is that we’ve made some good progress, but we still have work to do.

In terms of our key tasks, our focus has been on the whole process of registration, so at 1 April this year, for the first time, the health service was registered. Our task, quite clearly, was to make sure that we did that in a way that was balanced and fair, but also hitting our deadline of 1 April.

Q2 Chair: Do you feel that during that registration process, you added value? Can you identify value added that came out of that registration process?

Dame Jo Williams: That is a really good question and one we’re challenging ourselves with. When we’ve talked to the people we’ve registered, many have said to me that one of the things that came out of the registration process in the health service was that it provided a very rigorous framework. In some cases, the executive have used that to reshape their performance framework.

I think many people-Chairs of boards and non-execs on boards-found the way in which we were approaching it helpful to them, because it was raising questions that for them were very important in terms of the quality of services that they were providing. So there’s that aspect of it. Since then, in looking at those we registered with conditions, we’ve seen some significant success stories over the last few months. In that sense, we can say that we’ve seen real improvement, and in terms of public safety and clinical effectiveness, we can say we’ve added some value. Milton Keynes comes to mind.

Q3 Chair: How many did you register subject to those kinds of qualification?

Dame Jo Williams: We had 22 organisations within the health service.

Q4 Chair: How many of them still have-

Dame Jo Williams: About half. That said, we are also looking at three other organisations that we have concerns about that have emerged over the last few weeks.

Q5 Nadine Dorries: What would you identify as the weaknesses-the areas of weakness-in the CQC?

Dame Jo Williams: Because we are a new organisation, there is that whole business of establishing our culture. We have some real challenges in making sure that we are using our resources in the most effective way. That’s an ongoing challenge for us. We’ve been struggling, I have to say-

Q6 Nadine Dorries: Could you elaborate on that? You referred to culture. Could you give us a bit more background, paint a better picture than that? What do you mean exactly by culture?

Dame Jo Williams: In terms of the culture of the organisation, one of the things that we’ve been really driving hard on is making sure that when we’re looking at making a judgment, we take account of people’s experiences. This is part of the way in which we’re looking at the whole notion of quality. The issues are safety and quality of clinical intervention, but also what the experience has been of the individual and possibly their family as well.

We’ve been able to build on some of the work done in the predecessor organisations and to drive hard on that. The Healthcare Commission was a very data-rich organisation, but wasn’t concentrating in the same way on that. Integrating that way of thinking right across the organisation is very important to us. That’s just one example.

In terms of weaknesses, some of the issues to do with the infrastructure and technology have really been challenging for people.

Q7 Nadine Dorries: In what way would you feel that you had any direct responsibility for any weaknesses in the organisation?

Dame Jo Williams: Responsibility?

Q8 Nadine Dorries: Do you feel that you have any responsibility for any of the weaknesses? In what way have you been involved in those areas?

Dame Jo Williams: In terms of the board, what we are very clear about is that we’ve absolutely got a responsibility to hold the executive to account, but we also have to be supportive. One of the things I have been able to contribute over the last six months is really being absolutely clear about what the role of the board is and what the role of the executive is. That has been a helpful contribution in terms of us enabling the executive to focus on the key priorities, and allowing us as the board to focus on the strategy, to performance-manage wherever we can and to hold the executive to account.

Q9 Nadine Dorries: If we were to ask you the same question in, say, 12 months from now, what do you think your answer would be then? In terms of those weaknesses you’ve identified, for an organisation that is bringing three organisations together, I would have thought that you would have identified a wide range of weaknesses, but it seems you gave quite a short answer.

Dame Jo Williams: Perhaps I should say a bit more about what I think the challenges are for us. Clearly, I would expect everyone who works within CQC to be effective in their role and for there to be clarity in terms of the expectations we have of them. Secondly, one of the things I haven’t mentioned is that we have to build our public reputation and profile, so that the public recognise us as an organisation that they can trust. The public should be able to come to us with their own views about what is happening in their health and social care world.

I would hope that in 12 months’ time, in terms of some of the internal issues, we would be further on the journey. But, externally, I hope that will have begun to build much more on the reputation I think we have at the moment. Particularly in local communities, I hope we will have a profile that means people know how to access us and get information to us. Those two things are very important to me.

Finally, again, a weakness is that we are challenged to really describe to the public in an accessible way the information we have that will help them to make informed choices. I hope that we are working hard on that and we will have made progress on that in 12 months’ time.

Q10 Nadine Dorries: Just to finish, you are saying that you hope to identify the weaknesses of the culture and the processes of the organisation?

Dame Jo Williams: Yes, sure. But also, as I say, there is something about our reputation and our profile that we need to build. Organisations such as ours have to earn, build and develop that to enable people. We need to be seen as being responsive when people make contact with us.

Q11 Chair: I will bring in Valerie in a moment, but one of the things you said in reply to Nadine implied that there was a lack of understanding of the difference between governance and executive management, and that you have clarified that. Have I understood you correctly?

Dame Jo Williams: That is right.

Q12 Chair: And is that effectively a criticism of at least some of the predecessor organisations? Is that an area where there was a cultural problem?

Dame Jo Williams: No. I am not commenting on the predecessor organisations. I am commenting on what you asked me to reflect on in terms of what had happened over the two years since I was involved as a Commissioner with CQC. We did go through a period when there was some cloudiness around the executive and the governance.

Q13 Valerie Vaz: I just wanted to follow up on some of the remarks you made in your opening statement, when you talked about priorities. Given that you came into a situation that was slightly changing-you took over and you’ve now got a totally new entity-could you set out what your priorities are for the new organisation? Have they changed from those of the previous Chairs?

Dame Jo Williams: We are certainly very clear that we must complete the registration process for social care and for the independent health sector, which will be on 1 October. Dentists will come next year and GPs in 2012. So those priorities are very important. In my view, however, we need to be absolutely sure that we focus on those who are performing less well and concentrate some of our efforts, to do what we can through our powers to bring about improvement. So that is one key aspect for us.

Clearly, with the changes, we say in our strategic objectives that we work in partnership and indeed we do. I think that there will be considerable work to build on an already good relationship with Monitor, but we must not lose sight of that-that will be critical as things move forward.

For me, fundamentally I think that it is really about ensuring that we are absolutely focused on individuals’ experience of social care, mental health services and the health service generally. Are we listening? Do we understand what those experiences are? And how can we use that information to bring about change to improve those services?

Q14 Valerie Vaz: Do you know what your total budget is?

Dame Jo Williams: At the moment, it is about £168 million.

Q15 Valerie Vaz: Do you know how you will allocate that budget among your priorities?

Dame Jo Williams: What we have been looking at is ensuring that we are using all possible resources on the front line, so that those people who are able to can inspect services and do the analysis of what is happening on the front line. So we have been through a huge period of change: we have certainly been reducing our back-office costs; we have been closing offices, and we have been reducing the number of people in the headquarters, so that we can refocus our resources on those front-line staff.

Q16 Valerie Vaz: Given the constraints in the budget- assuming that you will have just £160 million for the next three years, possibly-how would you prevent something like a Mid-Staffordshire happening?

Dame Jo Williams: Clearly, the first thing that I want to say is that the National Quality Board conducted a review of the lessons to learn from Mid-Staffordshire. I think that we recognise that there are some really critical lessons there to learn. There are issues about leadership that we need to focus on; sharing information is important and we must be absolutely sure that we do share information. There are also the governance arrangements within organisations to focus on. Importantly, we must listen to experience and we must gather information about people’s experiences and those of their families.

Will we be able to prevent something untoward happening in the health and social care system? I would have to say that I do not think that we can give any guarantees in that area. I think that history tells us that, somewhat sadly, things can and do go wrong.

So one of the critical things that has emerged from the experience of learning from when things have gone wrong is that what needs to happen, first, is that we need to intervene and do something quickly, to safeguard those people who are directly involved. Secondly, we must reflect on the impact on the wider population. And finally, we must really think about what changes need to happen, to safeguard the interests of individuals.

Q17 Valerie Vaz: You talked about collecting information. How would you get the information out?

Dame Jo Williams: Okay. We’ve developed a process for gathering information. Regarding the registration process, we have gathered information from every possible data source that we can. In addition, we have certainly been looking at complaints that have been made, information from local link groups and information derived from people’s own experience. We have pulled that information together. I think that that is a rich source of information.

We have very much localised our work force. We believe that they will gather quite a lot of soft information while looking at local newspaper reports and while they themselves are building effective relationships in the community. So, as well as being a data-rich organisation, we recognise the softer information as invaluable.

Q18 Valerie Vaz: Could you describe the localisation of your members?

Dame Jo Williams: It is a regional structure, and working to a regional manager or director there will be groups of people who have responsibility for data analysis, but are also for looking on the ground, for going into and looking at what is happening, whether in the health service or in the social care sector. Each person-what they call a compliance officer-will have a work load of probably about 50 organisations and a support system which, as we gather data, will alert them if something is coming up that they might not have seen on the ground.

Q19 Valerie Vaz: Would you set your priorities from that information? Or are you setting priorities and disseminating information?

Dame Jo Williams: That information is very important. I hope the two things will come together, because through that we should be identifying those who are underperforming. Clearly, we may not be the agency of improvement, but we can certainly make sure that we are talking with those who are concerned with improvement. Sharing information is important to us.

Valerie Vaz: Thank you very much.

Chair: Can we look a bit at the functions you inherited from the Mental Health Act Commission? I think Sarah would like to ask you some questions about that.

Q20 Dr Wollaston: May I start by declaring an interest? I am married to a forensic psychiatrist, so I have been taking some soundings.

Are you aware of the very serious concerns in the country about the lack of provision of second opinion doctors?

Dame Jo Williams: Indeed, I am aware of that.

Q21 Dr Wollaston: Can you elaborate a bit and tell the panel what is actually happening and what the responsibilities are under the Mental Health Act 2007?

Dame Jo Williams: We appoint and run what are called second opinion doctors. What you are alluding to is that we are having great difficulty in recruiting sufficient people with the expertise to carry out that role. One of the changes with the Mental Health Act was that those who have a community treatment order should have access to a second opinion doctor.

What was probably not anticipated was the sheer volume of those requests which come forward for the second opinion. So we are talking with our colleagues in the Department about what we do about this and how we find a way forward, because there is real concern that we are not able-if we don’t have the right doctors available-to carry out that responsibility.

There may be a case to be made, for those who are undergoing treatment in the community with consent, for a relooking at whether a second opinion is required. I am not saying that is how we will go, but we are raising questions around that.

Q22 Dr Wollaston: There are also significant problems with patients detained under the Mental Health Act, and with the fact that many psychiatrists are being put in the position of being regulated by you and being expected to comply with the Act, but being unable to do so. Are you aware of what they are having to do to remain within the law? Which section of the Act are they having to use in order to prescribe for their patients?

Dame Jo Williams: No, I am sorry.

Dr Wollaston: They are having to use section 62-in other words, they are having to undertake emergency sections, which are completely inappropriate, in order to comply with the law. So, you are both regulating them and making it impossible for them to comply with the law.

Dame Jo Williams: Okay, that is something that I need to take away and look at.

Q23 Dr Wollaston: Is that something that you will raise with the Department of Health, as well as the issue with community provisions?

Dame Jo Williams: Absolutely.

Of course, the other thing that we haven’t discussed is our duty to detain patients through the work of Mental Health Act Commissioners.

Q24 Dr Wollaston: Do you see any other serious challenges to the work that you have, having taken over the Mental Health Act Commission?

Dame Jo Williams: We have been very mindful because many have said to us that it’s very important not to lose sight of this important work, in so far as the volume in relation to social care is concerned, and other organisations may deflect us from our task.

Because we want to be clear that we are really paying due attention to the mental health service, we have established what we call an improvement board. We have representatives from the professions as well as one of our Commissioners, who is a user herself. I know that the board is actively addressing some of the issues that you’ve raised. But I will certainly make sure that they understand the issue you’ve raised this morning, and we will raise it with the Department.

Q25 Chair: Can I raise a related question? The Mental Health Act Commission, I think I’m right in saying, used to be the appeals structure for individual patients against sections.

Dame Jo Williams: Yes.

Q26 Chair: Is that a function that you’ve inherited?

Dame Jo Williams: Yes, absolutely. We have.

Q27 Chair: It strikes me slightly odd that the regulator should be dealing with individual patient appeals, if that’s the case.

Dame Jo Williams: There are some questions that we’ve all had about the role of the regulator in relation to, for instance, being a provider of the service itself. That is quite a fundamental question. But those responsibilities have come across to us, and we take them very seriously. We want to exercise our responsibility.

Q28 Chair: But it is not an issue that you’ve considered as a board-that there is potentially a conflict between being the regulator of an institution and being the court of appeal against the decisions taken by that institution?

Dame Jo Williams: No, we haven’t, but it’s a good point.

Q29 Chris Skidmore: Dame Jo, I have received the Government’s White Paper. The forthcoming Health Bill presents some significant changes to the CQC in its present form. In particular, the Government’s new consumer champion, HealthWatch, is, according to the White Paper, going to be located with a distinct identity within the Care Quality Commission. I will be interested in your views about what "distinct identity" means. How do you envision that working in the forthcoming years? How do you expect the CQC to adapt to what is presented in the White Paper?

Dame Jo Williams: I think I’ve said already that we have established relationships with LINk groups, which I think will become the local HealthWatch. We are already talking with our officials about how we create or contribute to the creation of the super or national HealthWatch. For me, given what I’ve been saying about individuals and our experiences being central to what we are trying to achieve, it is absolutely right and a good fit with us to have that notion of the voice of the consumer coming through into our organisation. It builds on what we have.

What I think is really important is that we shouldn’t lose sight of the fact that for HealthWatch or LINk-and then a local HealthWatch-to be really effective, it needs to have links to a network of organisations, so that we have the diversity and range of views in that community. In our contribution to the creation of this new body, we would want to make sure either that we built other things in to ensure that we had that diversity of voice, or that HealthWatch did so at local level as well as nationally.

In terms of governance arrangements, if the proposal is that it should be a separate entity, but working within CQC, clearly we will need to think carefully about how that would work. Would the Chairman of the HealthWatch be a member of the board of CQC? How would they connect with us and hold us to account, as well as us holding them to account? In terms of principle, we are very pleased with the notion that that voice can reinforce, and be central to, what we do. The devil will be in the detail of ensuring that it is effective, that we have good governance arrangements and that the accountabilities are clear.

Q30 Chris Skidmore: Do you think that that is plausible within the constraints of your current budget?

Dame Jo Williams: Again, that is something that we will be debating. At the moment, the organisation has a discrete budget and local authorities commission the local links, so we will need to make some arguments about how those resources are used in future.

Q31 Fiona Mactaggart: I have been thinking about HealthWatch. Public information is really key in the social care sector and when families make choices about care settings for loved ones. How important do you think your work is in helping people make those decisions?

Dame Jo Williams: I think that it’s very important, and it has been to date. To return to what I said earlier, one of the most important things that we can contribute is information on our findings that is understandable so that people can use it to make really informed choices. Translating some of the mechanisms that we are building-such as our quality and risk profile-into a usable set of messages for individuals in a local community is one of the things that we are looking at very carefully. You will know that our predecessor organisation had a star rating for providers of social care. We are currently consulting on what might be the most appropriate system for the future and anticipate that that will be concluded this year, with the new system probably starting next May.

Q32 Fiona Mactaggart: But are you thinking about what information people need? I would like you to tell the Committee about the information that you think isn’t easily available. That is really important when people are finding safe and happy settings for loved ones.

Dame Jo Williams: All our evidence suggests that people are interested in how they will be treated and whether people will treat them as individuals and recognise their individuality, the things that are important to them and their relationships. People are also interested, if they are alone, in the opportunity to build new relationships in the settings where they live.

Those are the sorts of things that people value enormously. When we look at the kind of care that is provided, we see that on the one hand there is a question about the hotel-side service of it, with a clear message about that, so that people know what to expect. But on the other hand, it is the relationships within the setting, the treatment, the respect and the dignity that people find very important.

Q33 Fiona Mactaggart: How do you find that out? People often say that this is all a bit "tick box". I don’t see how you can find that out through a tick box.

Dame Jo Williams: One of the things that we have certainly done is build on some of the very good things that our predecessor did. That was based on the idea that there is no substitute for going in, talking to people, listening to their direct experiences and observing what is going on. That’s certainly a role for our staff, but there are lots of other people going into settings, and tapping into that information will be very important. Again, that’s possibly something that people who are involved in local HealthWatch can get involved in, because that’s what matters to people, day in, day out.

The third and final thing that I’d say about this is that one of the most critical things is the kinds of quality assurance systems that the particular organisation is operating, and how it is finding out what is going on, day in, day out, demonstrating to us as the regulator that it is taking that very seriously.

Q34 Fiona Mactaggart: I noticed that when you talked about partnerships earlier you referred to your partnership with Monitor. To what degree are local authorities a partner in this field, and how do you operate that? You’re not training their inspectors or staff.

Dame Jo Williams: No. In fact, we have a very effective working relationship with the Local Government Association, local authorities themselves and the Association of Directors. One of the challenges is to make sure that there is a really good flow of information from what they are finding out when they’re contract monitoring. So, that again is something that we are really tapping into.

It’s true to say that our partnership agenda is wide-ranging. Certainly local authorities are critical, but so, too, are a whole range of voluntary and community organisations that are holding information that is extraordinarily useful to us when we’re making an assessment and a judgment.

Q35 Fiona Mactaggart: Many of these homes are tiny. I am concerned that unless you have some standardised system to get the contract-monitoring data from local authorities, what is likely to happen is that relatives will look at your website or whatever and say, "This has two stars-it’ll be all right." But that might be a tiny home that since then might not have got any local authority placements because the local authority thinks that it has become dangerous. I’m concerned. What is the process that makes sure that it’s always good enough?

Dame Jo Williams: There is no substitute for families going to look for themselves. That is the first thing that I’d want to say. What I am also trying to establish, about working with our partner organisations, is that that softer information-having our antennae to the ground-is vital.

One of the things that is concerning is that people say to me, "We know where things are not right. We’ve known that this is not right." I don’t know whether they do that in your communities, but people certainly say that to me. How we use some of that information is absolutely vital, but in terms of our systems and processes, it is through our quality and risk profile that we will be gathering information about complaints, from the ombudsman and from people directly, and also, of course, listening to what’s happening on the ground through our localised offices.

Q36 Fiona Mactaggart: I think that you’re right that sometimes people do know when things are not right, but the problem that I see with this kind of informal network, is that they don’t always know. I think back to something that you possibly know of from your Mencap days: Longcroft care home, on the borders of my constituency. The local Mencap group thought that it was fine, and yet patients were being raped and starved in that home over a number of years.

The home owner was eventually successfully prosecuted. The person who ran the home was very charming, was involved in the Rotary and was very good at all that schmoozing-informal networks-and the residents didn’t have an effective voice. It just carried on. I’ve been in group homes talking to residents about what they would like best, and I remember so vividly the residents of one saying to me, "Our own toothbrush." If you are a national organisation picking up this informal information, unless you have structured the information that you require from these people, I don’t think it’s going to deliver what you need.

Dame Jo Williams: I don’t want to mislead you. We do, through the registration process, have a very clear structure. I think what I’m saying, though, is that although that’s one side of the story, that softer information adds to it. I absolutely agree with you that we need to be rigorous in thinking about this. It’s clear that the circumstances of the people you describe make them very vulnerable.

What we know from history is that isolated institutions, particularly where people don’t have a voice, can be extraordinarily dangerous places. I think that kind of healthy approach to our work is part of the way in which we are operating and will continue to operate. It’s absolutely the way that our staff are thinking about, because of the learning from previous experience. We do need to make sure that people feel able to let us know what’s happening and that they feel safe in doing so, because we also know that many people, possibly working there, have felt that in raising their voice, they could be themselves penalised. That’s absolutely an issue that we’re concerned about.

Q37 Fiona Mactaggart: Finally, on that point, how do you do that? How do you have a whistleblower structure where everyone who might whistleblow is absolutely confident, say in a private care home, that they’re not going to lose their job as a result?

Dame Jo Williams: I don’t have the absolute answer to that, but I do think that in how we respond and follow up, we do have, through our regulation, powers to take action. Now, I know that individuals may themselves feel they’re going to be extraordinarily vulnerable, but I hope we can learn from what’s gone before and ensure in whichever way we can that they don’t lose out.

But you have raised a very real issue, across the sector. People who themselves are providing services don’t necessarily tell us everything that might be happening in a hospital, because they say it may not be in their business interests. So we recognise there’s some very real challenges about helping people to speak out.

Q38 Nadine Dorries: At the beginning, when I first asked you what you thought the weaknesses were, you said that they were culture and process. Yet, having gone around the questions this morning, there are far more which have been exposed. You also said in your opening statement that you felt very much that the patients were at the centre and that there was a focus on people, but given the weaknesses that have been identified this morning, going around the table, do you not feel that perhaps you need to look at a way of drilling down a bit further yourself into the Commission and identifying further weaknesses and dealing with them yourself?

Dame Jo Williams: I think it’s very important for me to keep my finger on the pulse. That’s absolutely right. One of the things that I’ve been doing since I’ve been in this role is certainly going out and looking for myself at what’s happening right across the system. That gives me an enormous amount of insight into some of the challenges, but also, of course, some of the ways in which we are trying to deal with them.

There is a balance to be struck, in the role of Chair, between taking that sort of helicopter view, if you like, but also drilling down into what’s really happening within the organisation. I think it’s very challenging to make the right decisions about how you use your time most effectively.

Q39 Nadine Dorries: Any of the concerns about culture and process are the remit of the chief executive, whereas yours would be more about identifying the problems, drilling down and seeing how the organisation works. It is about identifying those problems and taking them to the chief executive to be addressed.

Dame Jo Williams: Well, I think that’s true. That’s one of the issues on which we as a board-the Commissioners and myself-try to spend a proportionate amount of time, by going out, looking at what is happening on the ground and reflecting back on that in our activity.

I don’t entirely agree that my concern about the culture is something that should rest with the chief executive. We cannot deliver, carry out our functions and serve the public effectively unless we have an operation, and a climate and culture internally that focuses on people’s individual needs and understands the pressures in the system and the real experiences of people on the ground.

I may have started there in my opening remarks, but the real issue in terms of what we are trying to do is about getting to those issues and protecting and offering a better system and service for the very people that your colleagues have been talking about this morning.

Q40 David Tredinnick: I am sorry that I was not able to be here for your opening remarks, but I picked up on something that you said when I came in and I would like to explore that. You hinted that information technology was a problem, but it is fundamental to running any organisation. We know that Governments have a lot of problems with computers generally. You didn’t say this, but you might have said that there is a problem with interface between the organisations. Is that correct?

Dame Jo Williams: When we started there was, yes.

Q41 David Tredinnick: Is that now better?

Dame Jo Williams: It certainly is.

Q42 David Tredinnick: How is it better? What did you do?

Dame Jo Williams: We now have a new system that works effectively. There are probably still some glitches in it, but it enables us to draw down all the necessary data from a variety of different sources, and to feed that in so that the analysts can look at what is happening.

Q43 David Tredinnick: You have an immensely distinguished background and CV that absolutely overlaps with the requirements of the Department. However, I would like to explore your management style. Listening to Fiona’s questions and to Nadine, it seems that there is a lot of emphasis on looking at what is happening on the ground and on people, but I wonder whether there is a strategic grip from the top.

I am minded that we have received a submission from somebody very much in the know who has had to deal with Government Departments and who described your organisation as a pretty hopeless regulator. Going on from that, I wonder what internal reporting systems you have, and whether they are the same in the three different organisations. The impression I get is that it is possibly all a bit amorphous and "let’s go out and see". I do not feel that there is a rigid structure and I would like to know how you deal with things internally.

Dame Jo Williams: I am disappointed to hear the comment that we are "hopeless."

Q44 David Tredinnick: It was one comment from an individual who had been in the know. It may be completely inaccurate.

Dame Jo Williams: Well, I would like to influence their view and demonstrate what I think we have achieved over the 18 months we have been operating. I absolutely agree that getting a strategic grip is at the heart of the role that I am currently acting in. We certainly have had to work very hard to reach some operational deadlines-there is no doubt about that-such as the registration of the health service in April and the registration of social care from 1 October. We have had to monitor performance very carefully in relation to that.

We are, as a board, provided with performance management information on a regular basis. As you will appreciate, making sure that it really is focused on the most important things is the challenge for us, really-drawing down what are the key indicators that tell us whether we are achieving our objectives. So we spent some time discussing that, and looking at it; but in overall terms we have a strategy, which, clearly, we will need to revisit in the light of some of the proposed changes. Making sure people get good, safe services is central to that. We certainly have used our powers, I think, to date, to demonstrate that we are very serious about taking that objective, too, right out there, and doing everything we can to bring about improvement.

I said earlier that, as we have gone through the registration process, it is clear that there are some issues about how we use our powers to deal with those organisations that are underperforming. Again that is, I think, something that we will be concentrating on over the coming months. Clearly, working with other organisations, making sure we have clarity about our role and theirs, as well as drawing in information from other organisations, will be critical.

It is my view that we have achieved our objectives over the last 18 months; and the challenge, of course, which the Chairman raised at the beginning, was "Are we adding value to the system?" That’s our internal challenge.

Q45 David Tredinnick: One short, last question. Have you made any changes to the board since you have been there, and do you propose to make any changes? What value do you think the board is? Do you use the board very much? Do you talk to them very much?

Dame Jo Williams: I haven’t said, but I do believe that it’s an eclectic team. We’ve got two people with medical backgrounds, an accountant and someone who is experienced in mental health services and was herself part of the Mental Health Act Commission. We have recently recruited someone whose background was both in regulation and local government. If you confirm my appointment, that will mean there is a further vacancy on the board of the Commission. We haven’t had this debate, but this does seem to me one of the things that we might want to look at: is there someone from the private commercial sector who would wish to join us, whom we can recruit, who will bring a different dimension to our board?

Q46 Grahame M. Morris: I want to ask about the qualities that you are bringing to this post and some of the challenges you are facing. As someone who takes an interest and is trying to act as a champion, as other colleagues have, for people with learning disabilities, I was obviously delighted to hear of your background with Mencap and with your response to Fiona’s remarks about needing to speak up for those who are vulnerable and who don’t have a voice themselves, particularly in relation to residential accommodation.

But there are some pressures you’re going to face, with bringing together three organisations and being expected to deliver a more efficient service, with all of the comment and criticism-constructive, I am sure-about delivering that with a budget of £60 million less, and with the pressures within Government for deregulation.

Do you feel that you’re going to be strong enough, and the organisation is robust enough, when the Department of Health says, "Take one of these additional responsibilities"-for example, reviewing arm’s length provisions like the Human Tissue Authority? Will you be considering that and saying, "Well, can we realistically do this? Are there conflicts and tensions? Is it appropriate we do it?" I’d be interested in your views, Jo.

Dame Jo Williams: I certainly don’t underestimate those challenges. It’s absolutely right; it’s a very big agenda that we have already. As I’ve said, we’ve rigorously looked at how we make best use of what we have, and we know that there is absolutely no point in asking for more resources. We will begin to look at some of the proposed changes through the arm’s length body review-we are right at the beginning of this.

Your question is absolutely right: will we have the resources to do it well? There may be some gains to be made in terms of some of the back-office issues, but special skills may be needed for which we would have to recruit or integrate those who are currently working there.

As things emerge, we have to make our case alongside everybody else. I have spent most of my working life in situations where we’ve never had enough money to achieve our aspirations, and I have had to argue my corner in a variety of different ways. This may be on a larger scale, but, in that sense, it is absolutely part of my responsibility, and I would be failing the public if I did not draw attention to the limits of what we can achieve if we overstretch.

There is no doubt about it: the challenges that we have at the moment are very stretching, but if we go further, we cannot play our part as the regulator in safeguarding and bringing about change and improvement, and that is what is driving me to do this job.

Q47 Chair: Thanks very much. A final question, if I may: given the broader public expenditure context, do you think it is part of your responsibility to volunteer a reduction in your budget this year?

Dame Jo Williams: I think we’ve made huge changes already. For instance, we’ve reduced accommodation-we’ve asked people to work from home-and that has reduced our budget expenditure by £20 million. I believe that we are rather lean already, so I don’t think that we will necessarily be volunteering, but I will continue to look at whether we are using our resources to best effect, and, if we are to take on other responsibilities, whether economies of scale can be made, notwithstanding what I’ve said about the need to recognise the issues and some of the special skills that are required.

Chair: Thank you very much. Unless anyone has any further questions, we would like to thank you very much for coming. It is our intention now to go into a private session to draw our own conclusions, and to publish a report as quickly as possible, probably in the early part of next week.