1 The management and governance of
the Care Quality Commission
1. The Care Quality Commission (the Commission) is
the independent regulator of health and adult social care in England.
It is a non-departmental public body, overseen by the Department
of Health (the Department). Its objective is to 'protect and promote
the health, safety and welfare of people who use health and social
care services'.[2] Formed
in 2009 by merging the Healthcare Commission, the Commission for
Social Care Inspection and the Mental Health Act Commission, it
currently regulates over 21,000 care providers against 16 'essential
standards' of quality and safety, through registration, inspection
and, where necessary, enforcement action. Tougher enforcement
powers were a key element of the Commission's design and the new
system brought more providers, including dentists and GPs, within
the scope of the regulator.[3]
2. Although the Commission has more responsibilities,
its budget for 2010-11 was 6% less than the combined budget of
its predecessors for 2008-09.[4]
Despite this, the Commission has consistently underspent against
its budget. For 2011-12, it is projecting an underspend of £14
million (10%), mainly because of the continuing delays in filling
staff vacancies.[5]
3. The Commission focused the staff it did have on
registration rather than inspection, and as a result carried out
far fewer inspections than planned. The Department clearly underestimated
the scale of the task it had set the Commission.[6]
The Department told us that it is ultimately responsible
for ensuring there is improvement in the Commission's systems
and processes, and that where there are problems it is accountable
for ensuring these are addressed. The Department's Accounting
Officer set out five areas where she would like to see improvements.
These were: clarifying the Commission's strategic direction; setting
clear priorities, matching resources to them, and understanding
what things cost; improving accountability between the Department
and the Commission; improving engagement and communication with
the public; and developing the regulatory regime to get the right
balance between inspection, the 'user voice' and the use of information.[7]
4. We have serious concerns about the leadership,
governance and culture of the Commission.[8]
In its most recent annual report to Parliament, the Commission
reported incorrect information, claiming to have completed twice
as many inspections and reviews than was in fact the case. One
member of the Commission's Board has been so troubled that she
has made public her concerns about how the Commission is being
run. She told us that she had still not had adequate opportunity
to discuss her concerns with the Department, and that she had
been ostracised and vilified since she challenged the Commission's
leadership.[9]
5. The Commission has been criticised for being overly
concerned with reputation management at the expense of transparency
and accountability.[10]
Staff leaving the Commission have been made to sign compromise
agreements containing confidentiality clauses, tantamount to gagging
clauses. This Committee has expressed concern on previous occasions
about the use of such clauses. The Department confirmed that confidentiality
clauses are not in themselves prohibited, but its guidance makes
clear that clauses that seek to prevent the disclosure of information
in the public interest should not be allowed. We are concerned,
however, that the use of confidentiality clauses makes people
reluctant to speak out, even though their whistleblowing rights
may be legally protected.[11]
6. The Commission's strategy and focus remain unclear.
In particular there is confusion about the extent to which its
role goes beyond regulating against the essential minimum standards
into wider quality improvement.[12]
This was illustrated by the evidence we heard. One witness felt
that the Commission should be doing more to drive improvement,
while others considered that the Commission's primary role should
be to ensure minimum quality and safety standards.[13]
7. The Commission has not defined what successful
regulation would look like, even though it has been operating
for nearly three years.[14]
Currently its performance metrics are quantity-based measures
of activity, such as the number of reports produced, with no measures
of quality, a position we find astonishing given the Commission's
purpose is to regulate quality.[15]
8. The Commission is the third regulator for health
and adult social care in the last decade. None of the witnesses
we heard from was in favour of further reorganisation, stressing
that the existing arrangements need to be made to work better.
The Department thought that visible and sustained improvement
should be apparent in two years time. [16]
9. The Department has proposed to transfer the functions
of the Human Fertilisation and Embryology Authority and the Human
Tissue Authority to the Commission in 2015.[17]
The Chair of the Human Fertilisation and Embryology Authority
(the Authority) argued passionately against this change. The Authority
already shares premises and back-office functions with the Commission
and has achieved the savings set out in the public spending review.
The Chair felt there would be little benefit in merging the Authority's
specialist role of regulating IVF services with the wider role
of the Commission. Furthermore, a merger would put the standard
of regulation at risk and would not provide value for money.[18]
10. The Department congratulated the Authority on
the way it had worked with the Commission. In the light of the
discussion it had heard at the Committee, the Department said
it would have a full consultation before further decisions were
made about transferring the functions of the Human Fertilisation
and Embryology Authority and the Human Tissue Authority to the
Commission. This is a welcome pause.[19]
2 Health and Social Care Act 2008, part one, chapter
one, para 3 (1) Back
3
Q 48, C&AG's report para 1.3 & 1.5 Back
4
Q 111 Back
5
Qq 113, 196, Ev 46 Back
6
Q 49 Back
7
Qq 53- 58 Back
8
Qq 52, 118, 165 Back
9
Q 104 Back
10
Qq 22, 35, 40, 56 Back
11
Qq 102-107, Ev 45 Back
12
Q 12 Back
13
Qq 13, 18, 20 Back
14
Qq 143- 149 Back
15
Qq 35, 52 144 Back
16
Qq 32,165, C&AG Report para 1.2 Back
17
Q 5 Back
18
Qq 2-6 Back
19
Q 117 Back
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