House of Commons - 2013 accountability hearing with the Care Quality Commission

2013 accountability hearing with the Care Quality Commission - Health Committee Contents

4 Regulatory model

Surveillance

40. The CQC plans that future inspections will be informed, and on occasion prompted, by an ongoing surveillance process. The CQC said in their consultation on the proposed reforms that they would not draw definitive conclusions from the indicators they use to assess risk, but such indicators would be used as "smoke detectors which will start to sound if a hospital is outside the expected range of performance or is showing declining performance over time for one or more indicators."[49] Offering more detail, David Prior said that the surveillance model would use over 150 indicators and therefore they were "not capable of being gamed in the way that five or six may be."[50]

41. The CQC intends to use three tiers of indicators to analyse risk. They describe the system as follows:

Tier 1 Indicators

The first set of indicators will be the centrepiece of our new model. It will include data and evidence such as mortality rates, never events, specific results from the national NHS staff and patient surveys, information from whistleblowers, information from individual members of the public who make complaints, raise concerns and provide feedback, and information from Quality Surveillance Groups.

They have been selected because they are things that have a high impact on people and because they can alert us to changes in those areas. An example of a trigger would be higher than expected deaths for people who have had operations that would not normally carry that level of risk. [...]

Any indicator in this set which points to a potential concern or a decline in quality over a period of time will trigger questions from us. Our response will vary depending on the concern. For example we may ask the trust responsible for the hospital for more information and explanation; we may carry out an inspection; or in extreme cases we may suspend a service.

Tier 2 Indicators

The second set of indicators will include a much wider range of intelligence which on their own may not trigger action by us. We will check them if the first set of indicators signal a concern, to help understand the issues raised and decide what an inspection should focus on. This second set of indicators will include nationally comparable data such as results from National Clinical Audits, admission profiles for each NHS trust, wider sets of patient and survey results, and information from accreditation schemes.

Tier 3 Indicators

42. In their written evidence the CQC summarised how the new system of tiered indicators was intended to inform the inspection process. Their evidence stated that:

43. If it is to build public confidence in a risk based regulatory system the CQC will require early identification of developing problems. The surveillance system must identify problems and trigger inspections before they become widely publicised by the media, patient groups or local representatives. If the CQC's surveillance model cannot pre-empt high profile failings it will be viewed as purely reactive and will not be regarded as a credible basis for regulatory activity.

STAFFING LEVELS

44. In oral evidence the CQC outlined how their new model would assess the adequacy of staffing levels in hospitals, care homes and other providers. David Behan told the committee that the CQC was working with NICE and NHS England on "a tool that can assess the adequacy of staffing"[53] The Government has since asked NICE to set out:

45. Mr Behan said that the CQC wanted to be able to assess how many people were actually working on a ward on in a care home as opposed to the theoretical establishment. He added that the CQC was "actively building an assessment of the adequacy of staffing into our new inspection model."[55]

46. The Committee welcomes the importance attached to staffing levels by the CQC. We believe that analysis of staffing figures should not only be part of inspection but should also form a fundamental part of the surveillance model. Staffing data should extend beyond the ratio of registered nurses to patients working on a hospital ward and should examine other measures, such as consultant coverage in emergency departments, which is a crucial factor in improving patient outcomes.[56]Information gathered from surveillance which suggests that staffing levels are inadequate should be a trigger for inspection as "the quality of care that people receive is related to the number of staff on duty."[57]

47. Significantly, David Behan pre-empted the Government's full response to the Mid Staffordshire NHS Trust Public Inquiry by saying that "the fundamental standards will also address this issue, so the regulations will need to address the appropriateness of staffing"[58]. The Government's full response to the Public Inquiry said:

48. The Committee welcomes the commitment made by the CQC that the fundamental standards by which providers are registered will incorporate appropriate staffing levels. It is essential that those providers that fail to achieve adequate staffing levels are aware that they are in breach of fundamental standards and therefore liable not only to inspection but also to regulatory action including prosecution. The regulations have yet to be published and it is vital that the public have the opportunity to scrutinise how they define an 'appropriate staffing level'.

PATIENT SAFETY INCIDENTS

49. In the report of the Committee's last accountability hearing with the CQC we questioned the rationale for transferring the functions of the National Patient Safety Agency (NPSA) to NHS England. The committee recommended that "the Secretary of State should reconsider whether prime responsibility for patient safety should reside with the CQC."[60]

50. In oral evidence David Prior told us that patient safety is something which the CQC Board "feels ought to be with us, not with NHS England."[61] David Behan rightly cautioned that these responsibilities would extend beyond "critical incidents where patients have been badly cared for"[62] and include alerts about "machinery and equipment"[63] which would raise questions about the breadth of the CQC's responsibilities.

51. The committee is pleased that the CQC is, in principle, willing to take on the responsibilities that once resided with the NPSA. It is illogical to split different aspects of patient safety between NHS England and the CQC and this reform would simplify the regulatory environment. The Committee believes that would allow more information to be quickly factored into the CQC's surveillance model which already includes 'never events' in its first tier of indicators.

Financial monitoring of social care

52. The Care Bill [Lords], currently in Public Bill Committee, proposes to give the CQC specific powers to monitor the financial strength of approximately 50 to 60 care providers whose financial collapse could trigger a local crisis in the delivery of care.[64] Subject to the Bill receiving Royal Assent, from April 2015 CQC will:

"i. Require regular financial and relevant performance information from some providers.

"ii. Provide early warning of a provider's failure.

"iii. Seek to ensure a managed and orderly closure of a provider's business if it cannot continue to provide services.[65]

53. The CQC said that this "will strengthen our ability to help make sure that concerns about people's care are identified and acted upon as early as possible."[66] They add that they will:

"i. Carry out financial checks on a small number of providers (based on their size, local or regional concentration and specialisation of services which makes them difficult to replace).

"ii. Monitor risks to financial sustainability and, depending on the level of risk, ensure these providers have effective 'sustainability plans' in place to satisfy us that it can manage the risk. We will need to be sure that the provider is taking sufficient steps to address a threat to their business sustainability. We will be able to commission an independent business review to help the provider become financially sustainable.

"iii. Require information from providers in order to facilitate an orderly closure of a provider's business, should that become necessary, and ensure the continuity of care for people who use the service.

"iv. Oversee and coordinate the process when a provider fails across all involved local authorities, and communicating nationally on progress to provide reassurance and information."[67]

54. The CQC has been asked to take on this additional responsibility because it relates specifically to adult social care, a sector which Monitor, the economic regulator for NHS Foundation Trusts, does not cover.[68] The Government's response to their consultation on Market Oversight of Adult Social Care explained the reasoning behind the CQC being tasked with these functions:

55. David Behan told us that in order to fulfil their obligations the CQC will need to "buy in skills from organisations that do insolvency work".[70] David Prior explained that the CQC did not have the financial skills that were required and it is highly unlikely that they would want to have them in house.[71] Mr Prior also observed that many of the backers of adult social care businesses were "private equity companies with very complex capital structures".[72]

56. Undertaking the financial monitoring of adult social care is a significant challenge for the CQC and it is essential that they procure the right skills to fulfil this role. David Behan noted in his evidence that there was a close correlation between poor quality and poor financial performance, saying that "[m]aking a distinction between finance and quality is a false distinction."[73] We do not dispute this point, but the Committee believes that, ultimately, it is easier to identify and address poor quality at an early opportunity than it is to demonstrate that a provider is financially distressed.

57. We recommend that the Government should reconsider its decision to allocate this responsibility to CQC and that it should ask Monitor to undertake this role. Although this development would divide oversight of adult social care between Monitor and the CQC, it would facilitate the reduction of boundaries between healthcare and social care and would maintain the existing distinction of principle between the CQC, which focuses on care quality, and Monitor, which focuses on financial performance.

A FIT AND PROPER PERSONS TEST

58. Part of the revised registration process arises from the Government's desire for the CQC to operate a fit and proper persons test (FPPT) so that "named directors or leaders of organisations are personally held to account"[74] for the commitment made at registration "to deliver safe, effective, compassionate, high-quality care."[75]

59. It is expected that the powers to implement penalties as part of the FPPT will come into force in April 2014. The ultimate sanction in this regard will be the power to remove board members from their post by placing a condition on a provider's registration. Allied to this, the CQC could bring a prosecution resulting in a fine.[76]

60. The Government proposes that regulations should define a fit and proper person, and the Government's consultation on the proposals stated that:

The CQC said in written evidence that over time they would develop intelligence to guard against individuals who would fail the test being appointed elsewhere:

61. In order minimise the administrative and bureaucratic burden of the FPPT the Government proposes a model whereby:

62. The Government proposes that the requirement for a FPPT should apply to "the senior governance positions"[80] of NHS Trusts and Foundation Trusts, independent healthcare organisations and social care providers, but the CQC stated in written evidence that it would not be asked to apply the test to Chairs of NHS Trusts or Foundation Trusts.[81] The FPPT also provides an additional dimension to the regulation of private providers of care by providing a link between those who determine the quality of care and the financial performance of a provider, and David Behan noted in oral evidence that the purpose of strengthening registration was to allow the CQC "to hold people who sit behind service provision to account"[82].

63. The Committee welcomes the introduction of the fit and proper person test for senior governance positions, but does not understand why it is proposed to exclude Chairs of NHS Trusts and NHS Foundation Trusts from the scope of this test. It does not believe that this exclusion will be understood or accepted by public or patients.[83]

Inspections

64. The process of inspection is changing significantly as the CQC adopts a model of differentiated, in-depth inspection. In relation to hospitals, the CQC has said that inspections will typically last for a total of 15 days with 6 to 7 days on site.[84] The Department of Health summarised the new approach in its evidence and said that CQC inspectors would:

65. In the report of the last accountability hearing with the CQC, the Committee was critical of the CQC for using specialist inspectors in only 13 per cent of inspections.[86] The new model abandons generalist, generic inspections and from 2013-14 the CQC intends only to operate "teams of inspectors who specialise in particular types of care."[87] The CQC said that in-depth inspection teams should be in place by Q3 of 2013-14.

66. Commenting on the old model of inspection, David Behan told the committee that "I was absolutely clear on coming into this job that the generic model did not work and we needed to move away from it and to specialist inspections."[88] Explaining the new system, the CQC's consultation document said that differentiated inspection means that some hospitals regarded as outstanding might only be inspected every 3 to 5 years. Good hospitals might only be inspected on a 2 to 3 yearly basis, adequate hospitals annually and inadequate hospitals as and when required. Mr Behan confirmed, however, that in the new system no provider would go as long as five years without inspection. He said that the CQC "got a very clear message from our consultation that five years is out. Nobody is interested in anything being on a five-year frequency."[89]

67. The CQC told the committee that although indicators within the surveillance model would be the trigger for inspection[90], at ward level specific problems in otherwise good or outstanding hospitals might not be picked up.[91] This builds on the observation made by David Prior that it was not possible for the CQC to "pick up everything in a hospital"[92] and that providers were ultimately responsible for the standard of care provided. Mr Prior said:

Echoing this view, the FTN warned in their written evidence that "primary responsibility for the standards of care provided to patients lies with the provider boards. [...] Unrealistic expectations of what CQC can do risk it being set up to fail."[94]

68. The CQC has an important role in providing quality assurance for a vital public service, but it cannot guarantee care quality. Primary responsibility for the quality of care delivered to patients rests unambiguously on the staff and management of care providers.

69. The Committee believes that generic inspection was a failure and the new model is a necessary step towards making the CQC an effective regulator. The proposed system represents a comprehensive improvement but the CQC must ensure that inspection is accurately targeted at risk. Surveillance will not always identify specific risks in outstanding hospitals and some high risk services will require frequent inspection even if they are regularly classified as 'outstanding'.

ASSESSING THE CULTURE OF PROVIDERS

70. In the report of the Committee's last accountability hearing, we recommended that:

In response to this the CQC said they would work with Monitor, the NHS Trust Development Authority and NHS England to agree how culture can be assessed and how the fundamental standards should be developed.[96]

71. The CQC's fifth key question to be examined during inspection asks whether a provider is well led. The CQC said that:

72. The Department of Health emphasised that in relation to NHS hospitals "the Chief Inspector of Hospitals will consider the culture of a Trust during inspections visits, in particular whether it is well-led, when deciding an overall assessment."[98]

73. The Committee welcomes the CQC adopting our recommendation to assess the culture of providers as a core part of the inspection process. This assessment must be developed so that it does not simply measure Board level governance practices, but properly assesses whether a culture of openness and challenge exists amongst frontline staff.

74. In the report on the Committee's 2012 accountability hearing with the CQC we concluded that:

A key element of this assessment [of culture] should be a judgement about the ability of professional staff within the organisation to raise concerns about patient care and safety issues without concern about the personal implications for the staff member concerned.

The Committee believes that the CQC should undertake an assessment of both the number of concerns raised by staff members and the way in which those concerns have been addressed. This would serves as a useful proxy by which the CQC can begin to measure the culture of an organisation.

Staffing and workforce planning

RESTRUCTURING

75. In oral evidence David Behan provided an overview of how the CQC workforce would be restructured to meet the demands of the new inspection model. He said:

We are committed to introducing our restructured organisation where people will be organised on a specialist basis by 1 April next year, so we will begin that process of restructuring and moving from the current model we have of people being organised geographically and generically into our specialist model. That is a huge change. All 2,000 people in this organisation will change their role.

76. In written evidence the Royal College of Nursing's (RCN) written evidence expressed concern about the process that the CQC is undertaking to change its workforce. Their evidence said:

100

77. The FTN has welcomed the concept of specialist inspection teams, but they too expressed concern that "there are shortages of skilled inspectors in some areas, such as governance, which CQC must address urgently".[101] The CQC explained in oral evidence that whilst they would eventually employ approximately 1,110[102] full time inspectors there would also be a bank of clinical experts who could be added to inspection teams as and when required.[103]

WORKFORCE PLANNING

78. In order to establish new teams the CQC's business plan recognised the requirement for extensive staff training in new methodologies over the course of 2013-14.[104] In addition, an element of the costs associated with the strategic review (£20 million in total) has been allocated to the recruitment of "more experienced specialists into senior inspector roles".[105] The CQC's additional written evidence noted that the recruitment programme for inspectors in each speciality would largely be determined by the Chief Inspectors and that the overall programme was expected to last approximately 18 months.[106]

79. In their written evidence the CQC provided an overview of the training programme that would be necessary to develop the inspection workforce to service the new model. The evidence stated that:

107

80. The CQC is planning to recruit an additional 150 inspectors to increase their establishment from 950 to 1,100.[108] This process is vital to improving the effectiveness of the organisation; we therefore recommend that the CQC set an early target date for the achievement of this increase and provides regular reports to Parliament on progress towards delivery of this objective.

FUNDING FOR WORKFORCE CHANGES

81. David Behan told us in oral evidence that in total the CQC would "need about 2,700 staff in the future to discharge our responsibilities".[109] The CQC's additional written evidence outlined the support services which lie behind the core inspection teams:

110

82. Beyond the £20 million allocated by the Department of Health to support the recruitment, training and workforce development programmes, David Behan told the Committee that £29 million would be available in the next year to support the new inspection process.[111] The CQC's written evidence conceded, however, that exact proposals for how this funding would be deployed had yet to be put in place: "some of this additional funding would be spent on recruitment; we have not yet calculated the exact costs."[112]

83. Substantial additional resource is being directed towards the CQC; the Committee recommends that the CQC Board reach early decisions about the allocation of this additional resource and that it make its decision public.

Ratings

84. In its consultation document 'A New Start' the CQC proposes a rating system for NHS hospitals comprising four separate classifications:

Proposed hospital ratings

i. Inadequate

ii. Requires improvement

iii. Good

iv. Outstanding

The Department of Health said in its written evidence that the new regime was needed to:

113

85. The CQC has confirmed that following inspection all providers across health, adult social care and primary care will be afforded an overall rating. In oral evidence David Prior explained that large hospitals would be given an overall rating but:

114

115

Mr Prior added that the eventual aim was to rate every service within a hospital, but did not attach a timeframe to this. David Behan explained in oral evidence that the process for establishing rating methodologies in adult social care and primary care remained at an early stage.[116]

86. The Committee welcomes the decision to publish ratings for all health and care providers. It is essential that the CQC act quickly to establish public understanding of, and confidence in, the ratings system.

PROVIDING INFORMATION TO THE PUBLIC

87. Behind the headline rating attached to a hospital, care home or GP surgery, there will be a detailed inspection report. In our last report the Committee recommended that CQC explore how they "can more effectively communicate with residents of care homes and their relatives about the outcomes of inspections".[117] We made this recommendation because "providers are not simply offering an episode of care with a finite end date but offering residents a permanent home combined with life-long care".[118]

88. David Prior informed the committee that the CQC was "going to consider writing to residents of a care home, for example, telling them in words of plain English, 'This is what we have found'."[119]The Committee is disappointed that the CQC is still "going to consider" this issue. It regards early action as fundamental to delivery of the core purpose of the CQC. It recommends that this recommendation of last year's report is adopted and implemented by the CQC no later than 30 June 2014.

49 CQC, A New Start, June 2013, p 22 Back

50 Q106 Back

51 CQC, A New Start, June 2013, p 24-25 Back

52 CQC (ACQ 02), para 16 Back

53 Q19 Back

54 Government Response to the House of Commons Health Committee Third Report of Session 2013-14: After Francis: making a difference, Cm 8755, November 2013, p 30 Back

55 Q23 Back

56 Health Committee Second Report of Session 2013-14, Urgent and emergency services, HC 171, para 74-75 Back

57 Q19 Back

58 Q19 Back

59 Department of Health, Hard Truths, The Journey to Putting Patients First, Cm 8754-I, January 2014, para 28 Back

60 HC 592, para, 19 Back