1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health (the Department) and the Care Quality Commission (the Commission) on the Commission’s capacity and capability to regulate the quality and safety of health and adult social care. We also took evidence from Warrington and Halton Hospitals NHS Foundation Trust, Quantum Care, and a GP and Partner of the Jenner Practice in Lewisham who is also Chair of Lewisham Clinical Commissioning Group.
2.The Commission is the independent regulator of health and adult social care in England. Its purpose is to “make sure health and social care services provide people with safe, effective, compassionate, high quality care, and to encourage them to improve”. The Commission is a non-departmental public body, sponsored by the Department of Health (the Department). Its 2015-16 budget is £249 million, funded by grant-in-aid from the Department and fees charged to regulated bodies.
3.The Committee of Public Accounts last took evidence from the Department and the Commission in 2012. The previous Committee then expressed serious concerns about the Commission’s governance, leadership and culture, and its failure to intervene quickly or strongly enough in failing providers of health or social care services. The Commission has since been working with the Department to implement significant changes, under a three-year transformation programme between 2013–14 and 2015–16.
4.The Commission originally set out to inspect and publish ratings for all acute hospitals by 31 December 2015, all adult social care providers by 29 February 2016 and all GP providers by 29 February 2016. In July 2014, the Commission’s board agreed to revise the inspection timetable for 2014–15 and, in March 2015, the Commission published revised targets to complete all NHS acute hospital inspections by April 2016 and rate all adult social care providers and GPs by 1 October 2016. By September 2015 the Commission had inspected 75 against its planned trajectory of 132 hospitals by that date. It has a target to complete inspections of 585 hospitals by March 2016. The Commission expressed confidence that it would have inspected all acute hospitals by March 2016, and all community and ambulance trusts by June 2016. For adult social care and primary care services, however, the Commission confirmed that it was running behind the trajectories it had set. By September 2015 it had inspected 4,487 adult social care providers, against a planned trajectory of 5,992 by that date and 13,286 by March 2016. The Commission had inspected 1,217 GPs against its planned trajectory of 1,924, and had a target to inspect 5,087 by March 2016. At this rate, the Commission forecast that at the end of March 2016 it would be below its planned trajectory by 6% in adult social care and 8% in primary medical services. The Department agreed that the Commission was not meeting the ambition the Department set for it but emphasised that it was important for inspections not to be a tick box exercise and for them to reach the right judgements.
5.The Commission has struggled to recruit and retain the number of staff it needs to deliver its inspection programme. By mid-April 2015, the vacancy rate was 34% for inspectors, 36% for senior analysts and 35% for managers. The Commission told us that it was on course to achieve its target to make job offers to 600 new inspectors by December 2015, and that the Department had given sufficient funding for this. The Commission does not expect to reach its full complement of 263 hospital inspectors until June 2016. It explained that it was essential, given past criticisms of the Commission, to raise the quality of staff joining the organisation. The need to attract high quality staff, however, had made it harder to recruit people. It has also had to recruit more people because staff turnover, running at 7.5% in 2014–15 and around 8% in the first two quarters of 2015–16, continues to be higher than the 5% rate the Commission had planned for.
6.The Commission has used contractors to fill gaps in its capacity, particularly in areas where it needs specialist expertise to transform the way that it works. Using contractors can be more cost effective than employing permanent staff when people with specific skills are needed for short periods. However, in 2014–15 the Commission spent £17.2m on contractors, many of whom worked in central functions like information systems and technology. Some of these staff were involved directly in providing services to the public, in the National Customer Services Centre, or providing business services support to inspectors. The Commission told us that if it had been able to recruit the permanent staff needed earlier, and relied less on bank staff to carry out inspections, then it would have spent less.
7.The Commission’s ability to achieve its inspection schedule for adult social care providers and GPs will be influenced by budget allocations and fee decisions for 2016–17, which were yet to be finalised at the time we took evidence. As part of the Government spending review, the Commission had been asked to model the impact of grant reductions of between 25% and 40%. The Commission told us that one of the consequences of any reduction in its grant could be fewer staff, and that would impact on the Commission’s ability to do all its work. The Department confirmed that costs could be passed on to providers in the form of higher fees, subject to consultation with regulated bodies and final approval by the Secretary of State for Health.
8.The Commission is not currently achieving its target to complete inspection reports within 50 days and the Department accepted that performance both on timeliness and accuracy needs to improve. In September 2015, on average, it took 49 days from the end of the inspection for the Commission to complete and publish its reports on adult social care providers and 67 days for reports on GPs. The Commission told us that they did not think it would ever be possible to deliver an inspection report for a hospital in 50 days, due to the scale and diversity of these organisations. Currently reports for hospital inspections are completed in an average of 83 days but the Commission believes a more realistic target would be between 60 and 70 days.
9.Providers told us they too were concerned with the time taken to receive inspection reports. In particular they were frustrated by the lack of consistency between the feedback they received at the end of their inspection visit and the report they received some months later. The chief executive of Warrington and Halton Hospitals NHS Foundation Trust told us that their draft report identified some areas as ‘requiring improvement’ despite having received positive feedback during the inspection itself. The Chief Executive of Quantum Care added that reports contained a lot of surprises. The Commission told us they now write to hospital trusts if they identify concerns during an inspection so that the trust can take action without waiting for the report to be produced. The Commission expects the trust to take that letter to the board in public.
10.Providers also told us they had to spend too much time dealing with factual inaccuracies in draft inspection reports. Warrington and Halton Hospitals NHS Foundation Trust told us it had identified about 210 inaccuracies in the draft report. Some of these were minor, for example grammatical errors, but the report also contained inaccurate evidence that could have been corrected at the time of the inspection. The Trust told us that the Commission had accepted 64% of the points raised and changed some of the ratings in the report as a result. The Chief Executive of Quantum Care told us that the Commission’s process for dealing with inaccuracies was not working as well as it had in the past. The Commission said that it has strengthened its internal processes to ensure greater consistency and quality of judgements, but that building in internal checks and balances had also led to delays in publishing reports.
11.The number of concerns raised by whistle-blowers, complaints about providers, safeguarding calls and statutory notifications from providers increased from a total of 173,931 in 2013–14 to 208,720 in 2014–15. However, the National Audit Office found that one out of three safeguarding alerts raised with the Commission was not acted on within the Commission’s two-day target. The Department acknowledged that the Commission had long-standing problems with how it reported and responded to safeguarding alerts but assured us that the Commission had now put more rigorous systems in place. As part of its inspections, the Commission also looks at how hospitals, care homes and paramedical services respond to complaints. It has developed its methodology by speaking to people who have raised complaints about the quality and safety of care, as well as other organisations that people go to when they have a complaint.
12.The Commission takes the time to talk to patients, staff and carers during an inspection. However, providers were concerned that this only provided the views of people inspectors met on the day of the inspection and meant the Commission could be at risk of placing too much reliance on anecdotal evidence. The Commission organises formal patient and carer consultation events in advance of its inspections, but these may not necessarily be well attended or representative of all people using the services inspected. A GP and Partner of the Jenner Practice in Lewisham told us that, for general practice, the Commission uses a patient questionnaire. However, he felt that the central questionnaire was not very sensitive to local circumstances. He also made the point that responses might reflect an unrealistic or outdated view of what people thought GP services ought to be, rather than how primary care is changing to best meet patients’ needs.
2 paras 1, 2, 1.3
4 , paras 2, 1.4, 1.6
5 , para 2.8
8 ; para 2.5
9 ; , para 2.6
10 ; , para 2.7
17 paras 3.6-3.7 and Figure 9
Prepared 9 December 2015