In April, I wrote a rather unkind retrospective of Cynthia Bowers period as Chief Executive of the Care Quality Commission. It was bombastic but not undeserved. It is now time to look to the future. David Behan arrives at the CQC at a time of intense crisis and he faces a daunting challenge. The importance of the role, however, is such that he cannot rely on his newly appointed status for very long. He needs to get a grip quickly and work effectively at improving the quality of the regulator so that when he leaves in due course, I will be able to write kinder things about his than I had about his predecessor. CQC loves the phrase ‘looks like’, as in ‘providers need to know what compliance looks like’. What will success ‘look like’ for David?
First, there needs to be a recognition that although the same regulations and guidance apply to all services, not all sectors are alike in nature and they require a different approach. It is a nonsense to treat a huge NHS Trust in the same way as a care home for a few service users. To his credit, Behan has already acknowledged this and has promised change. He has also promised a change to annual inspections, favouring instead a risk based approach. That too is welcome.
There is also a need to recognise that one inspector does not have the expertise to inspect the full range of regulated services. A social worker with a background in residential care does not have the expertise to regulate complex governance and clinical provision of an acute hospital. Again, Behan has indicated that he understands that and the practice of trying to shoehorn inspectors into shoes that could never possibly fit, looks likely to disappear quickly.
A successful regulator also needs to be able to present information clearly to stakeholders that may be new to the sector, for example a middle aged person choosing a nursing home for their parent. The star rating system had flaws, but at least it enabled some degree of quick comparison. CQC rightly abandoned proposals for a new quality rating after they were rejected by the sector and roundly criticised, not least by the Health Affairs Select Committee. The problem, however, was not the notion of a quality rating, but rather the system that was proposed. CQC were planning on it being optional (yeah, right!), would be run by an unaccountable external body and would involve an additional fee. No wonder it was rejected.
As things stand, each provider has a profile page on CQC’s website which indicates ticks or crosses against standards. There is no way, however, of knowing whether crosses indicate a minor, moderate or major concern without delving right into the heart of the report. That makes it difficult for stakeholders to make meaningful comparisons quickly. A quality rating system, if it were fair would be of great use.
Given some high profile scandals in care, Behan will be most likely to be judged on how well he prevents similar abuse in the future. In a recent seminar on the future of healthcare regulation, CQC said that it is not CQC that abuses service users and providers have the first responsibility to prevent abuse. That is a worrying position. Of course providers must prevent abuse, but the reason we have a regulator is that without regulation, not all providers can be relied upon to do so. Also worrying is that CQC still maintains that it cannot investigate complaints about services. That is very likely to be misinterpreted by inspectors, as was the case in the Winterbourne abuse scandal. Success looks like taking complaints and dealing with them not palming them off to others. It also means using a wider range of enforcement powers. Warning notices are issued so frequently that there is a real danger that they will lose their deterrent effect.
Finally, and perhaps most importantly, success looks like listening. That was the real problem in recent years. Many of the problems that arose were so very predictable to most of the sector, and yet CQC ploughed on regardless of the sensible objections raised. CQC should receive well-reasoned communications and complaints from the sector in the same way it expects providers to respond to CQC when it critics them. That means being self-reflective and ensuring that middle managers consider challenges to inspectors, rather than inspectors answering themselves which inevitably encourages defensiveness. Behan needs to be a strong leader, but for a super-regulator with such wide-ranging responsibilities, that leadership needs to come from careful listening rather than straining at the bit.