The scathing criticism of CQC by the Health Committee in its annual report will come as no surprise to the sector. Last year, providers were scratching their heads wondering why so much time and effort was being invested in re-registering providers who were already providing services. The idea, of course, was nonsense. In practice, it was always obvious that only a handful of providers would be refused registration as refusing a large number of registrations would have been a logistical impossibility for commissioners. Whilst thousands of man-hours were spent on the charade, CQC was unable to commit its resources to what really mattered – inspecting services and concentrating enforcement on the small proportion of poor providers. The result has had disastrous consequences for vulnerable service users who were not adequately protected by the regulator.
CQC blamed the plummeting number of inspections over the last year on the new registration system, though it provided no evidence that it asked for more resources or that it had advised the Department that re-registration would be onerous and unnecessary. In fact, it is unthinkable that CQC’s predecessor organisations did not have a dominant role in drafting the Health and Social Care Bill and agreed the re-registration process.
What is so frustrating for the sector, is not only that re-registration was not a good idea, but that it was so obviously a bad idea. Commentators, providers and their representative bodies were screaming as much from the rooftops and their views were simply ignored.
The same goes for other decisions CQC makes. The star rating system was flawed but rather than addressing those flaws, CQC decided to ‘sponsor’ an excellence scheme to be run by a third party, plainly breaching a general public law prohibition against delegating powers in this way. The consultation document it produced about the scheme was so ill-thought out that responses to it, especially the well-considered response from the Royal College of Nursing, made CQC look amateurish in the extreme. Following the Health Committee’s report, the idea has finally died a death.
It is in the area of self-assessment that the regulator’s bad judgment is most extreme. The historical background to self-assessment was in regulation by the Healthcare Commission. The problem with self-assessment is that it creates a moral hazard. A moral hazard is a situation where people or organisations are incentivised to act in a way which is contrary to be the public good and are able to do so because of imperfect flows of information.
In the case of self-assessment, the regulator has an imperfect view of the quality of a provider if it fails to fully inspect it. Under those circumstances, a provider has an incentive to overstate its degree of compliance and hoodwink the regulator and other stakeholders that use that information.
That problem is, once again, obvious. Ask any person on the street which assessment of a care home is likely to more favourable; the assessment of an independent regulatory or the assessment of the care home itself and you’d be likely to get some funny looks; obviously the care home will give itself a better assessment.
I attended a conference on patient safety a few years ago where a policy officer from the Healthcare Commission explained how the new system of self-assessment was working. I asked whether the Commission had attempted to validate the Trust’s self-assessment through its own independent assessment. As it turned out, the Healthcare Commission had conducted random reviews of its own and its own assessments were less favourable than the self-assessments of the Trust. The Healthcare Commission officer attributed the difference to teething problems, and predicted that the difference would narrow in time. That analysis was obviously flawed. The true cause of the difference between the outcomes of self-assessment and independent assessment is that self-assessment is like asking pupils to award themselves their own grades.
Mid-Staffordshire was a direct consequence of that fundamental flaw in methodology.
Underlying the failures of CQC and its predecessor was the willingness of the senior manager to kow-tow to political will; political concern about the burden of regulation as regards the Healthcare Commission, and falling public spending in the case of CQC. This was very much a case of the tail wagging the dog. Had Cynthia Bower written to the Department explaining that a burdensome re-registration process and falling budgets were threatening the capacity of CQC to protect service users, it is unthinkable that a solution would not have been found.
Providers understand that the sector needs regulation. The problem is that bad regulation means that low quality, low cost provision is able to crowd out good quality. The inevitable result is harm to vulnerable people.
Following the Health Committee’s report, let’s hope that CQC can begin to avoid making so many obvious mistakes. It stands the best possible chance if it really begins to listen.