Imagine if you will a world where public and private providers of health and social care are dealt with an even hand. A world where private providers of care are given the support and room to offer good quality care to their service users. A world where inspections and ratings are not excessively relied upon to record the quality of care provided: Unfortunately, the regulation of the UK’s health and social care sector is at odds with these musings.
Healthcare providers, of which the majority form part of the NHS, are treated very differently to their privately-owned health and social care providers equivalent. CQC, in particular, might say the reason for this difference in treatment is owing to the difference in size of those organisations and the need to coordinate inspections to ensure that the relevant individuals are available; there is a fundamental difference in treatment not only in relation to the manner in which inspections are called but crucially in how the different organisations are treated after an inspection has taken place. The former, NHS publicly owned providers, usually are provided with up to three months advance notice of an inspection; whilst the latter, largely privately-owned providers’ inspections are largely called without any advance notice. This disparity offers the publicly owned provider with more opportunity to prepare itself in advance of inspection. In relation to the improvements offered to NHS providers they have access to large amounts of resource including NHS Improvement which works with NHS Trusts in order to encourage improvement. Conversely if a private provider of care finds itself subject to a negative inspection report or enforcement action it is largely left to its own devices to improve itself or suffer the wrath of CQC, at its most aggressive this can involve an urgent action for closure.
This lack of support for private healthcare providers is a fallacy since this leads to the creation of providers who are working to pass an inspection rather than the focus being on the delivery of good quality care. In procuring a system which is focused on inspections and ratings and involves little intervention without regulatory sanction CQC has created a system which is not designed to promote or improve providers.
The delineation between private and public providers of health and social care could be called into question as there is a large level of public funds which run through the so-called private organisations. To call those private providers an extension of the NHS would be met with shudders by some; but the reality is that the function that they perform is so integral to the successful delivery of good care more broadly that they should be treated with the respect their contribution to society deserves. Private providers can be treated negatively and there is a presumption of guilt drawn from viewing a minor incidence of practice and disproportionately drawing adverse inferences which are multiplied and magnified to develop a narrative which runs counter to the actual provision of care.
Being critical and scoring points against providers of health and social care is not a difficult task. CQC’s modus operandi is to monitor, inspect and regulate services to ensure that users of those services receive high quality, safe, effective and compassionate care. There has been a disproportionate focus on ensuring that all services have been inspected and rated to the detriment of building up services to enable them to provide good levels of care. CQC has developed quite a formidable stick (in its enforcement action) but it has some way to go to develop the carrot which will necessarily drive up standards within privately owned providers in particular.
A recent report commissioned by the Kings Fund and Alliance Manchester Business School on CQC’s impact on provider performance found that a rating had little or no bearing on the future performance of a provider. This calls into question the usefulness of inspections and their respective ratings as being objective evidence which is reflective of the care provided at a location. A better option might be to move away from the inspection model and closer to a supportive regime as is found in the public healthcare sector. In cases where there are significant concerns found the better approach might be to understand and work with the provider in situ to improve their service not in the detached manner in which the current system of inspection and enforcement appears to be based.
The important role that private providers of health and social care hold should not be undervalued and should be cherished as much as NHS services are by CQC. Admittedly there are occasions when the quality of care provision is such that intervention is necessary irrespective of ownership; in our experience this intervention is much more readily reverted to for private providers. The limits to the inspection model of regulation should be acknowledged for the flaws that are inherent in its process. An inspection reflects the opinions of an inspector on any given day, it does not provide an accurate assessment of the providers approach to care delivery. This apparent subjectivity may be lost on the reader of a report who are likely to only go as far as reading the overall rating and part of the summary at best. Further it is not known how many providers make effective factual accuracy comments in relation to inspection reports. A great deal show a deference to CQC in accepting and not challenging findings or fail to have the necessary capacity to mount an effective challenge. If we are correct then the presumed baseline of care in the UK which CQC claims to have is little more than a rubber stamping of its own findings.
CQC have recently been carrying out a market-shaping role in applying its guidance Registering the Right Support regarding the provision of accommodation for service users with a learning disability. CQC have been applying this guidance to the strict letter most notably with respect to the number of beds that the regulator intends to register. This would appear to be a substantial increase in the activities of CQC and shows and abject misunderstanding of the feasibility of imposing this guidance in a blanket manner without due consideration to the demand for such Homes which exceed the numbers it is willing to register. In guidance issued to CQC’s own inspectors it states that it will be difficult for current providers to meet the required standards if it is already in operation. This step into shaping the market for care represents an outward step from CQC’s usual role and arguably requires clear statutory footing to ensure compliance and respect.
In an ideal world CQC would have sufficient resources available to it to replicate the NHS Improvement model as employed with NHS Trusts and carry that system of improvement through to private providers of care. Whilst it is understood that this improvement function does not lie with CQC itself, substantial support should be offered to private providers of healthcare to improve. Whether this improvement function lies within CQC or is independently set up the overall health of the provision of health and social care in the UK is dependent on this. It is hoped that CQC will shift away from an over reliance on inspections as forming part of its regulatory function. The important role that private providers play should not be lost in a historic view of how to regulate the provision of care in the UK. CQC announced its intention to relax its inspection schedule for services it rates more highly which will allow the CQC to target more closely on those providers it deems to be below that standard. Standards can rise or fall at any time and at times very quickly. To leave services which are perceived to be good to practice without effective oversight is to risk greater failings in the sector. The focus will shift to concentrate on those services that CQC identifies as not meeting standards but in so doing this could mean that services that were perceived as being good fail to be monitored as closely as other services.
CQC is on the precipice of its next phase of thinking in relation to the direction of health and social care market. The underlying purpose of regulation of the sector is to ensure a vibrant, successful and diverse provider population so that those in need can have the confidence that good care options remain available. If CQC is to effectively regulate the sector, it should offer the private health and social care sector more support which will help nurture existing providers and new entrants to the market for the benefit of all stakeholders.