Necessary but not sufficient – the role of regulation in health care quality
In the first six months of this year I experienced CQC inspections as both the Chief Executive of an inspected Trust and as the Chair of an inspection at another Trust. I found it a fascinating experience being on both sides of the process and it prompted me, once both inspections were completed, to want to write about that experience and my views on where regulation sits in ensuring high quality health and care services.
CQC comes in from time to time for a bit of criticism. I, however, found the process of inspection on both occasions robust and fair. Post Francis it was inevitable that the regulator needed to adopt a more intensive process and I am probably, in any case, a supporter of a “boots on the ground” methodology as long as it is used proportionately. From my perspective there is much to be gained from an inspection team visiting services and meeting front line staff and service users as well as relying on external or internal data. The CQC process puts a lot of emphasis on the triangulation and corroboration of evidence to reinforce the validity of the judgements which are made. I welcomed the involvement of peer specialists and of experts by experience and the very significant added value they both brought to the inspection process. Finally the methodology rightly allows for a focus on good practice as well as the more rule bound aspects of quality.
Inspections are like visits to the dentist. Nobody enjoys them at the time but they are necessary to the health of the system. There are also clear benefits to the organisation being inspected if the process is embraced in the right way. At my own Trust the process of preparing for our CQC inspection was very powerful in helping us draw together the strands of our quality work and in ensuring good engagement with front line clinical teams on key issues. The report, both its validation of what we do well and the recommendations of where we can do better have been helpful in driving our decisions as an organisation of where we go next. I could see much the same at work in the organisation I was part of inspecting and very much welcomed the open way in which the senior team at that Trust received our findings, both good and bad.
In a system as complex as the NHS there will always be issues with any system of quality regulation. When the reputation and, at times, the future of senior individuals and organisations hangs on what is said by the regulator there will inevitably be tensions about negative judgements and ratings. CQC focuses on providers and providers may feel hard done by when the fundamental issues behind the judgements made about their performance relate to factors out of the provider’s direct control. This is particularly an issue when there is a blatant mismatch between the levels of demand providers are trying to manage and the level of investment made by commissioners. In an environment which is increasingly putting more and more emphasis on system performance it is appropriate that the focus of regulation should shift more in that direction. How to do so is still very much to be worked out.
Another unforgiving aspect of inspection is that judgements have to be made on the basis of what is seen at the time not what might be intended to happen in the future. That can be harsh on organisations where there is a genuine engagement with quality improvement but where there are major structural or cultural issues still to overcome. Whatever is said in the report a good inspection process will explain the context to judgements and recommendations and give recognition to the efforts of clinical and managerial leaders to tackle underlying issues.
From time to time there has been a debate about whether the strengthened system of inspection has been the right answer to the concerns about quality identified in reports about Mid Staffordshire and Morecambe Bay. I firmly believe that a robust system of inspection is a necessary feature of a good quality care system and that CQC’s regime, while it has room to develop and adapt, is fit for purpose. However at the same time inspection and regulation cannot be the only mechanism for ensuring and improving the quality of care.
First and foremost quality needs to be owned by the Boards and leaders of organisations. That ownership should be reflected in the amount of time devoted to quality in Board discussions and the level of inquisitiveness which Executives and Non-Executives have about what is really going on in their organisation. Wherever an organisation is in its quality journey a good inspection report should bring few surprises to the leadership of an organisation. If it does that is a judgement in itself. Boards should be prepared to invest in quality improvement. They also need to understand the implications for quality of other changes and pressures in their organisation and have an acute sense of where their “red lines” will be in terms of the risks of compromising quality.
However quality also needs to be owned by the system and not just seen as the business of providers. Improving quality is not always a question of additional investment but at a time of rising demand it is likely to have financial implications. One of the key roles of the regulator must be to provide an independent voice for quality standards with the willingness to “blow the whistle” when financial expediency potentially compromises the quality of care received by patients.
A regulator of quality is an essential component of a high quality system of care and if CQC did not exist it would have to be invented. It needs to do its job well and with integrity and now as much as ever it needs to be uncompromising in championing the voice of quality against other pressures in the system. However no one should assume that, on its own, CQC can be the guarantor of good quality care. That is all of our business.