There’s too much mud-slinging going on as a result of the latest CQC debacle. If we can look behind the rhetoric, there are some pretty clear reasons as to why the health and social care regulator finds itself in the firing line once again.
Whilst internal organisational failure was clearly the trigger to these latest failures, we have to ask why it was possible for those things to happen. For me, the fundamental problems are around system design, mission and purpose - with three underpinning causal factors.
1. CQC’s creation was a botched job from the outset. The responsibility for this rests firmly with the former Labour Government. They created it and determined how it should be set up – so no smug anti-CQC platitudes from opposition spokespeople please.
Its creation contained four big mistakes. (i) Its budget was inadequate for the purposes. Memory tells me it had around one third less money that its combined predecessors (HCC and CSCI). (ii) It was rushed and was a forced creation with no visible attempt to learn from evidence in business mergers about the problems that always result in the short term from such imposed changes. (iii) The rhetoric around its creation was about developing a tough, no-nonsense approach – so the people recruited to senior jobs displayed those characteristics – and we have just seen the consequences of that. The fourth big mistake was that …..
2. The brief it was given was wrong from the outset. Politicians took an explicit decision on CQC’s creation to remove responsibility around service improvement or development its brief. A regulator whose role is focused upon compliance with minimum standards and has no statutory improvement role is on to a loser. Every manager will tell you that a focus on minimum standards (whatever they may be dressed up as) will rapidly mean that, for many, they become maximum targets. The best way to ensure compliance with minimum standards is to aim higher. Reach for the sky and, whilst you might not get there, you’ll find better things than if you only aspire to keep your head above water.
A further failure in the brief was the removal of responsibility for regulating commissioners. Only checking on the quality of what exists, and not the process by which it was decided those services should be there at all, is like shutting the stable door after the horse has bolted. Why does Ofsted have a role around children’s commissioning but CQC does not for health and adult social care?
3. The lessons from history were ignored and/or forgotten. I love history. You can learn a lot from it unless you are so arrogant as to believe you are always right. The HCC and CSCI learnt through incidents such as the Cornwall abuse and its review of older people’s services that it needed to have inspectors with specific expertise, ‘experts by experience’ on inspection and review teams and a methodology that placed rights and life outcomes as a core component. Those things were scrapped by CQC at its outset, significantly because of the reasons I note in point 1 – not enough money, ‘experts’ knowing best, leaders who didn’t listen. Many of these things began to be re-introduced after Winterbourne – others will now probably follow.
So what’s to be done? It has to be fundamental, and three things should be at the core of action:
a. Money. If you believe in regulation, then you have to invest in it. The reason given to me recently by a senior CQC manager for not having experts by experience in all review teams was a lack of money. That is short sighted. The financial cost of failure to the taxpayer is much greater than the comparatively small extra cost of effective regulation – so give it enough resources to do the job. However, I would not want to see it given more money to continue doing the same things – so;
b. Change the job CQC is supposed to do. Give it an explicit brief to review how organisations are improving services and a role in supporting that. Have an increased focus on outcomes rather than processes. Give it a role in reviewing the quality of commissioning.
c. Change CQC’s culture by requiring that real co-production is at the heart of all it does – from strategic governance through to inspection and review. I don’t mean a token user on the Board, or ‘experts by experience’ on some inspection teams but excluded from key decision-making. People who use services and their families should be at the core of all it does – as employees as well as external resources.
The one thing this fundamental change should not involve is another CQC restructuring or senior management change. That would just create a further period of inability to focus on the task. New CQC Chief Executive David Behan (not a man I have always seen eye-to-eye with) has been talking reasonable sense over the last few days. He’s an effective manager, an astute political operator and has some values and principles. That is what is needed. Let him get on with the job – but with a new brief from government, additional resources, and an expectation of cultural change driven by co-production. If that isn’t to happen, the only option is to forget national regulation and go back to the drawing board.
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