Singular advantage, by Victoria Macdonald

2 Oct 08
The consolidation of three health and social care bodies into one super-regulator has ruffled feathers. But shadow chair Barbara Young insists the Care Quality Commission will put the focus back on people and standards. Victoria Macdonald reports

03 October 2008

The consolidation of three health and social care bodies into one super-regulator has ruffled feathers. But shadow chair Barbara Young insists the Care Quality Commission will put the focus back on people and standards. Victoria Macdonald reports

It has been described as the bonfire of the quangos, although Baroness Barbara Young, the chair of the Care Quality Commission, prefers to call it a streamlining of the regulators.

Take your pick. But next April the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission will all be brought under the umbrella of the CQC, which finally became a legal entity this month.

It has been quite long in the gestation, says Young. It has also been controversial. Earlier this year, the heads of the three soon-to-be-defunct bodies all raised concerns about how such a super-regulator would work and about the timing of its creation. Even now, with some concessions, their support is muted.

Young appears unperturbed, unsurprisingly. For more than two decades she has held positions in public office or administration that attracted opprobrium and praise in equal measures. In the 1980s, she was in health service management when it was subject to constant cuts, changes and underfunding. She has also been chair of English Nature, vice-chair of the BBC and chief executive of the Royal Society for the Protection of Birds.

More recently Young gained a higher profile when last year, as chief executive of the Environment Agency, she literally had to don her wellies and tour England as it flooded. Later she had to explain to the Public Accounts Committee why the action plans for flood risk were largely incomplete. Her management style was questioned as being autocratic.

But if that was the frying pan, this is the fire, because now she is taking on a job that effectively guards the institutions held most dear by the British public. The first big outbreak of a hospital superbug such as C-difficile or MRSA on her watch and she will be the one – unfairly or not – who must answer for it.

Yet critics and supporters believe she will cope. Certainly, she comes across as confident and outspoken. During her health select committee interview for the CQC job she said her priority was 'getting the damn organisation up and running'. Repeatedly she has said her new role is to 'talk softly and carry a big stick', leaving no doubts about her approach or intentions.

Most importantly, she is politically astute. Baroness Young of Old Scone, aged 60, describes herself as a Labour luvvie, only giving up the Labour whip and moving to the cross benches in the House of Lords after her appointment to the Environment Agency. This was to the surprise of a number of Tories, she says, including former health secretary Kenneth Clarke, who complained to her that in her 17 years in health service management, nobody had told him.

Her acuity can be seen in her appointments of the first of the CQC commissioners – for example, Lord Patel of Bradford, the current chair of the Mental Health Act Commission. Earlier this year, he complained that his watchdog's dedicated programme of inspections was in danger of being interrupted by the CQC. He would appear to have been quietly appeased.

The other two appointments – Deirdre Kelly, professor of paediatric hepatology at Birmingham Children's Hospital, and Dame Jo Williams, chief executive of Mencap – mean that the health, social care and mental health prongs of the commission are all represented.

It was a deft strategy but then Young is aware that she is walking a tightrope between sectors that have not always worked easily together. From the start there have been fears, for example, that the new commission will focus on the NHS at the expense of social care, despite the latter making up the bulk of the work.

'We are absolutely even-handed. I think social care issues are going to become the issues of the future,' Young says. 'The baby bulge is moving through and I am part of it. We are all thinking about what we

need from elderly care, we are all very vocal and we are all used to getting what we want, so I think the social care agenda is going to become more politically crunchy.'

The second concern she acknowledges is that there might be an attempt to create a one-size-fits-all method of regulating health and social care or that, of the two models, one would get the upper hand.

'The reality is that we will benefit from both models. The Healthcare Commission model is lots of information and analysis and looking at things that seem from the information to stick out, whereas the social care model is regular inspection, because of the strong belief that they have to interface with the users and understand how it is working for them. They have a much bigger range of smaller providers and then they draw from the individual assessment of services the bigger principles that require policy change. So I think we can get the benefits of both the models and it will be horses for courses,' Young says.

There will be no revolution next April. She says that much of what happens next year will look remarkably like what happened this year because the three commissions are 'good going concerns, doing a good job. It is not as if they are basket cases, where we need to stop everything and start again. So we will take the things where we can get added value by the merger.' Which rather begs the question, why get rid of them in the first place?

There is still a lack of detail about how the

super-regulator will work, although it will account for about £105bn of public expenditure and regulate the work of 2.8 million staff in the NHS, local authorities and the private sector.

Earlier this month, Young and CQC chief executive Cynthia Bower produced an 'initial manifesto', described as a provisional statement until all the commissioners and a senior team are appointed. This includes declarations such as: 'Our vision is of high-quality health and social care, which supports people to live healthy and independent lives, which empowers individuals, families and carers in making informed decisions about their own care, and which is responsive to individual needs.'

'We are here to improve the quality of health and social care for people,' Young says. 'The important thing is that people are right at the centre of this: the patients, users, carers and families.'

So far, she has announced a new inspection regime for NHS hospitals, which will be denied a licence if they fail to maintain hygiene standards. Hospital boards will be required to sign a declaration that they meet the various requirements of the hygiene code.

'It is quite difficult to understand what the picture is in healthcare-acquired infections,' she said. 'A considerable number of the trusts are not yet totally implementing good practice. So we will have a new range of powers, which range from ticking people off to fining them to – as a last resort – taking their licence away and deregistering them.'

She does not believe that will happen often in the early stages because the Healthcare Commission's own inspection regimen has resulted in the issuing of only four enforcement notices (although 41 trusts have admitted failing to observe one or more parts of the hygiene code).

'That is not a huge number and what we would be saying is, “right, you are not reaching the standards we want but we will agree with you some action plan, we will register you on the condition that you achieve this action plan. If you don't, we will have to come and talk rather more sternly to you”,' she says, adding that she was a 'great believer in scores on the doors', that people deserve to understand the quality of the services, especially when there is more than one on offer.

'They are going to be making choices,' she says. 'Sometimes choice is not real, but what it gives patients and the public the ability to do is kick the shit out of local providers if they are not coming up to scratch.'

She has also promised a crackdown on NHS organisations that fail to adopt National Institute for Health and Clinical Excellence decisions, threatening a marked-down annual assessment rating. She says the system has been too patchy – now she intends to 'up the ante'.

'I keep saying that I do not want to be the Care Failure Commission. We are about encouraging people to think about quality and to learn from the good practice that we are able to glean from the work we do on regulations and inspection.' That is likely to irk the current incumbents, although nobody at the Healthcare Commission would be interviewed for this article, instead issuing a statement saying they would 'bend over backwards to make it a success' and that 'the CQC was the only show in town'.

CSCI chair Dame Denise Platt retains strong reservations, however, pointing out that the three commissions are not a 'coherent set of organisations and nor will they ever be, because they do different things'. Inevitably, she adds, there will be tensions because the NHS is so much more high profile and social care issues are often marginalised.

Earlier comments by Young describing the Healthcare Commission as taking a 'big brain' approach to regulation and the CSCI as more about 'running the finger around the toilet bowl' have also clearly irritated Platt. 'We are not glorified Mrs Mops. It doesn't show any understanding of how we work.

'The issue is that the new commission has not really sorted out what the message is meant to be,' she says.

The CSCI has always taken the position that if a merger was obligatory, it should at least be after the publication of health minister Lord Darzi's NHS Next Stage Review.

While not necessarily agreeing about the timing, Young acknowledges the importance of the Darzi review, not least because of the better focus on clinical outcomes. 'That will be extremely valuable information because that is what we want to be all about – a model of quality that has a range of parameters. The first parameter is clinical outcome: did the patient or user get better? The second is patient experience: did they feel valued, were their dignity and human rights respected, did they feel anybody cared about them?'

The third is what she calls functionality, which she believes is going to be the most difficult to measure. 'This is particularly important for long-term care. Is the person able to live life to the fullest? Is there potential as far as it fits their circumstances? Can they really live properly? We want all three legs of that quality model to be looked at and Darzi has, quite rightly, identified the fact that clinical outcomes need more focus and more work and we will be very pleased to work alongside him.'

On a practical level, there are still basic details to be worked out, such as what happens to the pensions of the staff moving from the separate commissions to the CQC. The majority of those from the CSCI, for instance, have always been in local government but the CQC will be in the NHS scheme.

In some ways, the lack of detail is deliberate. Early on, Young won a battle during the drafting of the Health and Social Care Bill, when there was an attempt to 'put structural stuff in'. She said she did not want to be locked in to anything that might look fine now but would not look fine in the future – not least because changing primary legislation is a nightmare.

Her policy is 'talk early, talk often'. 'We want to be heavily involved with users, well involved with the non-governmental organisations and advocacy groups. We want to talk a lot to the providers and the commissioners, so I think that the manifesto has laid out our stall on how we operate. We are anxious to reassure people that this is not some uni-dimensional organisation and that we want to work in partnership with people.' She estimates that within two years they should have made 'pretty good progress' in integrating the three approaches and they will make 'great strides next year'.

And with that, she was off to the next of many meetings. But before she left, she had a request: 'Don't use “Baroness”, I hate the bloody thing. Love the title – but in its place.' It seems one woman she was introduced to on a recent site visit curtseyed. The story has a ring of familiarity but serves to stress that she is simply one of the people – a good, honest, straight-talking Dame.

Victoria Macdonald is social affairs correspondent for Channel 4 news


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