By David Williams
23 March 2010
The Care Quality Commission is on course to register all NHS trusts in England. But it has been hard work for both the regulator and the trusts, its chief executive tells David Williams
‘The idea that an NHS trust can just bump along the bottom without an improvement is gone,’ says Cynthia Bower, chief executive of the Care Quality Commission.
To Bower, the final weeks before Easter represent a watershed, both in terms of her own work and for the running of the NHS. After just a year in existence, the CQC is on course to complete the registration of the 381 NHS trusts in England that provide health care services.
Registration will depend on trusts’ ability to show they meet minimum standards – those that cannot will have conditions placed on their registration, and will retain their licence to provide services only if the CQC is convinced of their capacity to improve.
Some 66 trusts were confirmed as registered on March 18, with two more batches expected over the following two weeks.
After that, the CQC will begin monitoring registered trusts. Then there’s the small matter of registering 44,000 private health and social care providers.
Anna Dixon, acting chief executive of the King’s Fund, says just getting to this stage is no mean feat given the project’s ‘ambitious timetable’. The CQC has had to draw up and consult on the set of 16 standards that providers are measured against, and then process a wealth of data from each of the trusts.
It hasn’t been an entirely bump-free ride. Bower tells Public Finance that the CQC and all the NHS trusts have had to work ‘phenomenally hard’ to get the system up and running inside 12 months.
She says the process hasshown that the CQC needs to strengthen the support it gives NHS bodies.
‘We’ve been inventing a new system and trying to implement it at the same time,’ she says. ‘The best lesson we’ve learned is how we sharpen up our advice to make sure we’re giving consistent advice and that our staff understand the system as well as they need to.’
At the time of going to press, only two trusts have been registered with conditions imposed: Milton Keynes Hospital NHS Foundation Trust and Mid Staffordshire NHS Foundation Trust.
Neither case should come as a surprise. In Milton Keynes, foundation trust regulator Monitor forced the hospital to bring in a team of clinical experts earlier this month amid concerns over the hospital’s maternity ward. Mid Staffordshire, meanwhile, was at the centre of a patient safety scare last year after an investigation by the CQC’s predecessor, the Healthcare Commission, found systematic failings in care.
Both trusts said the CQC’s conditions highlighted problems that directors were already aware of and plans to remedy the situation were in place and being implemented.
But conditions are not being imposed on every trust which has given cause for concern. The Royal Cornwall Hospitals NHS Trust has been registered without conditions, despite being placed among the bottom 5% of trusts by the CQC, which rated it ‘weak’ for the quality of its services in last October’s annual health check.
Bower says registration, which replaces the old performance rating system, has different criteria and, as such, direct comparisons will not tell the whole story.
She argues that linking the licence to practise to minimum standards has ‘absolutely made trusts focus on how they can assure themselves that care is safe’.
For those that aren’t making the grade, attaching conditions to the registration – with the implicit threat of revoking their licence if there is no improvement – has awoken under-performing trusts to the need to get their act together, she says.
‘We want a system that doesn’t catch organisations out but that works with them to generate improvement,’ Bower adds.
None of this sounds contentious but it nevertheless represents a subtle change in the role of the regulator.
Where before trusts were encouraged to improve by being rated on a four-point scale, the regulatory emphasis has gone back to basics. Now, the CQC is only assessing whether minimum standards are being met, although the regulator could raise these in future.
Back at the King’s Fund, Dixon says nurturing excellence will now have to become the primary role of commissioners. ‘That isn’t the fundamental job of the regulator,’ she says.
Bower agrees, arguing that the heart of regulation is to identify areas of risk, and not to tell trusts how better to run their services. ‘We’re not an improvement agency,’ she says. ‘We focus the minds of the organisation.’
‘Focus’ is a word that Bower uses repeatedly, and it typifies the difference between the new system and the old. Asked whether registration is a bigger burden on NHS trusts than the old performance rating system, she emphasises that the system will be more light-touch for the compliant majority.
‘If we don’t think there are issues emerging for trusts, we won’t be on their back day in, day out… where there are grounds for improvement, we will focus very closely on the things we expect organisations to do.’
It remains to be seen how strong the watchdog’s bite is – or even whether it will be willing to bare its teeth. Bower told PF that it was reasonable to assume that no trusts would be refused registration at this initial stage.
The CQC retains the power to withdraw the licence either for an entire trust or part of its services – say, for a maternity ward – but only where there is a risk to life and limb.
That power – effectively to close down an NHS trust on grounds of patient safety – is unprecedented for a health care regulator.
But Bower has previously described the measure as an ‘extreme nuclear option’ and indicates that it will be used very sparingly. ‘For that to happen to a whole hospital would be extremely surprising,’ she argues, given the other regulators, directors, commissioners and professional bodies also overseeing aspects of the health service.
Ultimately, says Dixon, the basic idea of registration covering health and social care in both public and private sectors should stand the test of time.
‘It’s independent of any other changes that might take place in the health and social care system, so it should be flexible enough,’ she says.
That the overwhelming majority of trusts are compliant is an encouraging sign as the NHS enters a period of ever-tighter budgets.
But, Dixon adds, meeting minimum standards can only be about providing assurance that patients are not going to be exposed to serious risk.
‘I don’t think any regulation process can substitute for internal governance,’ she says. ‘It’s really for NHS trust boards to recognise where they’ve got a problem and to be dealing with it before it gets to the point where the regulator is having to intervene.’
23 March 2010
The Care Quality Commission is on course to register all NHS trusts in England. But it has been hard work for both the regulator and the trusts, its chief executive tells David Williams
‘The idea that an NHS trust can just bump along the bottom without an improvement is gone,’ says Cynthia Bower, chief executive of the Care Quality Commission.
To Bower, the final weeks before Easter represent a watershed, both in terms of her own work and for the running of the NHS. After just a year in existence, the CQC is on course to complete the registration of the 381 NHS trusts in England that provide health care services.
Registration will depend on trusts’ ability to show they meet minimum standards – those that cannot will have conditions placed on their registration, and will retain their licence to provide services only if the CQC is convinced of their capacity to improve.
Some 66 trusts were confirmed as registered on March 18, with two more batches expected over the following two weeks.
After that, the CQC will begin monitoring registered trusts. Then there’s the small matter of registering 44,000 private health and social care providers.
Anna Dixon, acting chief executive of the King’s Fund, says just getting to this stage is no mean feat given the project’s ‘ambitious timetable’. The CQC has had to draw up and consult on the set of 16 standards that providers are measured against, and then process a wealth of data from each of the trusts.
It hasn’t been an entirely bump-free ride. Bower tells Public Finance that the CQC and all the NHS trusts have had to work ‘phenomenally hard’ to get the system up and running inside 12 months.
She says the process hasshown that the CQC needs to strengthen the support it gives NHS bodies.
‘We’ve been inventing a new system and trying to implement it at the same time,’ she says. ‘The best lesson we’ve learned is how we sharpen up our advice to make sure we’re giving consistent advice and that our staff understand the system as well as they need to.’
At the time of going to press, only two trusts have been registered with conditions imposed: Milton Keynes Hospital NHS Foundation Trust and Mid Staffordshire NHS Foundation Trust.
Neither case should come as a surprise. In Milton Keynes, foundation trust regulator Monitor forced the hospital to bring in a team of clinical experts earlier this month amid concerns over the hospital’s maternity ward. Mid Staffordshire, meanwhile, was at the centre of a patient safety scare last year after an investigation by the CQC’s predecessor, the Healthcare Commission, found systematic failings in care.
Both trusts said the CQC’s conditions highlighted problems that directors were already aware of and plans to remedy the situation were in place and being implemented.
But conditions are not being imposed on every trust which has given cause for concern. The Royal Cornwall Hospitals NHS Trust has been registered without conditions, despite being placed among the bottom 5% of trusts by the CQC, which rated it ‘weak’ for the quality of its services in last October’s annual health check.
Bower says registration, which replaces the old performance rating system, has different criteria and, as such, direct comparisons will not tell the whole story.
She argues that linking the licence to practise to minimum standards has ‘absolutely made trusts focus on how they can assure themselves that care is safe’.
For those that aren’t making the grade, attaching conditions to the registration – with the implicit threat of revoking their licence if there is no improvement – has awoken under-performing trusts to the need to get their act together, she says.
‘We want a system that doesn’t catch organisations out but that works with them to generate improvement,’ Bower adds.
None of this sounds contentious but it nevertheless represents a subtle change in the role of the regulator.
Where before trusts were encouraged to improve by being rated on a four-point scale, the regulatory emphasis has gone back to basics. Now, the CQC is only assessing whether minimum standards are being met, although the regulator could raise these in future.
Back at the King’s Fund, Dixon says nurturing excellence will now have to become the primary role of commissioners. ‘That isn’t the fundamental job of the regulator,’ she says.
Bower agrees, arguing that the heart of regulation is to identify areas of risk, and not to tell trusts how better to run their services. ‘We’re not an improvement agency,’ she says. ‘We focus the minds of the organisation.’
‘Focus’ is a word that Bower uses repeatedly, and it typifies the difference between the new system and the old. Asked whether registration is a bigger burden on NHS trusts than the old performance rating system, she emphasises that the system will be more light-touch for the compliant majority.
‘If we don’t think there are issues emerging for trusts, we won’t be on their back day in, day out… where there are grounds for improvement, we will focus very closely on the things we expect organisations to do.’
It remains to be seen how strong the watchdog’s bite is – or even whether it will be willing to bare its teeth. Bower told PF that it was reasonable to assume that no trusts would be refused registration at this initial stage.
The CQC retains the power to withdraw the licence either for an entire trust or part of its services – say, for a maternity ward – but only where there is a risk to life and limb.
That power – effectively to close down an NHS trust on grounds of patient safety – is unprecedented for a health care regulator.
But Bower has previously described the measure as an ‘extreme nuclear option’ and indicates that it will be used very sparingly. ‘For that to happen to a whole hospital would be extremely surprising,’ she argues, given the other regulators, directors, commissioners and professional bodies also overseeing aspects of the health service.
Ultimately, says Dixon, the basic idea of registration covering health and social care in both public and private sectors should stand the test of time.
‘It’s independent of any other changes that might take place in the health and social care system, so it should be flexible enough,’ she says.
That the overwhelming majority of trusts are compliant is an encouraging sign as the NHS enters a period of ever-tighter budgets.
But, Dixon adds, meeting minimum standards can only be about providing assurance that patients are not going to be exposed to serious risk.
‘I don’t think any regulation process can substitute for internal governance,’ she says. ‘It’s really for NHS trust boards to recognise where they’ve got a problem and to be dealing with it before it gets to the point where the regulator is having to intervene.’
