"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Friday, 14 October 2011

Monitor and CQC: unfit for purpose?

The report yesterday from CQC about dignity and nutrition at NHS hospital trusts raises several questions. Clearly it is unacceptable that people are not fed. However, one question that has not been asked is: why did these trusts get into the this situation?

The report lists trusts that they categorise as raising "major concerns and those that raised "moderate concerns". Interestingly the media give the aggregate of these two – 20 trusts – rather than reporting that there were just two that raised "major concerns". These two worst trusts are NHS Trusts, that is, they have not yet achieved Foundation Trust status. Of the 18 that raised "moderate concerns" nine are Foundation Trusts.

When Foundation Trusts were introduced the initial criteria were financial: if a trust showed that it had the financial skills to keep in the black (indeed, to make a surplus every year) then it was awarded FT status. When the Mid Staffs scandal blew up, the Foundation Trust regulator, Monitor, initially suspended all applications and then changed the authorisation criteria so that a trust has to show that it fulfils clinical as well as financial criteria. After authorisation a FT must continually prove that it meets the authorisation criteria (listed here, pdf) or else it will be in breach of its authorisation. Monitor has a range of powers varying from requesting that changes are made, to interventions like replacing board members, to the ultimate sanction of de-authorising a trust. (Of course, after the Health Bill is passed de-authorisation will not be an option since there is nothing a trust can be de-authorised to.)

Monitor states that FTs boards must continue to show that their trust complies with their authorisation criteria including:
  • delivering healthcare services to specified standards under agreed contracts with their commissioners;
  • maintaining registration with the Care Quality Commission and addressing conditions associated with registration;
  • complying with healthcare targets and indicators
  • cooperating with the Care Quality Commission and a range of NHS and non-NHS bodies which may have a remit in relation to the provision of healthcare services
This says that to remain as an FT a trust must show that it provides high quality healthcare. CQC inspects all FTs and reports their findings to Monitor who then issues notifications of breaches. Monitor says that:
"In cases where the Care Quality Commission indicates that it has material concerns regarding an NHS foundation trust’s registration with Care Quality Commission standards, Monitor will work with the Care Quality Commission to establish the most appropriate course of action to return the trust to compliance with those standards in a suitable timeframe."
So it is quite clear that between them CQC and Monitor have a responsibility to ensure that FTs have high standards of clinical care. If a trust's standards fall this should be picked up by CQC, who will then inform Monitor. Monitor then determines the intervention that is needed. 

Monitor lists nine FTs where an intervention was necessary, most of these interventions were due to poor financial governance and only one was listed in the CQC nutrition and dignity report. Monitor also lists 12 hospitals in breach of their authorisation, none of which are in the CQC report. CQC lists on its website the trusts that it has concerns about. This gives just three acute hospital FTs and none of which were mentioned in their report on elderly care. 

Why didn't CQC notice before that there were nutrition and dignity issues at the 20 trusts? Monitor exists to ensure that FTs are high quality. CQC has a responsibility to report on poor care. CQC and Monitor exist solely to ensure that Foundation Trusts are high quality, and any perennial failure in quality of FTs indicates that these two regulators are not fulfilling their responsibilities. There are serious questions that needs to be answered about whether these two regulators are actually fit for purpose. Finally, when the Secretary of State removes his own responsibility for the NHS bear in mind that we will be left to the mercy of these two organisations, there will be no one to take leadership over any failings in quality.

Update: Community Care have an article today about the reaction from Action on Elder on the CQC report. AEA say:
"These inspections suggest CQC has little or no sense or urgency in terms of its regulatory activity, often leaving very vulnerable people in neglectful or abusive settings while waiting for 'action plans' to be delivered by a care provider. In our view this is a major failing in its 'duty of care'."
Remember that CQC has not yet taken over the responsibility for inspecting primary care: GPs, opticians, dentists etc. If CQC are failing now, what will it be like when their workload increases due to these extra duties?


  1. The fact is that once you strip away a lll the beurocratic number crunching and gerrymandering of data the NHS has lost its soul. Monitor, CQC, CSCI ad nauseam. They have spent so much on Managerial expansion that it becomes a vehicle to justify its own existence and the people who are on theses inspection boards are always remote and senior. I know as an ex NHS senior manager that the first thing lost is the intrinsic need to really care about patients. I’m out of it now but the waste at sub prime clinical levels is shocking and useless

  2. It seems that CQC etc is as useless as almost every other regulator. The tick-box approach means that they end up endorsing the unacceptable, so arguably they do more harm than good. Exactly the same thing has happened with the QAA -see http://www.dcscience.net/?p=3675

  3. As an NHS complainant of over 6 years I wondered why previous regulator CQC predecessor Healthcare Commission offered to "take your complaint outside of complaints process".....we refused and challenged NHS Complaints to resolve complaint under due process....hence over 6 years later are still left battling for resolution (not money......truth!)
    CQC inherited the Mental Health Act Commission Remit to "safeguard interests of detained patients" HOW? Many Trusts fail to tell them who has been detained and Winterbrook View will confirm worst inhumanity!
    All to often MH is seen as the Cindrella Service of NHS(as if that's ok then!) CQC have highlighted "Care of the elderly" this week and criticized over 50% of Trusts for getting it wrong. Health Service Ombudsman said all this in her Care and Compassion Report published Feb 2011....where's that data now?
    Its all target and data driven not patient centred...as RCGP chairwoman Dr Clare Gerada's speech to RCGP Annual Primary Care Conference in Liverpool said yesterday "on a good day I want to be able to say ‘I saved a life’, not… ‘I met a budget, we must reject the language of the market and embrace the language of caring.”
    Hear Hear!!