Report by the Commons public accounts committee 11 December 2015
‘The Care Quality Commission has made substantial progress since the Committee last reported in 2012. But it is behind where it should be, six years after it was established, in that it is not yet an effective regulator of health and social care. Because of staff shortages it is not meeting the trajectory it set itself for completing inspections of hospitals, adult social care and primary care. There are also concerns about the consistency and accuracy of draft inspection reports, and the time the Commission takes to finalise a report after carrying out an inspection. At the same time, the Commission is not yet ready to implement new responsibilities it takes on in April 2016 to assess the efficiency with which hospitals use their resources. In addition, the Commission does not yet have the quantified performance measures, linked to explicit targets, that are needed to show whether it is satisfactorily performing its statutory duties. We will be returning to this subject to review what further progress the Commission makes in the coming year.’
Listening to patients, carers and staff, and acting on their concerns
11.The number of concerns raised by whistle-blowers, complaints about providers, safeguarding calls and statutory notifications from providers increased from a total of 173,931 in 2013–14 to 208,720 in 2014–15. However, the National Audit Office found that one out of three safeguarding alerts raised with the Commission was not acted on within the Commission’s two-day target. The Department acknowledged that the Commission had long-standing problems with how it reported and responded to safeguarding alerts but assured us that the Commission had now put more rigorous systems in place. As part of its inspections, the Commission also looks at how hospitals, care homes and paramedical services respond to complaints. It has developed its methodology by speaking to people who have raised complaints about the quality and safety of care, as well as other organisations that people go to when they have a complaint.
12.The Commission takes the time to talk to patients, staff and carers during an inspection. However, providers were concerned that this only provided the views of people inspectors met on the day of the inspection and meant the Commission could be at risk of placing too much reliance on anecdotal evidence. The Commission organises formal patient and carer consultation events in advance of its inspections, but these may not necessarily be well attended or representative of all people using the services inspected. A GP and Partner of the Jenner Practice in Lewisham told us that, for general practice, the Commission uses a patient questionnaire. However, he felt that the central questionnaire was not very sensitive to local circumstances. He also made the point that responses might reflect an unrealistic or outdated view of what people thought GP services ought to be, rather than how primary care is changing to best meet patients’ needs
Conclusions and recommendations
1.The Commission is behind on its inspection programme and is not, therefore, fulfilling its duty to be sighted on risks to the quality and safety of health and adult social care services. The Commission has struggled to recruit inspectors and analysts with the right skills. By mid-April 2015, the vacancy rate was 34% for inspectors, 36% for senior analysts and 35% for managers, and it did not expect to reach full complement for inspectors until June 2016. Staff turnover in 2014-15 was nearly 8%, much higher than the Commission’s 5% target rate, and was still at this rate for the first two quarters of 2015–16. Because of these staff shortages, the Commission is behind its original target dates for completing its programme of inspections. The Commission forecast that by the end of March 2016 it would be below its planned trajectory by 6% in adult social care and 8% in primary medical services. It expects to have completed its inspections of hospitals by June 2016, six months after its original target date of December 2015. It is likely that it will need to look for alternative solutions to its recruitment problems and is already, for example, using people on secondment to supplement its full time inspectors on mental health. The Commission’s current plans for inspection are based on funding plans made before the 2015 spending review. The Department has asked the Commission to model the impact of reductions in funding of 25% and 40% and, unless the Commission finds alternative solutions to its recruitment problems or changes its methodology, the Commission made clear that any such cuts are likely to lead to further delays to its inspection timetable.
We are very concerned about the effect being below staff complement has had on the Commission’s ability to carry out its full programme of inspections. The Commission should write to us in July 2016, with an update on staff turnover rates and whether it has met the recruitment targets it gave us in evidence. Specifically, the Commission should set out: whether it has reached a full complement of suitably skilled and qualified inspectors; whether it has sufficient analysts; and what impact staff shortages have had on its forecast trajectory for carrying out inspections.
The Commission needs to demonstrate how it will deliver its programme of inspections in the face of substantial funding reductions. This should include a robust and transparent analysis of risk if it adopts a more flexible approach or prioritises resources. It needs to be clear to the taxpayer and the organisations it inspects about changes of approach.
2.Too often the length of time between an inspection and a report is too long, and the Commission’s draft reports contain too many basic factual errors. At a time when the Commission is asking providers to pay substantially more towards the cost of their inspection it is more important than ever that the Commission can demonstrate the quality of its work. However, providers told us they find too many errors in draft reports, reports take too long to produce and there is too much variation in the quality of initial judgements. On average, inspection reports are not completed within the target of 50 days — reports take an average of 49 days for adult social care, 67 days for general practice and 83 days for hospitals. The chief executive of Warrington and Halton Hospitals NHS Foundation Trust told us they had identified over 200 errors in its draft report. Some of these were just grammatical errors or duplicated points, but some were inaccuracies in the data that could have been resolved while inspectors were still on site. She told us that the Commission had accepted 64% of the points raised and amended the draft as a result. The Commission told us it had strengthened its internal quality assurance processes, but this had lengthened the time it takes to complete a report.
Recommendation: The Commission should set out how it will improve the quality of initial draft reports, and ensure that the time between inspections and publication of reports is shorter. We expect to see progress on this in the next 12 months.
3.The Commission has not always made best use of vital intelligence from patients, carers and staff about the quality of care, or acted quickly enough on their concerns. We are concerned that the Commission’s data suggests that one out of three safeguarding alerts is not acted on within the Commission’s two-day target. The Department acknowledged that there have been long-standing problems with how the Commisison has dealt with safeguarding alerts, and assured us that new processes are being put in place. More generally. the number of calls the Commission receives from the public and whistle-blowers in response to concerns about the quality and safety of care is increasing. During inspections, the Commission also takes time to talk to patients, staff and carers. Providers told us, however, that inspection reports could place too much emphasis on potentially anecdotal evidence inspectors heard on the day of the inspection.
Recommendation: As it continues to build user feedback into its work, the Commission should publicise its role, make it easier for people to say what they think of care, and prioritise action in response to safety concerns. It must work with other bodies – including the ombudsman, central and local government and the third sector — to ensure that concerns are addressed quickly, particularly those raised by whistleblowers. It also needs to improve the quality of information available to people who are choosing a care provider.
4.There is no way for parliament or the public to know whether the Commission is performing its statutory duties to protect the health, safety and welfare of people who use health and social care services. In its March 2012 report the previous Committee criticised the Commission’s lack of adequate performance measures, but over three years’ later the problem is still unresolved. The Commission has developed a new performance framework, but only 6 out of the 37 performance measures included in it have specific, quantified, targets. Reporting performance against clear targets is vital for both transparency and accountability and measuring improvements over time.
Recommendation: The Commission should publish quantified baselines and targets for its performance across the board from 2016–17 onwards.
5.The Commission will become responsible for assessing hospitals’ use of resource in April 2016, but it will take over a year for it to implement these responsibilities in full. The Commission plans to pilot its new approach in April 2016, but it does not believe it will be ready to roll this out to all hospitals until January 2017. The delay risks giving the public the impression the Commission is providing full assurance over the use of resources by all hospitals when it will not be doing so until January 2017. The Commission published a consultation document on the morning of our evidence session asking for views on how it should implement its new responsibilities. But it is not yet clear how the Commission will coordinate with, and draw on the expertise of Monitor and the NHS Trust Development Authority to avoid duplication of effort by providers. We are concerned that there is not adequate preparation for this important additional area of work, which has been introduced before the Commission has the capacity to implement it and while it is struggling to fulfil its exisiting responsibilities.
The Commission should set out what its approach will be to provide assurance about the use of resources by hospital providers. It should do this as soon as possible as it takes on these responsibilities in April 2016.
The Department should clarify the roles of the Commission, Monitor, and the NHS Trust Development Authority for assessing the use of resources by health bodies, to avoid duplication of effort and unnecessary burdens. We have serious concerns about adding this responsibility to the Commission when it is not yet delivering its inspections.
6.The current regulatory system focuses on single providers and does not give adequate assurance over patients’ experience of the overall quality and safety of care they receive. It is becoming increasingly important for providers and commissioners to collaborate in order to integrate the services patients, particularly those with long term conditions, need from their GP, hospital and local community care services. But existing regulatory systems, including those operated by the Commission and Monitor, focus on services operated by individual providers, and do not look enough across organisational boundaries. A further complication is that providers’ performance is influenced by decisions taken by local commissioners, but the Commission has no power to scrutinise clinical commissioning groups or local authorities. The Department is developing, but has not yet completed, what it described as a ‘scorecard’ to assess the performance of clinical commissioning groups. The Department hoped that the Commission would be able to use this information, once available, populated and published, to assess the economy, efficiency and effectiveness of services to people living in a given locality.
Recommendation: The Department should report back to the Committee by the end of 2016 about how it will support the Commission to ensure that inspections take proper account of the needs of users in ensuring services provided by differenthealth and social care organisations are properly joined up. The Commission will need to work with other key bodies including, for example, the ombudsman, patient representative groups and local delivery partners to collect sufficient information to inform its judgements.