An event for members of Gloucestershire LINk on October 5 provided information about ensuring the quality of care, and about government plans for liberating the NHS. The two topics are related in a curious way, in that the work of the Care Quality Commission is to impose national standards of care, while the government plans are designed to liberate the NHS from that kind of top-down control.
This was by far the best meeting of any that I have attended since starting to take an interest in these NHS-related goings-on. The presenters seemed switched on and candid, and there was time set aside for those of us attending to interact and discuss (as well as great sandwiches).
Care Quality Commission
The Care Quality Commission (CQC) is a quango that regulates some aspects of health and social care in England. It only regulates certain care providers (not, for example, most GP surgeries), and it only regulates certain of those providers’ activities (not, for example, those NHS foundations trusts’ activities that the quango Monitor regulates). The CQC’s scope is, however, planned to increase over time.
The focus of the CQC’s activity recently has been to re-register care providers that were previously registered with obsolete quangos. This has been a big bureaucratic kerfuffle, but it is now over. The Care directory listing registered providers is now available. Oddly, it lumps private and voluntary providers together.
This presentation was mainly about the CQC’s Essential Standards of Quality and Safety, which came into force at the end of last week. Regulated providers must satisfy the CQC that they comply with the standards.
The standards are said to be in “plain English”, “people focused” and “outcome based”. However, the example of an outcome given in the presentation was:
People using the service:
• Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld
This sounds nice, but I think it is pretty meaningless, with no definition of “abuse” or “protected” that would make it a specific and measurable outcome. The detailed guidance about compliance is no better. For example:
• Take action to identify and prevent abuse from happening in a service
I suspect no one knows how to identify abuse before it happens so as to prevent it, and that this guidance is just flannel. What will surely happen is that providers will take some token actions just to get a tick in the box, even though those actions may be ineffective. As quoted in the presentation, the guidance does not mention risk management at all, nor upholding human rights (which presumably requires the services of specialist lawyers).
The CQC has plans to monitor compliance with its standards. It will also collect information from other sources (including LINks) about care providers, and then it will combine all the information it receives to create a Quality and Risk Profile for each provider. The profile will include indicators for the six groups of essential standards, for example “Involvement and information”.
There was little information about the profile, but I suspected quality and risk were being confused. For example, it seems to me that a provider might deliver mediocre quality very consistently, and so be low risk, while another provider might deliver high but very variable quality and be high risk. I did not see any evidence of professional-grade risk management in the CQC’s plans.
Despite my reservations about some of the content, this was a lively and interesting presentation from Chris Hastings, who is a CQC regional Compliance Manager, able to illustrate many of the points he made with actual examples. He wrapped up by acknowledging the LINk’s role in providing the CQC with information about services, and by inviting anyone who is interested to sign up for the CQC’s e-mail newsletter.
‘Liberating the NHS’
This presentation by Barbara Marshall, who chairs the LINk, outlined the plans set out in the government white paper, Equity and Excellence: Liberating the NHS.
The plans are quite complicated, and many details remain unclear. This presentation was a valiant attempt to extract the juicy bits, but even so it was heavy with bulleted lists, punctuated only by ferociously complex diagrams. For example, there was a Funding & accountability diagram with ten boxes and nineteen arrows, a Local HealthWatch Structure for Health & Social Care diagram with fourteen circles and sixteen arrows, and a Local accountability diagram with eleven boxes and fifteen arrows. (My statistics are approximate — every time I try to count the arrows I get a different result.)
An audience member complained that the plans will give too much power to GPs, which she thinks will be a bad thing. Her husband had taken his own life as a result of being refused treatment by a GP some years ago. She now believes the GP lied to her to save the practice money. It was pointed out that the new plans do not give individual GPs that kind of power over patients, as GPs will only get together in large consortia to commission services.
This kind of fear about the plans characterised much of the discussion. People who have had bad experiences of care in the past seem to assume that any change will be for the worse. Of course, they might turn out to be right if the changes do not work as intended.
For example, a fear was expressed that the plans will result in a “postcode lottery”. As there is variation in services across the country already, and as the plans include making it easier to change your GP, it is not clear how the plans will make things worse.
Another fear was that articulate people will be able to get better services. Again, this happens already, and there are specific plans to address the problem by providing advocacy and by facilitating complaints, so it is not clear how the plans will make things worse.
There was some support for the idea of involving people more closely in decisions about the care they receive, combined with scepticism about whether it will really happen.
Conflict of interest between local HealthWatch (the successor to the LINk) and the local authority that both funds it and whose services are to be monitored by it, was felt to be a potential threat.
Some people had examples of how the present system works well, and these compliments were noted so that they can be passed on. It surprised me that this happened at the meeting. I wonder whether it is generally clear enough how to pass on a compliment or a criticism of the care you have received. This is an issue the LINk should perhaps consider addressing.