Who should watch the watchers?

Like many others, I believe in the ultimate goodness of the majority of people, especially those involved with the care and protection of others. So of course I, like many others, hoped that the tranche of scandals emerging from a closer scrutiny of the NHS would now be over.  But we were wrong. This most recent disclosure of the failings of the Care Quality Commission (CQC) is perhaps the most shocking lapse of morality of all.

Although full details and allocation of blame are yet to emerge, it would appear that the regulatory body designed to protect the wellbeing of patients and maintain standards in UK care facilities have failed spectacularly in their duty. Not only have they failed to monitor standards in an efficient and robust manner, the former Chief Executive, Cynthia Bower, plus her deputy Jull Finney and the media manager Anna Jefferson stand accused of actively covering up damning information regarding their investigation of the high death rate of babies at the University Hospitals of Morecambe Bay NHS Trust.

There have been concerns over the CQC for some time and there is no suggestion that the new Chief executive was in any way involved but this latest scandal puts several major issues (again) under the spot light.

Firstly – just what has happened to the moral compass within pockets of our state funded health system? The Francis report, investigating the Mid Staffs scandal where up to 1000 patients may have died as a direct result of poor care was supposed to be the beginning of the end of these tragic stories. This latest shocker regards the maternity unit at the Morecombe Hospital Trust where a high baby death rate prompted investigation. Babies were possibly dying as a direct result of poor practice. It is now suggested that senior CQC officials covered up information which could have saved other tiny babies. And yet, it would appear, these people put their own jobs and personal interest above the care of the very people they were supposed to protect. At the risk of being over-dramatic, if they were guilty – how do they sleep at night? Is this because they were working in a poisoned environment, immersed a blame culture, with perverse team ethics or no collective emotional responsibility? This is heavy stuff.

Secondly – this demonstrates in blazing clarity the enormous task that faces the CQC. An impossible task in fact. How can a team of experts (I use the term loosely) monitor and investigate over 40,000 health and care facilities throughout the UK? Professor Julian Le Grand, from the London School of Economics stated today that the way the organisation was set up it was ‘daft’ by creating a generalist organisation and merging health and social care for this monumental remit.

Thirdly – the regulatory and monitoring landscape following last year’s health and social care act is very confusing. In a poster created by NHS Employers the section entitled ‘Monitoring the NHS’ describes the 3 key areas as follows:

Care Quality Commission: ‘..is the independent regulator of all health and social care services in England. Its job is to make sure that the care provided meets national standards of quality and safety’

Monitor:  ‘..promotes the provision of healthcare services which are effective, efficient and economic and maintains or improves the quality of services’
Healthwatch England:  ‘..is the independent consumer champion for health and social care in England. Working with a network of 152 local Healthwatches, it ensures that the voices of patients and those who use services reach the ears of decision makers’

This poster also describes NICE, Health Education England, Department of Health, NHS England, Clinical Commissioning Groups, NHS Trust Development Authority, and Health and Wellbeing Boards. All with some level of responsibility for standards. Confused? Who wouldn’t be?

How should we be monitoring our health and social care services? And who should watch these watchers? What needs to be done?

Clarify where the buck starts and stops: Well defined areas of organisational and personal responsibility, measurable standards and a simplified regulatory framework are needed

Give relevant experts the appropriate powers. In my opinion, one of the reasons that the cardiac and stroke networks were so successful in improving standards was that specialist units were awarded accreditation by appropriately qualified clinical specialists. It has emerged that lay people, fireman and other generalists within the CQC were tasked with inspecting hospitals – no wonder significant flaws were missed.

Neutralise conflicts of interest. It has been suggested that the newly formed Clinical Commissioning Groups should bear the burden of regulatory monitoring responsibility. No they shouldn’t – they have enough to do and there is already a risk of blurred lines between poacher and gamekeeper.

Separate health monitoring from social care monitoring. We don’t have joined up care yet so it doesn’t make sense to have joined up monitoring. If the CQC remains, specialist teams must be created.

And, most important of all….

Recognise that monitoring alone isn’t enough to create high quality care. Measuring only does that – it measures. Investment of time, energy and money are still required to build strong leadership within the NHS and support a culture of honesty, transparency, decency and clinical excellence.

I believe (and hope) that there is sufficient intellect, expertise, commitment and skills already within the NHS to make this happen. They just need gathering up and pointing in the same direction.

How can you measure care?

It has just been revealed by the Health Services Journal that Sir Mike Richards has been appointed as the new Chief Inspector of Hospitals. The purpose of this unenviable role has been described by David Cameron to ensure that “a hospital is clean, safe and caring, rather than just an exercise in bureaucratic box-ticking”.

The ‘clean and safe’ bit is relatively simple to monitor. There are a multitude of matrices available to set and measure performance standards, clinical outcomes and achievement of targets. But it is the care bit that’s tricky.

The new Chief Inspector, whose team will become part of the Care Quality Commission (CQC) has said that he ‘will champion the interests of patients’. This laudable aim fails to provide a definition of how to measure those interests so I looked to the CQC for clarification. Their website states their aims related to hospitals and GPs as:

‘We check all hospitals in England to ensure they are meeting national standards, and we share our findings with the public…..We inspect GP practices and other primary medical services in England to check that they are meeting the national standards of quality and safety’

It is absolutely right that national standards of quality and safety are met and monitored on a regular basis. But we still don’t have a benchmark for care.

Emotional intelligence is becoming an accepted principle for describing individuals, departments and organisations. One model to assess emotional intelligence is based on the three I’s – Intention, Interpretation and Impact. If you imagine a ward or GP surgery environment it is logical to project the three I’s to measure care and I would like to see this explored on a more formal basis for the NHS.

In the meantime, of course patient feedback and the ‘friends and family’ test are a valuable tool, albeit a subjective one. But then – care is subjective isn’t it?

Always happy to hear good news healthcare stories I am pleased to have two to report this week. One of my daughter’s colleagues is facing the agony of a very premature baby, born at 26 weeks, fighting for survival in a hospital in Portsmouth. The baby’s father has said that the one thing he doesn’t have to worry about is the care. A nurse is by the baby’s incubator at all times and the precision and intensity of each procedure (such as taking blood samples form underdeveloped veins) is enhanced by the palpable desire of each doctor, nurse and therapist for the baby to survive and thrive. The baby’s parents are in no doubt of the genuine commitment and care of the team who hold this precious life in their hands as medicine and care are combining to give this little mite the best possible chance.

Another example of care is much more low-key. Regular readers of this blog may recall my account of a gentleman (Tom) who was receiving poor care in a ward after breaking his hip. (‘Good care is about personal responsibility’ 21 April). Suffering bed sores, missing meals because he couldn’t reach his food, and becoming more frail by the day, the poor care received was having a direct impact on his will to live. I am pleased to report that Tom’s wife arranged for him to be moved to another hospital where the ward delivered the sort of care every patient should suspect. The medical treatment was the same, but the emotional and physical care was clearly far superior in this second hospital. Little things like making sure his cup of tea was just how he liked it, alongside scrupulous cleanliness and appropriate treatment for his bed sores. Tom is now home – working hard on his exercises and looking forward to walking his beloved dogs again before too long. What a difference moving from an environment with a poor emotional intelligence to one which embodied positive physical and emotional support.

I shall leave the last word to Tom’s wife – who used her own personal benchmarking system:

‘You could feel the care the minute we walked in the door’