What's next for CQC after systemic failings found?

Charlotte Ruthven

Hello and welcome to Health on the Line. I'm Charlotte Ruthven, the NHS Confederation's senior policy and delivery manager. The full review of the Care Quality Commission is out and we hear direct from the report's author. 

“These are really, really complex considerations whether you're sitting in an ICB, you're sitting in a care home or you're sitting in an acute trust and does our model of regulation take into account that complexity?” [Nigel Edwards, senior advisor at PPL]

And later we catch up on what happened at the launch event of NHS Confederation's report on neighbourhood health, Working Better Together in Neighbourhoods. 

“If you engage with the community and the people at the sharp end of the inverse care law are not in the room, it's not engagement. You shouldn't be paying for it. There are standards for how you do this stuff. It's not an accident. There's a science to it, there's a skill to it, there's a process.” [Victor Adebowle, chair of the NHS Confederation] 

But first, Penny Dash, chair of North West London ICB. Penny's full report from her review of the Care Quality Commission has just come out and she spoke to Matthew Taylor, who began by asking her what were the key things she wanted people to take away from the report. 

Penny Dash

The first is, and that's been the bit which has almost attracted the most attention over the last few months, is that unfortunately operational performance has suffered a big hit at CQC. So that is definitely a key message. I think it's unfortunate.

It's in part down to a major new IT system, which has not worked particularly well. It's in part down to restructuring of the teams and it's in part a very long hangover from covid.

But the impact of that collapse in operational performance has been significant delays in people being re-inspected, having had a required improvement rating. It has been increasing times between assessments. And it has been significant delays in people receiving reports and indeed the quality of those reports, which are being increasingly produced by IT systems. In some ways, that's the bit that's received the headlines. 

That is all true and CQC will need to address that. But some of the other things I think are probably the more interesting things and where they pose quite significant questions for us as a health and care system. 

And those are around what is it that CQC looks at? How does it define high-quality care? How does it measure high-quality care? And therefore as a result, what should and could providers do in order to improve the quality of their services? And on that, that is all around the new single assessment framework that CQC has introduced over the last few years, started to adopt and use now about just under a year ago. 

And so now has around ten months experience of using that framework, the feedback that I've heard, I've been out there, I've spoken to a lot of providers, care home providers, domiciliary providers, as well as healthcare providers. The feedback from them is partly around the operational performance, but is also around the single assessment framework. 

And where I've gone deep and indeed Sir Mike Richards has gone deep is into the content of that single assessment framework. And the things that have come out are, first of all, that we have moved quite significantly towards safety versus effectiveness. And as part of that, there is no longer, and there used to be in the past, there is no longer a review of use of resources. 

And I think that is important because as we have all seen over the last few years, we have seen a big increase in staffing without necessarily the improvements in outcomes and in models of care that we may have hoped to see and indeed in activity.

And in part, that is because of they've been increasing top-down mandates around safe staffing levels. CQC has reinforced those by going in and looking at staffing and so on. Whereas I've got some interesting reports from 2016 where CQC, the national quality board, would have looked at use of resources, effectiveness of resources in a broader context.

So that's been really quite interesting is this move towards safety per se and not necessarily some of the broader aspects of quality of care as well as use of resources. So that's been something which doesn't necessarily jump out and come out of some of the key things, but is an important bit because it is a bit about what do we say we are here to do as a health and care system. 

So that is something that I would flag. 

I was also asked to look at innovation and the degree to which CQC supports or hinders innovation. 

This has been quite an interesting one because CQC has actually done quite a bit of work to look at different care models. For example, how to evaluate virtual wards or how to think about use of CCTV for monitoring, for example, mental health in patients.

But there is still a sense that comes through from providers that they are concerned that sometimes the evaluation framework is looking at a particular view as to how to deliver care, when indeed there may be opportunities to look at how to deliver care in some quite different ways. 

Matthew Taylor

Can I just stop you there Penny, because I mean there's so much there, but, and I want you to go on, but what springs to mind from the first part of what you said is that the issue of risk is not one that we've managed terribly well. We've focused on particular risks at the point of delivery of care, but there are systemic risks which somehow kind of get missed in that. 

I think it's fascinating. I mean, I find that when I go around the health service that our approach to risk has kind of grown up, but it's been really hard. There's a kind of wood for the trees issue, it seems to me. Is that in a way what you're pointing to? 

Penny Dash

Yes. And many providers flag this as, you know, chief exec of a large complex acute trust. They may have said to me, well, one of the things we struggle with is CQC comes in and looks at very specific things but I'm sitting here as the chief exec and I need to look at exactly as you say, know, balance of risk across the board. 

Or indeed, if you go to an ICB, an ICB, which I know from my day job as it were, now we're sitting here with, I've got my instance, £6 billion pounds. How do we spend that £6 billion? How much should we be putting into acute activity and into the unit cost of acute activities? Not so much the volume, but the unit cost. Because if we add staff, if we add equipment, if we add this, if we add that, the other, for example, that increases the unit cost, that then means we can't do as much activity. 

And how do we think about how much goes into acute versus how much goes into community versus how much goes into primary care versus how much goes into prevention? A, it's really difficult, but B, do we have a regulator that is looking at things through that lens? 

Now CQC will would say, well, that's exactly what we want to do in terms of our assessment of ICSs. For a large acute provider that is struggling with, can't get people out of the back door into a care home because there's certain rules and regulations about what you can do and when you can discharge and when you can't and what a care home can do. 

I've got people coming in the front door and how do I think about balance of risk between are they in the ambulance, are they in the A&E, are they in the wards? These are really, really complex considerations whether you're sitting in an ICB, you're sitting in a care home or you're sitting in an acute trust. And how we think about those in the round is complicated. 

And does our model of regulation take into account that complexity? 

Matthew Taylor

That's fascinating. And your point about innovation is also fascinating to me. And I don't want to caricature it, but we're kind of used to a slightly baleful innovation cycle in the NHS where bit of good practice is identified, possibly not fully understood or evaluated, everyone's encouraged to do it, people do it, it doesn't quite work out and then it's abandoned for five years and emerges in a different kind of form. 

So the way in which we innovate and evaluate innovation, it too is very complex and I guess I'm hearing from you that this is another thing that CQC needs to somehow get its head around a bit more?

Penny Dash

Yeah, I think so and of course the question is, this is not simple, it's not straightforward. And so what resources does CQC need to do this? What skillset, what capabilities and so on? Those are all very valid questions and things that will need to be considered. 

How do we set strategy at the national level? How do we roll things out? How much does get left to individual ICBs? What gets done nationally and so on? All of these are very valid questions. And exactly as you say, we need to really get sort of better at thinking through the trade-offs between what money do we put where, what resources do we put where and so on. 

And it's very easy to say, use this word ‘safe’, which has taken on quite a life of its own over the last few years, you know, is this safe? Isn't it safe? Well, that's quite a hard thing to say in a health and care environment. It's actually about what are the different healthcare interventions that we know have an impact on people's health? If that's the ultimate objective, what is optimum way of delivering those? What's the most efficient, most effective way of delivering those? Which may be, of course, increasingly around using different sorts of technologies, maybe around using different sorts of workforce. 

And then how do we optimise the delivery so that we can provide as much of those impactful interventions as we can and not deliver the things that are less impactful? 

So this question around both allocating resource and having really efficient delivery should really be at the heart of what we do and we need a regulator that can support that and endorse that and encourage that rather than almost be regulating in a quite old-fashioned view of the world.

Matthew Taylor

Just got one last question, which is what do you see as the relationship between your work and the ten-year health service strategy? 

We've just had Darzi and I had somebody described Darzi as the first chapter of the ten-year review. I've just spent a lot of time recently at the Labour party conference, lots of fringe meetings, the consensus there was we know what we want to do or where we want to get to. 

Now, so the issue is how do we do it? It sounds to me as though your report, as well as focusing on the CEQC, has also got some quite important messages about this critical question of how we achieve change. 

Penny Dash

Well, I think we need to be very careful that as we develop regulation, because no one wants to break the regulations. You don't want to be sitting there on and aboard or anywhere really doing something which you are worried is seen as being against the regulations.

So regulations are really important and we need to get the regulatory framework right so that we can encourage people to move in the direction of travel that we want to go. 

So therefore we need to think through the ten-year plan. If we want to move to a model of care which is more focused on prevention, which is more focused on out-of-hospital care, which is much more digitally enabled, those are the big three planks of what we're trying to do, then does our regulatory system support movement in that direction? So that is a fundamental question which we need to address. 

And then in terms of the relevant roles of different bodies, what is it that we want a large NHS provider to do? How do we assure ourselves that a private provider is providing high-quality and efficient care? How do we assure ourselves that a care home is doing that as well? So we need the entirety to be working together and not have one bit pulling against another. 

Sounds very simple, but quite complicated to deliver. But it has to be something that we contemplate as we develop the plan. 

Matthew Taylor

Penny, thanks so much for joining us and thanks so much for the work that you've been doing on the CQC, because I know that it is the system as a whole. And of course, you're a member of the Confed is deeply grateful to you for this very timely work. Thank you. 

Penny Dash

Thank you.

***

Charlotte Ruthven

Last week saw the launch event of Confed's eagerly awaited report on neighbourhood health, titled Working Better Together in Neighbourhoods. Produced in partnership with Local Trust and PPL, the report outlines what steps must be taken to improve health at a local neighbourhood level. Confed's chief exec Matthew Taylor kicked off the launch, highlighting the challenges of shifting the current model of care

Matthew Taylor

This is about doing things very, very differently. It is about a different model of care. It is about a different relationship with people and communities… And I think a lot of what we're talking about today is going to be how do we understand what this concept is? How do we understand some of the examples of good practice out there? 

We, along with NHS providers, are a membership organisation for community trusts. And I think it's important, therefore, in the context of it being community services, just to recognise the effort being made by people working in primary and people working in community to move to different ways of working, to implement elements of the Fuller review, the work that ICBs are doing in that space as well. As we emphasise the need for change, for new ways of working, it's really important to recognise how many people are out there right now doing this good and great work, and we should applaud the work that they're doing. 

So this is change that we have to do. There is no sustainable future for the health service unless we do develop different models of care and of engagement. It's what we need to do for our patients because too many of the people we work with experience health service in which they bounce around never really fully being seen and supported as people and as members of communities. 

I have visited fantastic practice all around the country from East Birmingham to Oxford to last week rural north Norfolk. I see some really great and inspiring work, but at the moment it feels like tiny sparks of great work.

Charlotte Ruthven

One of those notable tiny sparks is W12, a resident-led board set up in West London. Its leader on health issues is Jenny Chigwende.

Jenny Chigwende

I mean, think something that was very helpful, certainly for me going into this, is that I work in the NHS and I have done for the last 20 years. So some of the acronyms that we use which alienate a lot of people that come in from for community. We were able to talk about the language that we use. And I think one of the big things that we talked about was the need for humility in meetings. 

So what happens often is that when the voluntary sector invited in and people say it's a co-produced piece of work, it's actually whether the people feel confident enough to speak in that space. 

They've got so much information to bring but they feel intimidated by coming into the space and because the NHS is very hierarchical, they watch who speaks and who's allowed to speak and who isn't allowed to speak. And actually there's a community organiser that can actually solve this problem for us that we spend six or seven meetings later that are scheduled in everyone's diaries, but actually they don't get a chance to speak. So I think as the chair of W12, I wore a different hat being able to go into spaces and we did lots of focus groups where it was about people being able to say what they wanted to say. 

And a lot of it was about the NHS often feels that people in our community in W12 are hard to reach and I find that statement really quite frustrating because I don't feel anyone's hard to reach. I feel that it's the way in which we're communicating that we are not reaching them in the correct way. 

So in W12 our health work is a lot around culturally appropriate interventions. 

Charlotte Ruthven

The report's author is Nigel Edwards, senior advisor at PPL. What struck Nigel was how structurally different and to some extent idiosyncratic, successful local healthcare interventions were, compared to traditional top-down healthcare models. 

Nigel Edwards

The approaches that we see are pretty non-linear, then very non-hierarchical. The approach to change has to be much less prescriptive than we've been used to in the world we occupy. It has to have quite a long term, this is a bit of a slow-burn thing. Many of the projects we saw are taking time to get going. 

They build a momentum and unfortunately it doesn't look like there are many shortcuts to that and it's almost that sort of careful building of relationships that has given them their power. It's quite hard, you can't rush it. And as I've just said, these are really based on relationships rather than the sort of systems and management processes and standard policy things that we are, we're used to seeing in the world we operate on. 

How do you scale something without killing it? How do you get it spreading to other places without the dead hand of NHS England? I'm not supposed to be rude about NHS England, but you'll forgive me, the dead hand of templates, spreadsheets, performance management and standardised change management models. 

So that's the big question for me. 

Charlotte Ruthven

However, Nigel said there were some shared commonalities among successful examples of neighbourhood interventions. 

Nigel Edwards

They're all based on very careful listening and efforts to understand what is important to communities. So all of them have got some form of really good dialogue where they engage neighbourhoods. They build relationships throughout that community with local employers, with statutory services. 

They're based on the principle that we're empowering people within the neighbourhoods to take action for themselves. And that will come back to this point, but that has got some implications for the people who are funding, sometimes commissioning these services about how they think of them. 

We're not very good in the end, just about tolerating diversity of approach, very often are we. But these are very different. They've got degrees of commonality, but Leeds is a very interesting example where there are multiple examples of these models which have been commissioned in some cases and more supported in others by the local council. And they're all different, and that's fine. So we've got to be able to embrace diversity.

They've all got a clear common purpose. They know what they're for. Very often, unlike the NHS, which isn't so great at this, they have actually prioritised and decided to focus on a small number of really things that are important to them. They also require us to act and think sustainably. So quite a lot of different changes in mindset. 

Charlotte Ruthven

And the case studies in the report raised other interesting issues.

Nigel Edwards

One of the questions that we grapple with is what is a neighbourhood? And it's not immediately obvious except to the people who live in it. 

So the answer here is you have to take the definition of the people who define their community. Now unfortunately that often doesn't map on to statutory services. So really understanding what is the community and then trying to align the goals of the statutory body so that they are supporting and aligned to the work of these communities looks like it's really important. But their definition is the one that matters. 

What about methodology? There's quite a library of different methodologies supporting various types of asset-based community development. What we found was that people knew about these methodologies, but they'd taken a very sensible and pragmatic approach to pick nda mix and to build their own that worked for them.

And I think the conclusion I came to here, a bit like in the quality improvement literature, is it doesn't matter probably which methodology you have as long as you have some sort of method because it's quite a helpful guide and a checklist to work out what you should be doing. 

So helping people understand what the library of methods is something that's helpful but don't get, like the quality improvement movement in the NHS has done a bit ideologically, get into a long theological debate about which method is the right one. It almost certainly doesn't matter.

Charlotte Ruthven

Victor Adebowale is chair of the Confed and has previously worked extensively with grassroots health initiatives. He had quite a different perspective. 

Victor Adebowale

I'm really passionate about this. You know this, don't you? I think when I took on the chair of the Confed, this is the kind of work we should be doing. I personally believe it's the future for the NHS. But I believe more than that, actually. I think the future for many of the things that we worry about, democracy, you know, it's in the hyperlocal. So I just wanted to say that. I think we've got to deliver this. And I was pleased when he went to see Secretary of State that he gets it.

However, there are some things that we're going to, some myths that we're going to have to kill. The first is that this is about power, ultimately. It's about transfer of power, and power isn't given up easily, which is why we're not doing it. We know what to do, we know it works, we've known this for years, but we haven't done it because we haven't faced one of the elephants in the room, which is power. 

And this is about transfer of power from people who do to people who do with. And I think that's quite challenging. I do think, in response to your work, which I do think is excellent, we can and should go faster. And the requirements for going faster are that we are very clear about what government can do to support us. The reason why I say that is because the NHS wasn't created in Whitehall. It wasn't created in Whitehall. 

It was created by people who weren't as qualified as most of the people in this room. The reason why it spread is because there was scaffolding provided by the policy and legislative framework and it had the support of leadership. 

So that's what we need to provide for Wes. But I think this is, I feel really passionate about it. I don't want to go on too long because I just think it's fantastic. Hopefully I'll get to say some of the things later, but I do think this is the core of the change process we have to bring to the NHS. We're in the last chance saloon. There isn't a plan B. This has to work.

Charlotte Ruthven

However, transferring power to local groups comes with its own challenges. Rachel Rowney is chief operating officer of Local Trust. 

Rachel Rowney

I think we've focused today on lot of geographic communities and we know within communities there's communities of identity as well. And often what we ask them to do through Big Local is to work together, to come together and share and create a plan that they can all buy into and then deliver. 

But I think we have in a lot of places seen a lot of conflict as well, or people trying to work out what is the best thing for that community and a million pounds only gets you so far. 

So how might you start to divvy up the money? So it's really interesting what W12 have done with your three priorities. Other people have looked at actually, is it older people that we want to focus more on? But then actually, what does that mean for younger people? 

And there have been really intense discussions about where should that money go? How should it be divided? And how do you come to consensus about what's best for that place and what should we focus on and how is that complemented by others. So there is conflict and there's disagreement and there are some instances where the physical space is contested. 

So you've talked a lot about it's really important to have a place to meet. It is, but some people don't feel comfortable going into certain spaces. So in some big local areas they've wanted to meet in pubs and some communities have said actually we're not comfortable doing that. How do you expect us to participate if that's the community hub? Some areas, you know, look out when it's a good time to meet. So it goes down to real granular things of actually we all work, we want to meet in the evening. Whereas other people saying, well, we don't work and we're older, we want to meet during the day because we feel safe for going out at that time. 

And so we're trying to find a way where you're not necessarily pleasing everyone, but you've got enough people in the room that can make informed decisions that broadly reflects that area.

Charlotte Ruthven

The session concluded with a powerful message from Victor Adebowale. 

Victor Adebowale

First of all, community engagement isn't a free good. It's not without standards. So the answer to your question is, if you engage with a community and the people at the sharp end of the inverse care law are not in the room, it's not engagement. You shouldn't be paying for it. There are standards for how you do this stuff. It's not an accident. There's a science to it. There's a skill to it. There's a process. 

Secondly, I did mention the commissioning. We spend a hundred and a billion quid commissioning stuff. In fact, NHS England, when I was on the board, it was called the NHS Commissioning Board. It commissioned things. That's how the money gets spent. But we don't have standards within commissioning that insist that it's done from the ground up. 

And there are myths, myths about this. When you talk to people, they will say, well, it takes too much time. To which my response is, how much time is wasted not delivering services to people who need it, who should be getting it. That's the waste of time. 

Or they say it costs too much. And I say, well, how much do we waste on negative value services that actually involve people falling through the net who should be getting the services that end up costing us more later? 

So those arguments are weak. They're just weak arguments. They're about maintaining the status quo and maintaining power where it is as opposed to where it should be. And that's what we have to point out. It's not rocket science. It's just commitment and clarity and vision. 

And I'll just end by saying that this is not going to be easy. We said this to Secretary of State this morning. I would like him to really hold the system to account. And he does that by asking some of the current structures, like NHS England, whom we all love, simple questions like what is it that only you can do? What is your unique contribution to the delivery of healthcare which is based on the needs of individuals? 

And if the answer is vague, unclear, I think there's a question. What are you doing? What are you doing and why are you doing it and with whose money are you doing it? Because a chunk of that will be wasted. 

Secondly, we talk about from analogue to digital. One of things we must insist upon is that leadership goes from mine to system. That is not an accident either. That's about training, it's about expectations of our leaders and it's about accountability. It's not an accident. That's how you get the change in culture.

The third is that we have to insist that there are standards, there are standards for community engagement, there are ruleless You've mentioned some of them in your report, but let me just summarise it in some way, having done some of this work. 

First of all, if I tell you I'm listening to you, you've got no reason to believe me unless you've got evidence that you've been heard. 

Power is important. And when you're engaging communities, if they can't do something that they couldn't do before the engagement happened or during it, that ain't engagement. Right? That's not engagement. 

Thirdly, co-production isn't enough. I'm always shocked by the fact that middle class people get services designed by them, not with them. You notice that? Co-production is the minimum. If you want the system to work, then the people who are going to use the service have to be involved actually designing it, and they are capable of doing that, as Jenny and others have demonstrated. 

And the fourth and final one, which seems really simple, is that the outcome of any such engagement has to be explainable in a sentence by your mother, brother, lover, friend, community or neighbour. That's how we got the NHS. 

So I feel really passionate about this stuff. I'm not going to stop on it. I really feel it's one of the reasons I do what I do. You're all in this room, if you're all capable of talking to ten other people and giving them the facts, not just the passion, we might make change. 

But we have to make change, not just for you, but for the people who aren't in this room. 

Charlotte Ruthven

If you want to the full report, follow the link in the show notes. That's it for this edition of Health on the Line. Thanks for listening.