CQC – Can’t Quite Cope

The Care Quality Commission’s failure to stop the torture of patients at Winterbourne View Private Hospital in Bristol, despite the repeated pleadings of a whistleblower, is yet more evidence that it isn’t fit for purpose. And the CQC knows it. Last month, the Health Service Journal published minutes of a recent CQC board meeting, which acknowledged it faced ‘three major areas of risk, all of which were likely to happen.’ ‘1. Failure to effectively identify or deal with non compliance leading to persistently poor quality care for users. 2. Lack of volume and/or type of resource to meet the demands placed on it, leading to unacceptable levels of performance. 3. Failure to operate in line with required standards of probity and value for money.’

A key issue is whether the CQC should be both an investigator and a regulator. As the Eye argued 12 years ago (Eye November 1999), the NHS needs a lean and fast independent inspection team in every region, staffed by experienced clinicians, rather than ex-policemen, that can go into any hospital or GP surgery after one unexpected death or serious injury, complaint or staff concern, rather than wait for a whole pile of bodies to mount up. Labour created a Commission for Health Improvement (CHI) that started off well, but their reports were so hard hitting and politically embarrassing they soon fell out of favour. CHI was replaced by a Healthcare Commission (HCC) which lost independence when its inspection standards were decided by the Department of Health. A National Patient Safety Agency was set up to monitor NHS errors, but wouldn’t share its information with the HCC. And yet another regulator, Monitor, was set up for Foundation Trusts and didn’t want anything to do with the HCC.

The HCC’s Annual Health Check for hospitals was just a simplistic check list of supposed standards that managers found it very easy to game, and told patients little about the quality and safety of their hospital. Dr Foster’s mortality rates should have blown the whistle on Mid Staffs but instead were dismissed by both the Trust and West Midlands Strategic Health Authority (chief exec Cynthia Bower, now chief exec of the CQC). The HCC had at least retained a proper investigative arm which belatedly went into Mid Staffs and unearthed appalling care and between 400 and 1200 avoidable deaths, which they passed onto the CQC. The CQC were so angry they gagged the lead investigator, Dr Heather Wood, until she was finally allowed to give her explosive evidence to the Mid Staffs inquiry. Dr Wood – one of the HCC’s best investigators – has no confidence that the CQC, in its current form, would have unearthed Mid Staffs.

The retrospective  ‘system management’ of regulatory bodies is incapable of picking up scandals until the body count is too big to ignore, which is why it’s vital to listen to staff brave enough to speak up. But this is not the first time the regulators have palmed off a whistleblower. Dr Pal identified serious shortcomings in the nursing and medical care of patients on Ward 87 of City General hospital, Stoke on Trent, when she started working there in August 1998 (Eye April 8, 2009). She complained to all three regulators – CHI, the HCC and the CQC. She found out from the CQC that the regulators didn’t even pass information on when they were closed down and opened up again with a different name. ‘As you can appreciate we had no knowledge or information about your concerns that you had raised with HCC or CHI in the past.’ A subsequent review in May 1999 by Mrs T Fenech from the Infectious Diseases Unit found ‘serious deficiencies in nursing practice’ and that ‘the level of care demonstrated for some patients on the ward at the time of my audit was nothing short of negligent’. But this failure, on the doorstep of Mid Staffs, did not warrant investigation by the regulator.

The CQC has neither the money, the methods nor the staff to competently inspect and regulate the whole of health and social, in both the NHS and the private sector. They failed to meet their own standards and timescales in registering dentists, and imposed inflexible paper-based policies and vast amounts of red tape that have merely succeeded in taking dentists away from teeth. Now they move on to GPs. The Health Bill should merge regulators – there aren’t the resources for both a functioning CQC and Monitor, and you can’t separate the money from the quality of care. More urgently, we need a truly independent inspectorate in every region that staff and the public trust,  that goes in hard and fast to investigate patient harm and publishes its findings in time to save lives.  MD

Britnell’s Got Talent

At Prime Minister’s Questions on May 15th, David Cameron claimed had not heard of one of his health advisers, Mark Britnell, until he’d Googled him on Sunday. His interest was provoked by The Observer’s report of a speech that Britnell, Global Head of Healthcare at KPMG, gave to a group of private health companies in New York last October. According to a brochure summarising the conference, Britnell said: “GPs will have to aggregate purchasing power and there will be a big opportunity for those companies that can facilitate this process … In future, the NHS will be a state insurance provider, not a state deliverer…The NHS will be shown no mercy and the best time to take advantage of this will be in the next couple of years.” Britnell responded by saying that the quotes ‘did not reflect the discussion that took place.’ But in the same month, he launched a KPMG sponsored GP Commissioning Academy at the National Association of Primary Care conference attended by health secretary Andrew Lansley and health secretary in waiting Stephen Dorrell.

Cameron’s desire to distance himself from a member of his kitchen cabinet of NHS experts, assembled by his health adviser Paul Bate, is understandable. But to claim he’s never heard of Britnell stretches credulity. Britnell worked for the NHS for twenty years before he jumped ship to KPMG. He is ambitious and forceful, and has advised politicians from all major parties on NHS reform. So, as head of South Central Strategic Health Authority – which oversaw the new Tory leader’s constituency – it seems likely he would have collared Cameron when they both attended an Oxfordshire PCT meeting on February 19, 2007.

More worrying, given Cameron’s desire to protect and love the NHS, is his professed ignorance of a key architect of both Blair’s and his own health reforms. In Wales and Scotland, there was – and remains – no appetite for an NHS market. They just concentrate on providing the best service they can through cooperation. But Britnell was – and remains – a huge fan of commissioning. In 2007, he became Director General of Commissioning at the Department of Health and was voted third most powerful person in the NHS, ahead of health secretary Alan Johnson (Eye… December 2007). Britnell coined the phrase ‘world class commissioning’ and cemented the concept in NHS policy to the extent that the Tories are forming a National Commissioning Board and ‘liberating’ hundreds of GP consortia to ‘do commissioning’, rather than treat patients.

Britnell also came up with FESC (Eye Dec 2007), ‘a Framework for procuring External Support for Commissioners, which is part of the ‘buy’ option, providing PCTs with easy access to a bank of specialist expertise in areas such as data analysis, contract management and public engagement’. As the Eye observed, ‘FESC is just an excuse for clueless PCTs to buy the ‘expertise’ of huge for profit health insurance corporations. In America, these organisations keep costs down by offering doctors perverse incentives to deny patients the care they need (600,000 doctors have been sued for this) and there are widespread legal claims for misapplying fee schedules, errors in claims processing and delayed payments.’

In October 2009, Britnell jumped ship to KPMG, one of the companies that took PCT money under FESC and – presumably unknown to Cameron – secured a contract to do so for NHS London in January 2011. A revamp of the costly FESC is pretty much what Britnell is suggesting now, hardly surprising to Cameron’s health adviser Bate, a former Blair adviser who Britnell met on appointment, or his head of Policy Development Paul Kirby, formerly a close associate of Britnell at KPMG. Cameron may limply claim to have never heard of Britnell, but Britnell’s – and KPMG’s – agenda is alive and kicking in the Health and Social Care Bill.

MD

PS In 2006 Britnell was a director of the health research company Dr Foster when the Department of Health struck what the public accounts committee called a ‘backroom deal’ with it, costing the taxpayer £4million too much. In 2008, shortly before leaving the health department for KPMG, he awarded a contract to advise healthcare trusts on commissioning to a joint venture between…. Dr Foster and KPMG!