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Is there a 'club culture' at the heart of the NHS's quality regulator?

A look at the Care Quality Commission's choice of inspection chairs and overall processes reveals a predominantly white, male, corporate culture that risks letting down patients and staff.

Jeremy Hunt declared three years ago that the beleaguered  NHS quality regulator, the Care Quality Commission (CQC),  should become an authoritative source of a “single version of the truth. The CQC accordingly trumpeted a makeover of its inspection regime, with a purportedly more professional and expert approach.

However, CQC has continued to be criticised by parliament, complainants and whistleblowers for lack of attention to detail, failure to listen properly to concerns, inaccurate inspection reports and poor data quality.

The independent Mazars report on scandal-hit Southern Health questioned the CQC’s new regime – so-called ‘intelligent monitoring’, saying “"The national data the CQC uses for its intelligent monitoring may not be accurate.. As Southern Health hits the news again this week, following the revelation that its under-fire ex-Chief Executive has been shifted to a junior post but on the same £240,000 a year salary, it’s timely to ask more questions about whether the CQC sometimes obscures more than it reveals – and why.

A look at who chairs Care Quality Commission (CQC) inspections, and how they are run, raises questions about objectivity, expertise, diversity and club culture.

The CQC asked the Manchester Business School, together with the Kings Fund, to evaluate its new inspection regime. The Manchester evaluation painted a chaotic picture of programme that – whilst an improvement on past CQC methods – was still over-ambitious and inadequately organised, with patchy standards, insufficiently prepared and under-trained inspection staff, and a lack of clarity over roles.

The overly-complicated inspection regime also creates difficulties with recruiting staff, with inspection teams sometimes forming at the last minute, lacking key staff, and not analyzing the large volume of data gathered properly. The authors expressed suspicion that some of the data is in fact never used. Inconsistencies and variation between CQC inspection teams were noted:

In practice, from our observations and interviews we found that teams sometimes made up rules for themselves…”

A key concern is how the inspections are chaired – and by whom.

The CQC promised in 2013 that “Each inspection panel is chaired [by] an external expert.

And the Manchester evaluation states that each inspection was originally intended to be chaired by a medical professional, who should typically be a “senior doctor”, and led by a CQC compliance manager.

But in fact almost two thirds of CQC inspection chairs are current NHS trusts directors. Approximately half of inspections (48%) were chaired by senior doctors – and of nearly half of these were chaired by doctors who hold corporate roles as medical directors of trusts, regulators, NHS England and other bodies.

Furthermore, very few inspection chairs (less than 4%) are from visible ethnic minorities and there are about twice as many male chairs as female ones.

 The Manchester Business School report described worrying informality in the recruitment process for external inspectors and chairs:

“To recruit external inspectors or inspection chairs, senior CQC staff had used professional contacts and formal and informal networks (such as royal college affiliations) predominantly, rather than the open recruitment advertising process. One interviewee claimed that ‘my recruitment process was Mike Richards badgering me until I said yes’ (Doctor, CQC inspection team).”

Current CQC inspection reports on English NHS trusts reveal that 14 of 199 full-scale (‘comprehensive’) CQC inspections were not chaired at all. It was unclear why this was, but perhaps the recruitment problems described above played a part.

Inspection chairs were drawn from current senior trust staff, managers from other NHS regulators and NHS England, the chief executives of the Academy of Royal Medical Colleges, the Faculty of Medical Leadership and Management and the NHS Confederation, former senior NHS managers, and one former and one current director from private sector providers – the former Chief Medical Officer of the Priory Group and the Chief Executive of Swanton Care Ltd, respectively. 

The overall impression from CQC’s choice of inspection chairs is of a predominantly white, male, corporate culture that is perhaps too comfortable with itself, with insufficient boundaries between the regulated and the regulator.

Is some of CQC’s deafness to the concerns of patients, families and frontline staff (particularly ethnic minority staff) due to this skew towards privilege and corporate culture?

At Southport and Ormskirk last year CQC ultimately chose to believe a trust-commissioned report over the concerns of a large number of Black and Minority Ethnic (BME) staff.   The CQC inspection was led by three white men, including its chair. [10] Numerous BME staff raised concerns of less favourable treatment. The CQC noted that BME staff “felt highly disengaged from the executive. Concerns were expressed regarding limitation of opportunities for promotion and development, bullying and harassment and a punitive approach to medical re-validation and the application of professional standards to BME staff…Thirty members of the consultant staff also indicated in writing the presence of a culture of bullying and harassment.” However, CQC eventually concluded that the external investigation arranged by the trust was “thorough and comprehensive” and accepted its conclusion that there were “no evidence or grounds for the allegations”.

The poor diversity of CQC inspection chairs is of particular concern set against all that is widely accepted about the importance of inclusive and just culture to good quality healthcare.

The clubbiness of the chairs is also a concern given the lack of clarity in whether chairs can substantially intervene in the report writing or not (in theory, they do not, but in practice, the Manchester report suggests they do.

There is potential for objectivity to be compromised due to the predominance of current trust directors amongst inspection chairs. There is no obvious indication that this is the case when the ratings from inspections chaired by trust staff are compared with the overall pattern of ratings. In fact, CQC’s Chief Inspector and deputy inspectors seem slightly more disposed to rate trusts favourably, with only 2% of trusts reviewed by NHS trust staff rated as outstanding compared to 16% of CQC chief chaired reports, and 8.7% of trust staff chaired inspections rating the trust as ‘inadequate’ compared to none of the CQC chief chaired inspections.

Without controlling for other factors over a longer period, it is hard to be certain of how employing current NHS directors as inspection chairs affects the outcomes of inspections.

Indeed, questions also arise about the value added by inspection chairs relative to cost, if there is duplication of roles and some inspections can be conducted without them. Some in fact question CQC’s ratings model in general.

As for the appointment of a chair from the private sector to inspect NHS trusts, is it right for competitors of NHS services to be given access to large amounts of detailed intelligence about NHS providers or to be in a position to influence ratings on NHS providers?

Another matter that arose was that a CQC inspection chair is who has chaired 3 inspections is, according to information held at Companies House and on LinkedIn - a director of a private company that offers services helping to prepare organisations for CQC inspections.

Will the CQC listen to any criticism? Our NHS quality regulator has long been politicised. A leaked 2010 email by one of its directors said: Being hard hitting without presenting critical data will I suspect be more politically acceptable than criticising with evidence”.  Or is the CQC happy to continue its approach, current choice of chairs, and its role as part of an NHS “denial machine” ?


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