Wes Streeting is shocked – shocked! – to find that the Care Quality Commission (CQC), the healthcare regulator, is not fit for purpose. If this is really the case, one wonders what he has been doing since being appointed to the Shadow Health brief in November 2021. The CQC has been broken since it was established:
The CQC’s less than two-and-a-half-year history has not been a happy one. Cynthia Bower, its chief executive, was appointed on a salary of £195,000 a year despite her heading up the West Midlands strategic health authority, which had oversight of Stafford hospital, where a long history of poor care caused hundreds of patients to die between 2005 and 2008. The report of a public inquiry report is due in the new year.
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Seven months into its life, the CQC lost its chair, Baroness Young, who resigned in December 2009 after inspectors were sent into Basildon hospital, where dozens of patients had died through inadequate care. Just a month before, the CQC had ranked the hospital as ‘good’.
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When the Winterbourne View scandal erupted last May, her successor, Dame Jo Williams, chose to stay at her well-remunerated post. The appalling abuse at the specialist unit in Bristol for people with a learning disability was exposed not by the CQC but by BBC Panorama. The CQC later admitted to ignoring a whistleblower.
That’s from a Guardian report in 2011. It has scarcely improved since. In 2015, the Commons’ Public Accounts Committee (PAC) warned that the CQC was ‘not an effective regulator’; in 2017, a report from the Centre for Welfare Reform was utterly damning about its oversight of social care. A 2018 report from the PAC claimed things were improving – but by 2023 the CQC was being slated for mishandling whistleblowers, and a year later it’s not fit for purpose.
Now, we need to be a bit careful when sifting the avalanche of hostile commentary on a public service regulator, because there are elements inside every public service which simply do not like being regulated – consider the sustained efforts by parts of the education establishment to use Ruth Perry’s suicide to defang Ofsted.
There are, clearly, serious problems at the regulator. Its poor track record of dealing with whistleblowers is especially damning; however difficult it might be for spot inspections to catch deep-rooted problems, there is no excuse for not dealing with tip-offs properly.
Nor is there any reason to doubt reports that its inspectors are inexperienced and underqualified, and that it hasn’t been conducting the necessary volume of inspections – although as with so many areas of the public sector, this will in large part be a resourcing issue. Hiring adequate staff costs money, especially if you want good people who can command good salaries in the private sector.
There is also the structural challenge of regulating something as holistic as ‘care’. The above-linked CWR report opens with a damning description, which will be familiar to anyone who’s read Seeing Like a State, of how the CQC has ended up focusing on easily-measurable metrics, and how this has distorted providers’ priorities:
The standards and their interpretation have become far too complicated and prescriptive, so, rather than checking that the care itself is good enough, the CQC concentrates on the more easily measured standards and how they are being followed in the provider’s written records and procedures.
So, there is clearly scope for a more effective regulator – but if we’re honest, there is also probably a hard limit on how effective any regulator can be at fixing problems in the health and social care sectors.
Perhaps the most telling criticism of the CQC is this from Professor Martin Green, the Chief Executive of Care England, last year:
Currently, we have regulation that responds very differently to statutory and independent services and we have a system that allows statutory services to be under special measures for years. However, this would never be tolerated in the independent sector.
It ought not to be surprising that a regulator is more effective in a sector with lots of independent providers, for two reasons. First, such an environment affords more choice and power to patients, who can respond to low ratings and bad reports in a manner that rewards good providers and punishes bad ones.
By contrast, it is not at all obvious what the CQC – or any regulator – is supposed to do about persistent failings on the part of ‘statutory’ services. Almost by definition these cannot be shut down, and even if they could in theory our overstretched public provision model isn’t going to furnish any surplus capacity or competition to make so doing viable in practice.
Second, politicians and the state are much more comfortable taking an adversarial approach to regulating the private sector. It is a rare minister who is shy about cracking down hard on a private company caught in malpractice.
It’s quite different when it’s a publicly-owned monopoly, as we saw with the decades of official failure to catch wind of the Post Office scandal. The Health Secretary might be being commendably frank now, but there is a window for such things when your party has just entered office and you can blame any failures discovered on the other lot. It will be different in five or ten years’ time, when overturned stones will expose Labour’s record rather than the Tories’.
Perhaps Streeting will follow all this up with decisive action aimed at the NHS’ structural problems. More likely, he will unveil a new regulator. It is much easier to legislate for high standards than actually deliver them, which is why British politicians at all levels are addicted to trying to regulate their way out of problems – even as the standards of our homes, public services, and much else continue to decline.
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