Bye Bye Bower

Yesterday Cynthia Bower resigned at the Chief Executive of the Care Quality Commission. I remain amazed that she was ever seen as competent to run it in the first place but it’s easy to be wise in hindsight. Her departure is no surprise as the organisation has consistently been shown to be ineffective and unable to effectively or safely keep within its remit as the regulator of health and adult social care services in England.

As the Guardian states, at the time of Bower’s appointment by the Labour Government

Andrew Lansley, the then shadow health secretary, said at the time: “We have to ask whether it is right that the person in charge of the West Midlands strategic health authority at the time, Cynthia Bower, is now to be put in charge of the national regulator which heads up these investigations and which will be responsible for ensuring that this never happens again in Mid Staffordshire or elsewhere.”

Lucy at The Small Places refers to some of the closing statements at the Mid Staffordshire Inquiry which shine a light on the actions in the CQC at the time. She quotes Dame Barbara Young’s evidence – who had resigned as CEO of the CQC and was asked why – saying

I really believed strongly that we could only do a good job if we were on the ground locally inspecting with rigour and understanding what was happening locally in health core systems and in hospitals that were delivering services. And I knew that we were finding it quite difficult to ensure that that was the case with the resource we had. And I could see further restrictions in resources on the horizon, because by then it was clear that the service was going to share in cuts. And I could also see that that was going to happen at a time when the quality of care was going to be even more at risk than usual as a result of health core cuts in services.

So you’d be a regulator in a very difficult position, with government, accountable to government, but responsible really to the public, with less resource to regulate effectively, and services being more at risk And it just felt to me that that was not a job that my skills were best suited for.

Lucy, in her excellent post, points out, quite rightly that it was the Labour Government that was responsible for establishing the CQC in its current form. This goes beyond the party political. It is about creating a system which has allowed a more rigorous inspection regime to lapse faced with cost and faced with the potential to cause a political ‘stink’ when hospitals in particular might be found to be ‘failing’.

And where now for the CQC? Bower leaving was necessary but it looks as if the problems that run through the organisation are far more endemic than a change at the top. There needs to be trust restored in an organisation which is supposed to regulate services that we all depend on wholly.

My experience is more in the social care side than health and I see the dilution of regulation has happened over the years with poorer services, fewer inspections and inspectors with more experience in auditing paper records than inspecting care homes thoroughly ‘on the ground’.

Meanwhile, Paul Burstow calls for Dignity Codes for older people – who will be responsible for ensuring these ‘codes’ that apparently he wants care workers to sign up to are upheld? and his now cancelled so-called ‘excellence’ schemes which was unravelled and ratings sites – they all seem to be attempts to cover up the need for strong regulation and inspection because that would cost more money.

So Bower’s leaving is just an admission of failure and acceptance that she should never have been in that post to start with. She has barely displaying competence in ‘leadership’ but leadership is not just about one person and while the systems remain in place, we wait to be see if there will be any really useful changes in a regulatory body which has had such a difficult birthing experience.

CQC – the insiders’ views

The Inquiry into the failings in the Mid-Staffordshire NHS Foundation Trust has been going on for a while now but yesterday there was some hefty evidence from two CQC (Care Quality Commission) ‘insiders’ which blasted open the so-called regulator and lifted the lid on the poor practice that some of us have suspected for a while.

I would urge anyone in health and social care who serves are regulated by this body, take a look at some of the evidence presented yesterday. I did and I hate to say that I wasn’t surprised but let’s just say it confirmed some of my suspicions.

The two witnesses who provided the evidence were Amanda Pollard – an inspector with the CQC and Kay Sheldon – a non-executive director at the CQC.

I want to look at some of the statements that they made in the hope that these issues are picked up on by a wider audience.  Both Amanda Pollard and Kay Sheldon are ‘whistleblowers’ in the finest tradition and should be heartily applauded for the stance they have taken.

Is the CQC fit for purpose?

There was an interesting article in the Guardian yesterday about the Care Quality Commission which was set up as a new regulatory body for health and social care in 2009.

The CQC is headed by Cynthia Bower at a salary of £195,000 pa who was previously the Chief Executive of the West Midlands Strategic Health Authority – responsible for Stafford Hospital at the time it was found to have been providing substandard care.

How she was able to take post at the CQC is quite staggering to me, as an outsider but there she is, responsible for the regulation of health and adult social care services. You’d think it was the opening of a black comedy. Maybe it is.

There are some chilling facts that the Guardian have uncovered and they deserve repeating – over and over again – because the CQC is responsible for the regulation – not only of hospitals but of every care home and domiciliary care agency in England.

Thoughts on Stafford Hospital and the Mid Staffordshire NHS Foundation Trust Public Inquiry

I’m moving a little outside my ‘social care’ remit because I came across a link on Twitter from @shaunlintern (Health Correspondent for the Express and Star – the local newspaper covering the West Midlands, including Staffordshire)  which linked to some of the evidence given at the The Mid Staffordshire NHS Foundation Trust Public Inquiry (pdf) – in particular to the evidence of one of the nurses who worked there.

The document makes quite frightening reading and coming on the back of the report from the Care Quality Commission that nearly half of the staff in NHS hospitals are not able to manage the nutritional needs of older patients and 40% fail to deliver ‘dignified’ care (from The Guardian) it raises more than a few questions.

Having spent some time in my working life, dealing with hospital discharges, particularly for older people, I don’t think that this is remotely related to ‘uncaring’ staff or as a perception of ‘university educated’ nurses that the tabloids like to raise up from time to time. I have come across some of the most professional, thoughtful and hardworking nurses.

Indeed, if you look at the first link to the evidence of the nurse, Helene Donnelly, who gave evidence in the inquiry, you will see that what she describes is a management and systemic failure in the process of providing health care to patients. It is a top down malaise rather than bottom up ‘laziness’.

She tells of a culture of fear and bullying that took place at management levels and was covered up by falsifying processes to meet targets that had been set. The flight towards Foundation status cost lives and all those involved were complicit in the associated poor care, distress and yes, even deaths.

In paragraph 13 of the evidence she (Helene Donnelly) states that

‘’falsifying records seemed insane; if the department was seen to be meeting the targets, we would never be allowed to recruit more staff or buy additional equipment. If I ever raised this as an issue, I was told in no uncertain terms that, if we didn’t meet the targets, heads would roll and A&E would be closed, with all of us losing our jobs. I understood this point but I was equally concerned about the terrible effect that our actions were having on patient care. I did raise this with Sisters (names redacted) however their response was extremely aggresive, basically telling me that they were in charge and accusing me, and anyone else who agreed with me, of not being team players. Anyone who made trouble, as they saw it, was ostracised from the team and had to endure constant bitchy comments’.

Donnelly goes on to explain how visits by Monitor to regulate the services were ‘explained away’ by telling them that there were ‘fed a line’ about it being a temporary situation and that when the coveted Foundation Status was acquired, there would be more money for more staff.

Of course that comes as little consolation to those who have passed through the doors and passed away within the hospital during the drive towards Foundation status but I think that paragraph illuminates the management push within the hospital and the reign of terror affected on nurses and patients by their seniors. This is not about ‘ground level’ nursing support. It is about systemic and institutional abuse of both staff and patients by a use of power to mask real failings.

Donnelly went on to explain how she did make a statement in 2007 when she felt she had to ‘whistleblow’ and was told that a number of junior doctors told her it was ‘about time’ (paragraph 21).

She says

‘I responded by suggesting that they speak out too, however I understood and respected the fact that they were worried about their jobs. At one point, a band of doctors.. wrote a joint statement. However they were later persuaded to  retract this when a superior told them that it would not look good on their record, being junior doctors’.

So again, this a top-down abuse of power in respect to the ethical and moral codes of caring for patients rather than a grass roots problem.

As Donnelly’s evidence (and it is worth reading in full) she continues to recount what happens until an inquiry was requested.

She sums up her evidence with ‘learning points’ and for me, some of the most crucial parts of the evidence come when she talks about targets

In paragraph 53 she says

‘In principle, I agree with the government targets.. but the system is being completely abused. Patients are still lying on trolleys for twelve hours, they are just doing it in a different room; a room not classed as A&E… having a fine as a deterrent means that the Hospital loses out financially, so has even less money for staff and also increases the fear factor for the staff. Managers are frightened of the people above them in Government and they put that fear factor onto departmental managers which then trickles all the way down’.

For me, that sums up the problem that has been perpetuated in the health and social care systems. The targets and outcome measures in themselves are not problematic (in most cases!) but the push towards them that makes managers forget the small matters of personal care and attention to the experience of the hospital of the patient really do.

Papers that blame frontline nurses for not spending time feeding patients need to look at the ways the wards are managed and the ways the hospital is managed as a whole.

For me, though the questions remain:-

Have we stopped caring about those older people (as those were the group who primarily died disproportionately in Stafford Hospital) so an increased death rate wasn’t noticed?

Would it have been a different case had the patient affected been younger and more vocal and more mindful of their own rights to receive good care?

Would more independent advocacy in general hospitals help?

And finally-

On the basis that the so-called ‘buck’ stops at the top, how on earth was Cynthia Bower. who was the Chief Executive of NHS West Midlands (which includes the Mid Staffordshire NHS Foundation Trust in its remit) ever promoted to be Chief Executive of the Care Quality Commission – the organisation responsible for regulating care delivery in health and social care settings?