03 July 2013

Some organisations are set up to fail. Not deliberately of course. But in their creation lie the seeds of their destruction - reputationally, if not organisationally.

The Care Quality Commission (CQC), which has been over all the headlines again in the past fortnight over firmly denied allegations that its top officials conspired to suppress a report into deaths at Morecambe Bay’s maternity unit, is one such.

It was created not from any obvious policy logic but simply from a desire to save money. Its origins lay in the Gershon review into government efficiency which argued that Labour had created a whole stack of regulators that needed rationalising.

Gordon Brown, then chancellor, wanted in his 2005 Budget to announce a big quango cull. Tony Blair was equally keen. “This was a period when Tony Blair and Gordon Brown competed with each other to reduce the number and cost of public sector regulators that Labour had largely created,” Lord Warner, the health minister, at the time has recalled. Some of the most extreme ideas were seen off – at one point there was a proposal to roll five Home Office inspectorates for police, probation, prisons and much else into one. The health department did not escape so lightly. The Care Quality Commission was created out of the previous health inspectorate, the Healthcare Commission, the previous social care one, the Commission for Social Care Inspection, and the Mental Health Act Commission which worried about detained mental health patients.

It is of course true that patients want to see health and social care as one seamless service. But inspecting these very different services requires very different skills. Boots on the ground may work well for social care and detained patients. But hospitals are hugely complex places where on the ground visits can only tell you so much and where heavy data analysis will provide some answers but not all.

Furthermore, as CQC came into existence it was the third new quality regulator for health, and the fourth for social care, in only nine years. Indeed the abolition of one of its predecessor social care bodies had been announced just 11 days after it formally opened. Talk about tearing plants up by the roots to see if they are growing.

The result was that three very different requirements were rolled into one organisation as its budget was cut by a third and as it was given a whole new set of responsibilities, including registering 8,000 GP practices. The result was an entirely predictable disaster - which bad management then compounded.

Can it be rescued? It now has its best chance so far, despite the dire headlines of recent days. It has a new chief executive in David Behan, a new top management team and is completing a new board. In the wake of the Francis report, there are to be new posts of chief inspector of hospitals, chief inspector of social care, and, no doubt by the time ministers have finished, probably chief inspectors of general practice and much else. Not that those posts were specifically a Francis recommendation.

But there remains a worry that it is yet again being set up - unintentionally - to fail. Ministers appear keen to have an Ofsted-style star ratings system for hospitals. But hospitals are not schools. They are vastly more complicated. Even great hospitals can have poor departments and vice-versa. It has to be remembered that not everything at Mid-Staffordshire was awful. And the worry is that history will repeat itself. That the new CQC will award a five or four star rating to a hospital, or whatever, and it will then be found to have something dire going on somewhere within it and the credibility of CQC will be undermined all over again.

The truth is that the art of hospital inspection – something the UK has only been at for little more than a decade and in which the approach has already been changed four times – is still in its infancy.

The primary responsibility for quality and safety must lie with staff in the hospital, the boards set up to govern them and those who commission care from them. And quite how to use inspection to reinforce that is a skill yet to be fully developed. We – ministers and society – may be expecting too much of inspection and regulation in the health and social care sector. And if you create overblown expectations they are almost certain to be disappointed.

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