CQC response to the Government's White Paper, Building a National Care Service

Dame Jo Williams, CQC chair, said:

"The White Paper is an important step in beginning to address the need for a fairer and more consistent approach to meeting people's care needs. We welcome the emphasis that it places on personalised services and the importance of listening to service users and their families.


"We have been arguing for clear national standards for people's entitlements to care, no matter where they live, and that their assessments of needs should be portable if they move. In our State of Care report in February we called for a fundamental culture shift in health and social care to achieve joined-up services and give people more choice and control and support their independence."

New fees consultation launched

A consultation looking at the fees scheme for independent healthcare and adult social care providers to be registered under the Health and Social Care Act 2008 from October 1 this year begins today.

Feedback on the interim scheme, which will last for six months from the start of October until the end of March next year, can be submitted until 16 June 2010.

Please take the time to consider our consultation document and let us have your feedback.

We will publish our final plans later this year.

Find out more infomation about our consulation:

http://www.cqc.org.uk/getinvolved/consultations/interimfeesscheme.cfm

Ambulance trusts make infection prevention and control a top priority

Read the first edition in our new Regulating for better care series.
This series looks at high quality care and improvements in health and social care following action by CQC.

The first edition focuses on improvements made by Ambulance Trusts after infection prevention and control inspections by CQC.

As part of our unannounced infection prevention and control spot checks at over 200 NHS providers in 2009/10, we have inspected all 11 NHS ambulance trusts for the first time. Of those 11 trusts:

- four didn’t comply with the required government regulation
- six had areas for improvement.

However, Trust leaders told us that once they were aware of problems, they were very eager to change. We followed up at all 10 trusts where we had made requirements and our assessors were satisfied with improvements made.

Read the full story, including case studies on three ambulance trusts which turned their infection prevention and control around:

http://www.cqc.org.uk/newsandevents/mediacentre.cfm

Survey of NHS staff 2009

We have published the 7th annual survey of NHS staff. It provides trusts with information about the views and experiences of employees that can help to improve the working lives of staff and the quality of care for patients. Almost 290,000 NHS staff were asked for their views on working in the NHS in October 2009 (fifty-five percent responded).

The purpose of the survey is to collect staff views about their experiences of working in their local NHS trust. The results are primarily intended for use by NHS trusts to help them review and improve working experience so that staff can provide better patient care, and all trusts have been provided with their individual results.

CQC will use the results from the survey in a range of ways including:

- setting out national findings
- informing patients and the public of trusts’ results
- using the results in regulatory activities such as registration, the monitoring of ongoing compliance, and reviews

The Department of Health will also use the results to inform commissioning, service improvement and performance measurement, and to review and inform NHS policies.

Find out more:

http://www.cqc.org.uk/usingcareservices/healthcare/nhsstaffsurveys/2009nhsstaffsurvey.cfm

Care Quality Commission welcomes new addition to board its

The Care Quality Commission (CQC) has today announced the completion of its board, with the appointment of non-executive board member John Harwood.

John is a former senior civil servant and local authority chief executive. He retired in 2008 from the Food Standards Agency where he was the chief executive. He served for almost twenty years as the chief executive of Lewisham Borough Council and of Oxfordshire County Council. In 2000, he moved to central government to be the founding chief executive of the Learning and Skills Council. He spent 2004 as the interim chief executive of Cumbria County Council before later moving to the FSA.

John Harwood said; “I am very pleased to have been asked to join the CQC board. The Commission has a vital role to play in improving and maintaining the quality of health and social care across the country and I look forward to working with colleagues on the board and in the executive team in facing the challenges ahead over the next few years.”

Dame Jo Williams, CQC’s acting chair, said: "I welcome the appointment of John to our six-strong board. He will bring a great deal of knowledge and experience of local government and regulation to this important role and help us to push ahead with the Commission's ambitious programme of work to improve health and social care services."

The five non-executive board members already in post are:

· Jo Williams (currently the acting chair of the CQC);
· Kay Sheldon;
· Olu Olasode;
· Professor Deirdre Kelly;
· Martin Marshall;


This appointment has been made in accordance with the Commissioner for Public Appointments Code of Practice

All appointments are made on merit and political activity plays no part in the selection process. However, in accordance with the original Nolan recommendations, there is a requirement for appointees’ political activity (if any declared) to be made public. In this case John Harwood has declared no political activity or ministerial appointments

John Harwood is appointed to serve from the 4 March 2010 to the 3 March 2014

His remuneration for the role of board director is £7,752 per annum, plus travel and subsistence expenses

CQC prosecutes Yorkshire-based mental health hospital operator

The operator of the Yorkshire-based mental health hospital, Linden House, has been ordered to pay £17,015 in fines and costs relating to breaches of the Care Standards Act 2000.

At Beverley Magistrates’ Court on 2 March, Linden House operator, Care Principles Limited, pleaded guilty to five charges relating to the administration of medication.

The Care Quality Commission (CQC) brought the case against Care Principles, which manages the low to medium-secure hospital in Market Weighton near York.

The charges relate to evidence CQC collected at the hospital during unannounced visits in September 2008.

Despite on-going issues largely being rectified since they were found, the company was prosecuted over its failure to provide the minimum legal standards of care.
CQC senior enforcement manager Tim Weller said:

"We are encouraged that the standards of care for patients at Linden House have improved since legal proceedings against the operator started, although it is disappointing that legal action was required before standards were addressed.

"We hope the quality of care for these vulnerable patients continues to improve and will be scrutinising the services at this hospital for the further improvements we expect to see."
CQC had previously found minimum standards were not being met at the hospital in relation to issues including staffing levels, observational levels and suicide/self harm audits were not being completed. The regulator notes improvements have been made in these areas following a regular inspection programme.

Linden House provides services for patients with a learning disability and for patients detained under the Mental Health Act.

CQC comment on Panorama programme

With regard to the Panorama programme on BBC1 on Monday 8 March, Trust Us - We're an NHS Hospital, a Care Quality Commission spokesman says:

“This programme highlights some important issues. It is essential for NHS trusts to provide clear and accurate information about their performance, not only to the regulator but also to patients and the wider community they serve.

“We would stress that it is a trust board’s responsibility to ensure that the organisation is providing quality healthcare. That is why trusts’ assessments of their own performance are an important piece of the jigsaw when it comes to building a picture of performance across the NHS.

“But we would also emphasise that we do not just accept any assessment by a trust at face value. We rigorously check their declarations against hundreds of other sources of information, not least the views of patients, and we carry out spot checks if we feel it necessary. Indeed, as the programme shows, it is our follow-up inspections that have highlighted discrepancies between the trusts' own judgements and their actual performance as assessed by the commission.

“We should also point out that the reasons why trusts may declare inaccurately can vary – in some cases they are not as clear as they should be about what they need to do to meet certain standards.

“It is important to understand that the assessment process is about to get tougher. From 1 April, NHS trusts have to register with the regulator for the first time, and must meet new essential standards of quality and safety. At the same time we are moving to a new system of assessment that will be even more rigorous for the NHS. We will be using our data sources to monitor trusts' performance on a continuous, even day-to-day, basis, and we will have the flexibility to carry out unannounced checks whenever we feel there is a particular concern.

“In terms of the specific cases raised in the programme, we have had extensive dialogue with the Panorama team. As part of the registration process, we will take account of all the information highlighted in the programme. The outcome of all trusts’ applications for registration will be published in the next few weeks.”

CQC statement on the Radcliffe Hospitals NHS Trust announcement of a temporary suspension of paediatric heart surgery

Yesterday the Oxford Radcliffe Hospitals NHS Trust announced that it would temporarily suspend paediatric heart surgery at John Radcliffe Hospital. This follows four deaths since late last year. The trust has commissioned a review of the deaths to determine if there are problems with the care and treatment provided.

CQC last night released the following statement...

A CQC spokesperson said: "We will monitor this situation extremely closely. It is reassuring that the trust has taken action to ensure the immediate safety of patients. This is high-risk surgery and the trust is taking the right steps in conducting a review."

Also of note...

In 2007, the Healthcare Commission conducted an investigation into cardio thoracic surgery for adults and made recommendations for improvement. "... the service that the trust provided for patients requiring CABG, while not currently unsafe, lacked some key components of a high quality service."

The investigation report is on our website under publications from previous commissions:
http://www.cqc.org.uk/_db/_documents/Oxford_Radcliffe_tagged1.pdf

The trust's action plan:
http://www.cqc.org.uk/_db/_documents/Oxford_Radcliffe_investigation_Action_plan.pdf

Cynthia Bower Lecture, 2 February 2009 at Green Templeton College Oxford

Transcript of a lecture given by Cynthia Bower on the 2 February 2009 at Green Templeton College Oxford

Andrew Dilnot:

Okay ladies and gentleman why don’t we … why don’t we get … why don’t we get going. It’s great to welcome you all here to Green Templeton this evening for the chance both to hear from Cynthia Bower and to hear a little more about the Health Experiences Institute. I’m … I feel as though I know a lot of you but I’m Andrew Dilnot and I work at St Hugh’s. I was wondering why I was here tonight and the reason that I’m here tonight, which will be the reason that most of us are here tonight, is that Ann told me to come. But you know I was thinking well why, what was it which, which of the many reasons that Ann might of told me to come was it? And who knows? But I am a Pro-Vice Chancellor in the university. There are many Pro-Vice Chancellors and I’m one of the dysfunctional as opposed to functional ones. But I’m very happy to be here as a Pro-Vice Chancellor of the university because this kind of initiative is exactly the kind of thing that the university feels so passionately about, the seeking out of wisdom in ways that bring together insights from many disciplines and do it in new ways and ways that are possible because of the concentration of excellence in different ways that we have here in this city and university. This is the first in a whole series of events that are planned to help get the Health Experiences Institute off the ground and give more people the opportunity to hear about the ideas behind it and the progress that’s been made already. You’ll hear more about it as the evening progresses. You’ll have on your seat a copy of this, which you can read, mark and inwardly digest later on which sets out a little bit more about what’s going on.

It is an exciting thing to be doing. You might think why at this stage in the economic cycle would anybody think of trying to get a new institution together. Well, it’s always good to give opportunities for the really wealthy to serve in ways that can make a big difference for the population at large.

Health and illness, but health grows more and more important. One of the characteristics of societies as they grow richer is that alongside the increase in welfare, increase in opportunities, health absorbs a larger and larger share of our national economy in every developed world. And there is no reason to think that that will decline, And not only is that true at the level of the economy and therefore at the level of government but at the level of the individual. Almost all of us are touched in one way or another anxieties about our health or anxieties about illness. As technological progress and medical science goes forward there’s more and more that can be done and yet there’s a growing awareness that the person to whom all this is, this is done isn’t always as integral a part of the decision-making process as she or he should be. And one of the crucial insights of the work that Ann and her colleagues have done over many years has been the need to integrate the patient experience of both health and illness to find good ways of expressing that experience, of sharing that experience with other potential patients but also with policy makers and clinicians. The clinicians and the policy makers have traditionally been very good at doing their own jobs but they haven’t always taken as much account as many of us think they ought to of the experiences of patients and potential patients. And it’s in trying to bring those groups together the Health Experience Institute offers such an opportunity for really exciting, new institution in this place.

You’ll hear much more about that later on. I hope there will be many useful conversations over dinner about it and over the next few months. It won’t be easy to get this institution up and running, it won’t be easy to find the donors, it won’t be easy to find the institutional structures that allow a college and many departments to work together. It’s never easy to make multi-disciplinary work really successful. But it’s pretty clear that this is an area where we have to do that and given the momentum there already is, I’m confident that will happen.

Now, we’re very lucky this evening that we have Cynthia Bower here to speak to us. Cynthia has had long experience in various aspects of health care in the UK, much of it in Birmingham, a city which given that I’m a Principal of St Hugh’s, which is only just south of Birmingham, I feel close to affinity to. I also spent a happy couple of months, I think in 1995, 2005, or 2006, making a film about the NHS largely based in the university hospital there when Mark Britnell was Chief Executive, so I’ve, you know, I’ve seen some of the patients on whose behalf Cynthia was purchasing activities.

For the last little while, Cynthia’s been the Chief Executive of the Care Quality Commission. Now, this is a relatively new thing for Cynthia and it’s a pretty new thing for this country. It relates centrally to some of the issues that HEXI will be interested in, is interested already. It’s not a seat that I would happily choose to sit in even if Dr McPherson told to me to, but I’m very glad indeed that Cynthia, although of course I’d do it if she,

[Thank you very much]

Cynthia Bower:

Thank you, thank you, thank you, thank you. Thank you. And I was reflecting earlier on this evening what an enviable job I have in bringing the NHS into registration at this particular time in the political cycle, and trying to introduce to the NHS, or indeed introduce into the NHS a completely different regulatory model. And, and I will say something about that this evening because, partly because what I want to say about how we engage patients and service users, as I’m learning to say, because of course we will be the regulator of both health and social care in England. So I have to get my terminology right. But how we regulate health and social care and how we engage people who use those services and indeed patients in that process is very central to what we’re trying to do as a regulator and so I want to reflect on, a little bit about how we’re organising the task as I address the questions you’ve asked me to look at to, this evening, which are essentially about the user voice in the NHS or in patient care.

And I think as I was looking through my notes this afternoon and thinking about what I was going to say, I thought well what’s the central proposition really that we’re struggling with and I think it’s always the same one which is how we leverage change in the, in what’s undoubtedly the most complex environment you could choose to try and generate change within, which is the NHS or indeed any health care system. And how the notion of having a stronger, a stronger user voice is culturally becoming ubiquitous. It’s the issue that you have to address no matter where you’re talking, not just in the public sector. And how we respond to that and how we deliver on that to the satisfaction of people who are using services is a very complex issue of course. You all know that better than I do. And there’s no simple way of doing that. So, anyway, that’s the proposition so you can now fiddle with your Blackberry’s or do whatever else you’re, you might feel inclined to do. Or if you reflect on why you’re here too, and I’m reflecting on that myself. I suspect it’s because Ann told me to be here as well.

So I’m going to, one of the things we have to do as a regulator is that we have to publish a state of health and social care report. We have to produce that for Parliament every year and as luck would have it amidst this sort of febrile atmosphere around the election, it’s next week have to produce this annual state of the care report and so one of the things that I did was I just randomly pulled out a few statistics about what people were saying about their care. And so I’m going to read these but I’m going to try not to read very much. And I took the opportunity of not bringing overheads because I never speak, people take the trouble to write them and then I never speak to them anyway so it’s not that useful.

Anyway, so here are the things I’m going to read:

29% of disabled people using social care services thought that they were not communicated to in a way that helped them understand the things properly.

47% of people recall being offered a choice in hospital for their first out-patient appointment. And improvement from 30% in 2006.

Almost half of adult in-patients using acute health care said they were definitely not involved in decisions about their care as much as they wanted.

And 27% of people suing acute mental health care were not as involved in their care as they wanted to be.

So from my point of view that just about sums it up. We get a very mixed picture if we ask people from surveys. If we ask people about how involved they are in their care and how able they are to make choices. Another thing that I pulled from the in-patient survey which is one of the things that we do, was 1 in 4 patients said that doctors had talked about them as if they weren’t there. I’m sure this is something we find impossible to believe but apparently it does happen. And 1 in 3 people said they didn’t always understand the explanations they were given by the nursing staff when they asked for explanations about their care. So I do think there’s still in the most simple ways in which we engage people, before we get onto Web 2.0 or anything else exciting that we might want to talk about in terms of the engagement of people who use health and social care, we’ve got to think about some of the fundamentals of how people feel engaged in those processes. And I’m sure all of us who have, who’ve been through the health care system ourselves recently or have members of our family or close friends who’ve been through it would describe similar experiences to those of being talked about or not explained properly or whatever. So there’s still some distance to travel on all of that.

So I recently gave a talk to a private health care provider conference, it’s one of the things that I, I do get invited to these very luxurious events that the private sector arrange and one of the things that they asked us to reflect on for that was what did we think patients wanted from them. So we did a bit of work beforehand to think about that and I came up with I think five things that to me, that I could extrapolate from the work that we’d done. And I think that the first thing was, is that patients, people want assurance about quality of services. And again that might be a very obvious thing to say but I think one of the things that is clear from the work that we’ve done is that people, patients don’t necessarily want to have to take responsibility themselves for making choices based on the quality of care. They want to know that assurance systems exist so they don’t have to make those decisions about quality that actually they can take that quality for granted whatever other choices that they might choose to make in the system.

They want a good experience of care as consumers and a sense that their care experience within the health system should be similar to their experience as consumers anywhere else in, as they go around their daily lives. And of course it’s very different.

They want to feel that their care is joined up – and these are going to be some of the things that we talk about in the state of care report. And I don’t necessarily mean health and, between health and social care, but that is very interesting. But, again, when I was in the region, in the West Midlands region and we did some work around Lord Darzi’s report. What, I can remember talking to the clinical staff who were engaged in that process and we said to them why is it, you know, a lot of the time that people, patients are complaining that they don’t understand the care pathway, they don’t understand the care pathway and the clinicians were saying to us, well we don’t understand it. You know, we understand the bit that we do but a lot of the time we don’t’ understand, so we’re not in a position to reassure patients about those basic things about their care because often people come, you know, we know the five things that we’ve got to do and people move through the system and we often don’t know from where and to where.

People want care to be centred on their needs with the right degree of customer focus and to be treated with dignity and respect.

And last but not least, I think that, and it is fantastic to see the way in which the public, I mean I was looking at some work that MORI had done on patient, the public’s attitude to the NHS and there’s these, still these stunningly high satisfaction rates with the NHS which are extremely gratifying for those of you who are currently involved in delivering NHS services. But I do think that people’s sense of the health care system really being modernised and moving forward is still, won’t ever really move forward unless they can see older adults being treated in a completely different way by the health care system. And I think you only have to visit emergency medical wards, see elderly people admitted in emergencies, see the struggle often around discharge arrangements for them. One of the little preview of the social care report, one of the things that we’ve calculated is that if the best discharge arrangements in the country were duplicated everywhere in the NHS, the NHS would save two billion pounds. So there’s a lot of people’s experience of this as a modern patient-centred, user-centred, fast access system the way that we know that people want to see it is nevertheless mediated when we go and visit our elderly relatives in hospital and see the way in which they are often treated by the system.

So I think that there remain some challenges still if we’re going to develop a system that really does feel responsive to what people are saying they need.

Okay, so now I need to do the little advert for the Care Quality Commission. Well, the Care Quality Commission is a regulator the like of which the NHS hasn’t seen before. And I can say that without, in all, with all due modesty because it is a departure from the previous system, the Health Care Commission has some quasi-regulatory functions in relation to the NHS but it wasn’t a regulator in the way most people understand it. The Care Quality Commission is a licensing body for the NHS and so that’s a complete departure from the previous system. The powers that we have are set out in the 2008 Act.

So we’ve required people to do all sorts of interesting things but Parliament haven’t quite got round to passing the right, the affirmative regulations that will actually, but we have every confidence that they will come into existence before the `1st April. Now what the legislation has given us is 16 high level quality and safety standards that will apply across health and social care. And I think it is important within this, the context of this debate that you’re promoting and taking forward this evening because they are meant to be about enduring standards of care. They, I mean, I think where the regulator has to pursue whether or not the Oxford Radcliffe has hit the 98% A&E target, I think is not necessarily the most significant thing that the public want from the regulator. The public want the regulator to say that there is a level of safety and quality of care that we can reassure you, I don’t know if we can ever say we guarantee you, but the system is there to assure on that levels of safety and quality are there across health, social care and the independent sector, the voluntary sector, whoever is providing health or social care has to meet these essential high standards of quality and safety. And they are, they’ve got, I’ve written the list down because I always forget them because people ask me, but they’re things like, you know, are patients properly engaged in their care? Do you have proper complaints procedures? Are, you know, has the Board assured itself of the safety of the services that it receives? So they are very high level statements that we’ve brought down into six different areas and they are:

Involvement and information;
Personalise care, treatment and support;
Safeguarding and safety;
The suitability of staffing;
Quality and management; and the
Suitability of management.

And the suitability of management is virtually there because of social care, because we have to register managers for social care, although I know there’s a debate going on about the regulation of managers in the NHS as well. But no-one so far told us that that’s going to be part of our responsibilities if indeed that comes to pass.

So we are trying to move to a regulatory system that describes the quality of care that you should be receiving rather than describing inputs and processes. I mean, one of the things that I’ve been doing signing off people’s appeals against their annual health check rating over the last few days. And the letters go to 10 pages some of them, as we say well standard 10-3-R-Z/12 requires you to provide the following information. I mean, and we are absolutely trying to move away from a system that is about assuring processes. And I mean, I’m not being disrespectful, I think the Health Care Commission did an enormous amount to take forward issues around quality and safety in health care, but we are trying to move to something that is sensible for people who use services that they can understand is, seeks to directly speak to their experience and what their expectations would be of what care should look like.

The other thing that we’ve done is we’ve have to produce this elegantly titled documents called ‘The guidance about compliance’. And what, and that essentially tells providers how they’ll know whether or not they’ve met these 16 high quality standards. And we’ve expressed them all in terms of outcomes for patients. So, if you hit this standard the patient will experience this. So we’ve tried, in producing the guidance for people, to say this is what your end-use should experience if your care, if the care is good enough, if the care meets this standard this is what it should feel like for people who use that service. And we’ve produced as well a judgement framework for our staff and we’ve published all this on the web, so that’s all available to anybody who wants to look at it. They’ll see how we make judgements about whether or not organisations have met the compliance that the Act requires of them.

So the way that the system will operate will be this: the provider, you know, what we’ve had is the NHS now, over the course of this year, 27000 providers of adult social care and the independent health care provider will come into the registration system. So once we’ve got over the hurdle of the NHS coming into registration that we then have to register 5000 providers a month against the new standards in order to get the independent health care sector and adult social care into this model at the same time. But the provider says, “Yes I am compliant” and the Board of the NHS trust or whatever says, “Yes we are compliant. We believe that we meet these essential standards of safety and quality”. And then it’s our job to understand whether or not we think you’re compliant. What information do we have that would lead us to believe that you are or you are not compliant with that? And we’re developing something that we’re calling a Quality and Risk Profile and within that we will garner, into that we will put as much information as we humanly possibly can about the service provider. In the case of the NHS there’s an enormous amount of information we know about the NHS, every in-patient episode generates literally hundreds of pieces of data, we have interesting outfits like Dr Foster’s Imperial generating mortality information, but most particularly within the context of this debate we are trying to find ways in which we can garner the views of people who use services and their carers in a more imaginative and interesting way. And I mean, we’re, and I’ll come back to that in a second but increasingly we want the Quality and Risk Profile of every organisation to be, to contain within it information about what people who use those services think about that service and what carers, their carers think about that service. And, as I say, I’ll come back a little bit more to how we’re going to do that.

Now, on the basis of that, my assessors, the 1000 staff we’ve got to, our fieldwork inspectors of services will make, have to make an analysis of the risk. So are we getting information through that tells us that this, there is a risk that this organisation is not compliant with these standards. And, again, I would, one of the things that we’re trying to build into that model is information from patients, if patient groups are saying, “We are really unhappy with this organisation” or, you know, “This hospital is filthy,” or, “The quality of this particular service isn’t good enough”, that that trumps other information that comes into the system, so that we build a system that takes as much notice as we possibly can of what users of the system are saying about it.

Now, we then have to take a range of activities in response to that risk, and I’ll come back to that a little bit more as well. But in what we’re going to do is essentially, where we all go out and do inspections which of course we won’t do all the time, we can ring up the Chief Executive of the Trust and ask them what they think about the information we’ve got. We can talk to the PCT if they’re a commissioned body. We can talk to the Local Links, we might talk to the Overview and Scrutiny Committee, we can do a whole range of other things. We can talk to SHAs. But we might go out and do an inspection and our inspections will be based wholly on observing patient care. So we’re trying to move away from a model of assurance which is about looking at the information that an organisation is capable of, you know, I mean I can remember I was Trust Chief Exec in the days of CHI, those of you who can remember that and you used to dread the CHI visit. You used to dread your name coming up, didn’t you, on a list that they published saying they were coming to look. And what they did was they audited your assurance processes. They made sure that your clinical governance sub-committee had had the right number of discussions about your arrangements for blood transfusions or whatever it might have been that it was deemed to be required.

Now, I’m being, I’m sure it was more complicated than that but our, we’ve tried to move away from that completely and to say that all our inspection visits will be based on observing patient care, talking to patients, talking to front line clinical staff and we’ll only move into some sort of Board assurance process if we remain dissatisfied with the quality of care that we’re seeing. And from social care, because a lot of their work, because there’s very little data that’s available from social care, a lot of their work’s always been based on inspection and they’ve got, they’ve developed excellent tools, short observational tools that assist them in doing things like observing the care of people with dementia, people who are not able to comment much about the quality of care themselves. So looking at things like interactions between patients and clinical staff. So we are attempting to put into the regulatory model that we’re developing much more focus on observed patient care and patients’ view of care rather than paper-based assurance systems which do give Mr Nicholson the heebie-jeebies. He thinks that the, David Nicholson, the Chief Executive of the NHS is very, very nervous that this is going to be ‘Produce your 17 lever arch files of Board minutes to demonstrate to us that you’ve talked about everything in the requisite number of times”. Well, that’s absolutely, as far as I’m concerned, I mean, if in the end there’s a crisis in the system then you would have to look at how a Board has assured itself. But that’s not the model that we’re looking on.

Now, from our point of view there are three main routes to the user voice, from CQC’s point of view: there’s what we can do to drive responsibility from the provider’s point of view. And I mean, I know, that most providers don’t need any encouragement to do that. They’re conducting local service, I mean, I know there are issues about the annual patient survey but people are conducting their own local surveys, often bedside information collected from patients, having very robust complaints procedures, developing their own web activity, developing more sophisticated ways of getting feedback from their own staff. And a cultural shift within organisations away from complaints and dealing with complaints and looking at feedback which might be more off the cuff, more instant, more based on positive as well as negative information. But too many Trusts, I think, in our experience still rely on very formal complaints procedures. So, from my point of view, one of the things we will be looking at to make judgements about the risk or otherwise that organisations might not be doing what they need to be doing is to see how lively that environment that the provider has of active feedback from people who use their services.

I think the other thing that we want to be part of and many organisations, particularly voluntary organisations are already doing this, is to stimulate the public to engage more broadly in feedback and to lead opinion. And whether that’s through web activity, things like campaign, I mean, I mean I hesitate to use these words because they still mean very little to me but I understand it’s not a generational thing it’s just a thing. You know, but things like Facebook, Twitter, you know, campaigns, I mean I’ve been reading in the Evening Standard on the way up about the Facebook campaign to get rid of John Terry the England captain, but I mean the campaigns and dialogues can get going very, very, build up very, very rapidly on the web in all sorts of ways. Well, we can put ideas out there and encourage debate about what people think of the care of older people in hospital or what they think about maternity service in a particular area. We can do it through the local press, we can do it through the national press. So, we think part of our responsibility in this arena is to stimulate public engagement and activity in all of this.

And, last but not least, we are responsible for trying to capture the user voice through our regulator information and I, our regulatory activity. And I’ve referred to some of that but I’ll just quickly go, I’ve completely lost track of time, because I this evening, I’ll bring, I’m doing all right for time I think, and you’re still awake which is always a good sign. Nobody’s run for the door yet. Okay.

So, I mean, we, so what do, what routes do we have for the user voice. Well, one of the things is we do do surveys. Now, I mean, whether or, I mean we do, we have robust sample sizes, we use a recognised methodology, it’s snapshot information, it’s only a particular time. I know that there’s mixed views about the patient survey work that’s done at a national level but nevertheless, and it’s certainly a very expensive one. But nevertheless those surveys do feed people’s views of what’s happening in the NHS and I would be reluctant to see those national surveys go. Nevertheless in social care they’ve got a very limited potential. We get, we do spend a lot of time sending out surveys to social care users and we get, particularly for older people we get very, very poor returns, it’s not a great way of doing it.

We will, we are exploring using our own, putting our own opportunity on our website to comment on local health services. And although it sounds like an easy thing to do, and I get an enormous number of emails from members of the public. I mean, where, how they track me down I’ve absolutely no idea, but they absolutely do and I get a huge amount of people who email saying, “I am sitting in the Oxford Radcliffe”, I did actually have one of those, “I am sitting in the Oxford Radcliffe and I’m thinking this about the quality of service, Miss Bower. What are you going to do about it?” Or, so I mean it’s very exciting, it’s real time, it feels very modern, it’s a sort of thing our children would encourage us to do at all times. But I mean I think if we, and we will have to do. There is absolutely no question about it that I think CQC will either have to do it or be a portal to someone else’s way of collecting data. But I think it brings with it it’s own problems. It raises expectations from the public about what action you take off the back of all of that.

I mean, I was reflecting when I was thinking about this that if you look at, I don’t know why I’ve suddenly started looking at football on the BBC website, I think it must be my age or something, I can’t work out. I mean, I’m not a great football fan but if you look at it there’s, as matches are going on people are commenting constantly about the match. And I don’t imagine when they do that they think that on Monday morning the chairman of the Football Association is going to email them and say, “Thank you for your interesting comments about the quality of the refereeing”, you know, “when Arsenal played Manchester United on Saturday”, but nevertheless you do set up expectations from people that they are going to get feedback if they start to make comments. And they want to know what’s going to happen. So we’re trying to do an end to end piece which says, well, you know, if somebody does comment about the Oxford Radcliffe well then what, how then does that get fed through into systems and, you know, does our local assessor, how does our local assessor pick that up and what weight do you give to that, you know, view as opposed to a patient survey that’s telling us everything in the Oxford Radcliffe is marvellous. But I mean it’s undoubtedly the case that we all have to get our heads round that sort of more immediate and real time feedback.

We’re also going through traditional routes. We’ve developed proforma for people like Links and the Overview and Scrutiny Committees, other advisory groups to feed information onto our website through our, and to become part of our Quality and Risk Profile. So formal organisations can feed information that we, will become part of our risk profile of organisations. And we’ve set up advisory groups for both providers and we’re about to set up a user advisory group and we’ve got 2000 providers in our virtual provider group so, you know, there’s no lack of people who want to give us feedback. We have a thousand staff out there in our field force and they are absolutely as far as I’m concerned an enormously significant part of our understanding of what the user’s saying about services. Particularly in social care, but increasingly I hope in health care as well. So, our own field force staff and the observational tools that they use will become a very rich source of information about what’s happening in organisation.

We have, we use experts by experience as they’re known so many of our inspection visits, not as many as I would like but a large number of them, people who use services accompanying us so even at one extreme ex-detained patients will go on visits to detained patients within secure mental health facilities for example. So we try and use people, people with learning disabilities is a good example. We try and use people who use services to accompany us on our inspection visits and they are very, very good. I mean, I had fantastic account from an ex-detained patient the other day, talking about visiting a secure mental health unit and saying, you know, she noticed that the laundrette wasn’t working, the laundrette had broken down and the inspector walked past and she said, “Well if you’ve lived on a secure unit and the laundry isn’t working, I’m telling you, you know, your life is, I mean, not only is it very difficult but the nursing staff spend all their time going off the unit to sort your laundry out somewhere else in the hospital.” And so she gave me this in time narrative about laundries in secure units which, you know, not many people would necessarily pick up what’s a huge issue for her in terms of her experience.
So our field force will increasingly use people who have experiences of services to go with us on inspections. In terms of going back to the Quality and Risk Profile and how we pick up soft intelligence, I mean, we do, the Health Care Commission invested in some web spiders, you know, like the Google web spiders and they trained them to look for health care associated infection, information about health care associate infection, it’s very interesting. And so one of the things that we’re able to do is pick up information so if, you know, the Nuneaton Gazette, people are endlessly writing in saying, “This hospital is filthy”, then we will spot that because we have much better ways that Google, much more sophisticated tools than Google have to find that information. And increasingly we intend investing in that sort of software so that we can search websites, blogs, whatever it is that people have the time to do this sort of thing do to search for soft information about the quality of care. Because we are in a position whereby the amount of soft data out there about people’s experiences far, far outstrips anything that human, I mean, the Health Care Commission used to have people employed to read the newspapers to look at, and then try and look at what they thought about that and put that stuff into the system. Well, I mean, you know, it’s a bit sort 19th century so we are trying, we are investing in software that will help us look for key qualitative indicators that say that things are amiss in certain services. And indeed, one of the things that makes me nervous is that we’ve got huge inspection reports, particularly from social care, sitting in our own database that no-one’s ever searched in an authoritative way to look for qualitative information about what might be indicators that are things are going wrong in a care home or in a domiciliary care provider where it’s much, much harder to get quantitative information.
So I assume that over the next few years our surveillance tactics will rival the Homeland Security or whatever they are called, because we can, there are tools out there that we can usually, we can buy to support us in that work, to search for what people are saying about their local services.

And I think last but not least, you know, from my point of view in terms of the organisation that I’m trying to run, ensuring that we have a culture within the organisation that expects there to be a diversity of voices about the quality of care in the service, that respects and encourages multiplicity of views about what’s happening in a particular service. And actually seeks to different views and opinions instead of being assured by particular voices.

So, I think I’ve more or less come to the end of my, what I wanted to say which I think is probably quite timely. I mean, I think that I would go back to the proposition that I set out with. I mean, we’ve, you know, what we’re all interested in, whether you’re the regulator and I make this speech probably more than any other, you know, whether you’re a regulator, whether you’re a front line clinician, whether you’re a member of a Board, whether you’re a carer in a home, you know, what everybody is interested in improving the quality of care. And, I mean, I do, you know, from my own point, I think the regulator’s got a very particular role to play in improving care. I think the regulator’s got to absolutely align itself with the patient voice and in a system where there is power inequality between the provider and the receiver of services, it’s absolutely our job to try, we’ll never even it out but to redress the balance.

So how then in that circumstances can measuring the experiences of people who use services a) become more sophisticated, b) really be used to drive up quality and to work towards the continuous improvement that we all aspire to.

[Applause]