Eleanor Roosevelt, 1958

'Where, after all, do universal human rights begin? In small places, close to home -- so close and so small that they cannot be seen on any map of the world. Yet they are the world of the individual person... Unless these rights have meaning there, they have little meaning anywhere. Without concerted citizen action to uphold them close to home, we shall look in vain for progress in the larger world.' Eleanor Roosevelt, 1958

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Tuesday, 29 November 2011

Has the CQC over-promised?

Just a quick post... I've been musing on the late evidence submitted to the Mid Staffordshire Inquiry by CQC whistleblowers Amanda Pollard (a compliance inspector) and Kay Sheldon (a member of CQC's board).  I think Pollard and Sheldon both have to be commended for their bravery; it is not easy speaking out about an organisation you are still involved in.

As with the evidence of Dr Heather Wood, a former CQC employee who has since left the organisation, there is a great deal to consider in this evidence.  I just wanted to pick up on one issue, which is CQC's promise to inspect all care homes annually.  I've written previously that I was doubtful whether CQC could hit this target on current resources.  Amanda Pollard is a CQC compliance inspector; it is she and her colleagues who will be expected to deliver on this promise, and in her evidence to the Inquiry she stated:
The consequence of this commitement and the change to the way inspections are now being carried out cannot be underestimated. One consequence is that inspectors were told to conduct desktop reviews, rather than visit their providers. My view is that a desktop review is generally ineffective. By way of an example, I currently have a provider where there are a few service isseus. I have been comforted by the fact that the provider is on the local County Council's radar, from their Safeguarding perspective, and therefore they do not require an urgent re-inspection. However, I had planned to go back in to conduct a follow up inspection, but was told by my manager that I could simnply ask for evidnece and review that evidence to see if their responses were acceptable and write a report based on that. 
Playing pass the parcel with the local authority safeguarding team... haven't we been here before?  Would it be sensible, I wonder, if a CQC inspector had clocked the problems at Winterbourne View to make a compliance declaration on the back of a desktop review?  On the basis of paperwork supplied by the managers?

What we seem to be seeing is inspectors being squeezed to deliver targets without a concomitant increase in resources to help them do so.  I've been doing a bit of maths with some data the CQC gave to me under the FOIA.  As I wrote before, the cost per inspection has shot up in the last year - perhaps because of the problems alluded to by Pollard of inspecting against so many outcomes.  But let's estimate that the average cost of a key inspection is £3.73k, as it was in 2009/10 according to a calculation I did that CQC checked for me.  If CQC has to inspect the 18,063 care homes and 5769 domiciliary care services it has registered in 2010/11, then the total inspection cost would be roughly £88.9m.  Well, last year the CQC's total expenditure on social care regulation was £59m, and their total expenditure on inspection was £38m.  So this seems to me to leave a shortfall of potentially 130% in their inspection budget, or 50% of their total regulatory budget.  Given that CQC have only asked for an additional 10% from the Department of Health, I really do wonder if - as Pollard suggests - they have rather overpromised on this target.

To conceive this numerically, let's imagine that CQC get the 10% resource increase they've asked for, and channel this all into adult social care inspection and not other areas in CQC's remit.  So that's 10% of their TOTAL annual budget, which last year was £132.5m, which is £13,252.5k.  Add that to what they spent on inspection last year, £38,432, and that's a total of £51,685k for inspections.  They have to inspect 23,832 services (combining care homes and domiciliary care agencies), so that's an average of £2.17k per inspection.  That's less than a quarter of what was spent per inspection last year - which is admittedly quite an inflated score.  Or it's around 58% of what was spent per inspection in 2009/10.  The only way to achieve this target, it seems to me, is to compromise on the quality of the inspection process itself and - as Pollard suggests - to avoid getting entangled in time consuming follow up work where there are problems.  CQC have said they will no longer be inspecting against all 16 core outcomes every year; I will await with interest guidance for inspectors in helping them decide which outcomes to inspect against or not.

UPDATE: Department of Health grants CQC extra cash, but...
In June Community Care reported that the CQC had sought £15m extra funding from the government to support it in its extra inspections.  Last week they reported that the government had granted them the cash, but it looks as if this will only amount to £10m, not the £15m they requested (and less than the 10% I calculated with above).  CQC appear to be operating in a very unsympathetic political climate.  It seems to me that it suits the government quite well for CQC to take the flack for problems in the inspection regime, but they have only partially fulfilled CQC's requests for further funds.


  1. I wonder what the specific criteria are that trigger an inspector to move from a desk based review to a visit. It would be interesting to know how risk profiles are compiled and maintained.

    Really great to see the costs set out - it is not an area where savings can be easily made. The only way I can see is to get a really detailed inspection audit tool that can be filled in during the visit - thus reducing the five days allowed for write ups.

  2. Yes - I did wonder why there was such a huge leap in the cost of inspections last year. I attributed it at the time to inspection resources being invested in registration, but not being documented as such (the NAO report out today said that the CQC hadn't recorded this issue properly). But reading Pollard's evidence, I also wondered if the new inspection framework itself is just much more intensive. If it's intensive because it's thorough, that's one thing, but if it's intensive because it's a clunky computer system...

  3. Has the time come to see if there are any options that should be considered?

    We offered, as an independent holistic accreditation scheme based in the UK, to give oral evidence to the Inquiry about alternative hands-on based ways of helping to ensure that hospitals and clinics are, and remain, safe and fit for purpose. It is not necessarily a matter of replacing the CQC, but there might be ways of augmenting its activities and effectiveness.

    Sadly we were not invited to speak. I can only imagine they did not have sufficient time to consider looking at the potential options.

    In addition, has the Inquiry looked at how one keeps standards up in private hospitals as well as in NHS hospitals? Patients can come to grief in either and it would be remiss not grasp all opportunities to prevent predictable problems before they happen.