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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Thursday, 23 February 2012

An invidious position

As you may have already heard, the much-maligned Chief Executive of the Care Quality Commission (CQC), Cynthia Bower, resigned today.  I think most would agree this wasn't so much a matter of "if", as when, since her ongoing association with the organisation was reputationally untenable, and likely to be more so once the Mid-Staffordshire Inquiry report is published.  Although I'm no fan of Bower's, I'm not especially optimistic about the organisation's future without her.  The problems for CQC are largely structural and political; it's not that there aren't "personality" issues, rather that the politics will shape the personality that can head the organisation.

A change of leadership won't be able to turn around the juggernaut of a light-touch and poorly-resourced regulatory model.  I do feel that what is missed in the press's feeding frenzy on Bower herself (and Williams, to a lesser extent) is how far the problems at CQC relate to the way it was set up.  A few months ago I watched Labour MP Margaret Hodge cross-examining the CQC's leadership in her role on the Public Accounts Committee, but Hodge herself voted for the legislation that birthed the CQC in its current form.  Like genetics, a statute won't determine everything about the creature it produces, but it does go some considerable way towards shaping it.  The Health and Social Care Act 2008 did not seek to produce a body that could drive through improvements in the sector (so much as remedy failings), did not create a mechanism for handling complaints, and omitted several useful powers that the CQC could have done with to deal with problematic providers.  And the Department of Health - under red banner, as well as yellow and blue - must bear some responsibility for the shape the CQC has taken.  Yet I'm sure they're pretty relieved when Bower and Williams take the flack for a failed regulatory model.

By sheer coincidence, when I read about Bower's resignation I was flicking through the closing submissions of counsel to the Mid Staffordshire Public Inquiry on the CQC.  I really recommend reading this document, it's full of fascinating snippets and detail about the CQC's structure.  I thought I'd reproduce for you what Dame Barbara Young said when asked why she herself had resigned from the position of CEO of the CQC (paragraphs 379-80):
Q. Why did you resign?

A. I resigned for a number of reasons. I actually was looking back on my records yesterday, and at the beginning of September I wrote myself a note saying “Get another job” And I think the reason for that was several fold. One was it was clear to me that the model of an independent regulator, regulating services provided by a government minister, was never going to be a satisfactory model. It was always going to be incredibly fraught, because inevitably both the Deportment and ministers were torn between wanting good, strong independent regulation of healthcare and knowing that if good, strong independent regulation of healthcare happened, from time to time they would be put in the dock and found wanting. And I think that tension worried me not a little. I felt quite able to resist it, but I could see that in resisting it there would be constant conflict and that didn't feel good.

Q. When you say that didn't feel good, that is something that any new chair and indeed the chief executive of the CQC is also going to have to face, isn't it?

A. Absolutely, and generally speaking I'm not a quitter. But the second reason also was a weight in the scales, and that was 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.
I’m a campaigner. I believe that I’m not satisfied with doing a job unless I can demonstrate that I’m doing a good job for the people I serve. And I believed that the people I served were the public. And I had great doubts that I could do that properly, and so I decided I was going to do something else.
The original plan was that I would get another job. There would be an orderly handover process and I'd go. But to be honest, the whole thing was getting so fraught, in terms of the role of the regulator and how we were regarded, and having now been a regulator in three different departments, three different government departments, responsible for three different government departments, the relationship with the health department was by far the worst by an order of magnitude. And I didn't see any way that it was going to resolve itself. So despite the fact I’m not a quitter, I quit.

More emollient people than me would probably have regarded it as part of the normal come and go between the regulator and their parent department. I found it unhelpful and irksome, and  I was very impatient with it, and so personally I think I was the wrong person to do that job. But it was intrinsically because of the way it was set up, reporting to a government minister, regulating services that the government minister had responsibility for, it seemed to me that that intrinsic conflict was always going to be there, and that meant that you probably needed somebody who was much more flexible than me to head up the process. I wasn't sufficiently flexible and smart to do that.

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