The regulation of health care in England is multifaceted and in addition to bodies such as the Care Quality Commission (CQC) it includes organisations such as General Medical Council, the Nursing and Midwifery Council and the Health Professions Council to regulate individual members of the caring professions.
The CQC was created in 2009 following the merger of three regulatory organisations: the Health Care Commission, better known by health professionals as the Commission for Healthcare Audit and Inspection (CHAI), the Commission for Social Care Inspection and the Mental Health Act Commission. The primary function of the CQC is to regulate and inspect health and social care services in England.
Health professionals such as nurses had been regulated for nearly a century following the Nurses Registration Act 1919 under the General Nursing Council, forerunner to the Nursing and Midwifery Council. However, it is important to stress that before 1997 there was no national policy covering all aspects of safety and quality of healthcare provision in English hospitals.
In 1997, the Labour Government published a white paper, The New NHS, Modern, Dependable (Department of Health, 1997), which concluded that the quality of care provided had been variable and that the service had been slow to respond to serious lapses in quality. The report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary (Kennedy, 2001) showed that some parents suffered the loss of a child when it should not have happened and there were failings both of organisations and of people who worked within them.
The 1997 NHS reforms, which followed the publication of The New NHS were necessary after it emerged, for example, that the death rate from coronary heart disease in people aged under 65 years was almost three times higher in Manchester than West Surrey. Pivotal to achieving these reforms was the introduction of clinical governance, a new system for improving care standards (Scally and Donaldson, 1998).
To ensure that clinical governance was fully embedded the Government established a regulatory body known as the Commission for Healthcare Improvement (CHI, later CHAI), which followed the Health Act of 1999. The primary objective of this first regulator was to offer guidance to NHS providers on clinical governance. After 2003, when CHI became part of the Healthcare Commission, a more formal role of inspecting NHS providers, assessing their performance against national standards was implemented. Additionally, as part of the Health Act and to help in the development of national clinical guidelines and standards the Government established the National Institute for Health and Clinical Excellence in 1999.
Background
In context to the evolution of CQC hospital inspections, the Francis (2013) inquiry report was published in February 2013 and examined the causes of failings in care at Mid Staffordshire NHS Foundation Trust between 2005 and 2009. This report was critical of the role of the Healthcare Commission and the Care Quality Commission, which replaced it in April 2009.
Subsequent to the tragic events at Mid Staffordshire, the CQC was motivated to introduced more rigorous hospital inspections designed to avert future scandals. The post-Francis inquiry CQC inspections became not only more comprehensive but also temporarily longer, typically lasting 3 days.
In contemporary health care, the CQC's primary role is to ensure that hospitals in England provide service users with high-quality care, and encourage them to take steps to continuously improve that care. To achieve this it is necessary for the CQC to solicit data from hospitals on a range of topics, but central to the process is risk-based regulation.
As part of the regulatory process, risk can be explained as the likelihood of a hospital not achieving the outcomes that healthcare policy standards, codes, regulations, etc are designed to achieve. The CQC therefore uses a number of methods to gather, analyse and understand information, to identify the risks of poor care delivery.
Beaussier et al (2018) claimed that the central tenet of risk-based regulation is that regulators should not endeavour to prevent all possible patient harms, but should instead concentrate on controlling those that pose the greatest threat. Hence, the CQC has endeavoured to make its regulatory strategy more ‘risk based’ by targeting hospitals at greatest statistical risk of not achieving required standards. In this respect, the CQC relies on statistical objective data supplied by hospitals and subjective data gathered during inspections. The factual objective data and that which is observed or solicited during an inspection helps the CQC teams to answer five key questions, each of which are given equal weighing:
During an average inspection, the CQC team will typically review a sample of core clinical services provided by the institution, such as surgery, emergency department (ED) and children's and young people's services. The team will award the core service reviewed a rating of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate.
Within the context of the five questions, inspection teams ascertain whether the following fundamental standards developed under the auspices of the Health and Social Care Act 2008 are met:
The CQC inspections teams are made up of individuals who may or may not have a healthcare background and specialist advisers recruited from among experienced registrants from a variety of core services. For example, the CQC team that inspects an ED would typically include an inspector and up to three specialist advisers (an ED consultant, an emergency care nurse specialist and an emergency care charge nurse), all from other hospitals.
Additionally, the team might have access to a specialist adviser with a safeguarding background. This enables the CQC to ensure that its inspection teams are both professionally experienced and proportionate in their adjudication of the relative grading of the services under review.
Furthermore, the CQC also utilises the expertise of service users or carers of people using the services. They are known as ‘experts by experience’ and are invaluable in helping the inspection teams gather the views of patients using services on the days of inspection visits.
It is important to stress that all specialist advisers are trained to fulfil their regulatory role and are fully aware that they are conducting the inspection in real-time, real-life care environments, where patient care takes precedence over any regulatory activity.
Have hospital inspections resulted in improvements?
The new CQC inspection regime was designed to avert future scandals on the scale of the Mid Staffordshire NHS Trust tragedy. The new process was introduced in 2014 and the CQC has seen many NHS trusts make significant improvements. The CQC (2017) considers that strong leadership and a positive open culture have been important drivers of change.
Nurses play a significant part both in hospital inspection processes and in their own hospitals in embracing not only the aspirations of the CQC, but also fundamental standards of care. As with the NMC (2018) code nurses intuitively reflect the CQC fundamental standards in their daily activities of providing excellence in care. Many nurses have been motivated to make innovations in care delivery and see CQC inspections as an excellent vehicle of cascading new and novel approaches to other organisations. For example, nurses working in the elderly care wards at Walsall NHS Trust (2019) have implemented innovatory ‘What matters to me’ boards, which are fitted above each patient's bed to record things such as breakfast routines, favourite pastimes and important people in their lives. Such small changes can have a genuine impact on the quality of care and the CQC is interested in showcasing such innovations.
The initial post-Francis report hospital inspections were grand affairs and were initially announced, ie, hospitals knew the date of inspection in advance. However, researchers from the University of York recently published a paper (Castro-Avila et al, 2019) suggesting that CQC inspection regimes had become complex, costly and overly onerous for hospitals.
The researchers analysed data from 150 hospital inspections and, in particular, the rate of falls and pressure area breaches that subsequently occurred. They selected falls and pressure ulcers as being good indicators of safe care delivery, and the data appeared to show a decline in these indicators following inspection. This was attributed to staff being pressured both before and during the inspection process. The paper concluded that less resource-intensive approaches should be used by the CQC to allow staff to focus on the task of making and consolidating improvements.
However, the CQC has disputed these findings, suggesting that to cite falls and pressure area breaches from data generated over 5 years previously may actually be a result of improved risk management and a stronger learning culture in hospitals (Bodkin, 2019).
Conclusion
The CQC has already modified its inspection processes: many hospital inspections are now unannounced and specific core services are targeted for assessments of compliance with fundamental standards of care. There has to be a fine balance between those who inspect and those who are inspected. It should be stressed that it is primarily nurses and registrants from other hospitals who act as specialist advisers for the CQC in its adjudication of how well a particular hospital is faring in maintaining and improving care standards. Therefore, nurses have nothing to fear about a hospital inspection because it is not they who are being inspected but the service as a whole.
Nurses should seize the opportunity of a CQC inspection to showcase their ongoing achievements to put the memory of the failures Mid Staffordshire behind them.