State of the nation

The CQC’s ‘state of care’ report aims to be the definitive assessment of the health service in England. Worries about patient safety, the lack of leadership and a pressing need to innovate are all causing concern, but they’re all criticisms that could be levelled at the regulator

Open up a newspaper, turn on the TV or listen to the radio and you can’t escape the stories about a crisis in the NHS. Pick up the phone to your local council and – if you can find someone to talk to – you will hear of a social care system stretched to breaking point.
In stark contrast to all this is the view from Downing Street and the aspirational rhetoric of Simon Stevens, chief executive of NHS England, who, when speaking to the press after securing an additional £6 billion investment from the chancellor, explained how the money will “help stabilise current pressures on hospitals, GPs, and mental health services, and kick start the NHS Five Year Forward View’s fundamental redesign
of care”.
So, just what is the current state of the NHS? Helping us to make an informed judgement is the Care Quality Commission (CQC), who in October published its annual ‘state of care’ report The state of health care and adult social care in England 2014/2015. Bringing together the results of all of its inspections between April 2014 and March 2015, the 112 page document aims to be the definitive report on the health service in England.
It’s fair to say that the CQC doesn’t currently enjoy the best reputation, with MPs at the Public Affairs Committee recently branding the organisation “not yet an effective regulator”. The Committee noted some serious problems, highlighting a lack of staff and late and inaccurate reporting the Committee’s chair, Meg Hillier openly claiming the CQC has an “alarming lack of attention to detail”.
Recognising concerns over its performance, the CQC introduced a whole new assessment regime in October 2014, supported by a complete new set of ‘standards of care’. These standards assess five different areas, ensuring that they are: safe, effective, caring, responsive and well led. Organisations are graded on performance in all of these areas, with the CQC deciding whether they are outstanding, good, require improvement or inadequate.
Between April 2014 and May 2015 assessors visited 47% of acute trusts (including hospitals, trusts and mental health organisations), 17% of adult social care services and 11% of GP practices.

Guessing game
By its own admission, in the first year of its new regime the CQC is targeting those it has had concerns about, stating that “we chose the services for early inspection based on risk”. As a result of this and the changes in inspections it is impossible to accurately draw any overall picture of performance and to compare the ratings of organisations with previous years.
When asked where the system is facing the biggest issues, Dr Devin Gray, CQC clinical fellow, said: “London tends to have a higher number of inadequate practices than elsewhere in the country. However, we won’t have the real picture of performance across the country until we have completed this inspection cycle.”
As a result of the new inspection regime the report includes no geographical breakdown or analysis on any of the key indicators. Inevitably, local commissioners will know of local failures and those particularly worried or concerned could identify failing health organisations by searching through the CQC’s website, but it’s questionable whether they should need to do so.
So how should they use the report? “Commissioners can review the ‘state of care’ as well as inspection reports to help them better understand what we are finding to be working well for patients as well as where we think improvements need to be made,” adds Gray.
The CQC is keen to point out it works with – not against commissioners. “While we don’t regulate CCGs [clinical commissioning goups], we’re working towards the same goal, which is helping people to get safe and high-quality care,” says Gray.
The report makes interesting reading for those familiar with the CQC and the NHS but for those on the outside, the lack of any information on where the CQC has been is likely to leave the reader scratching their head and unable to draw any conclusions.

Better, safer care
Overall, the ‘state of care’ report strikes a positive note, with 71% of all services inspected rated as good or above. Across the health service, patient safety is the biggest area for concern, with 6% of primary medical services, 10% of social care services and a worrying 13% of all acute services rated as inadequate or requiring improvement.
When asked about how primary care specifically is performing, Gray is positive. “We are delighted to find that most (85%) GP surgeries are good or outstanding, and we’ve also identified some examples where doctors have gone beyond their duties to support some of the most vulnerable people.”
The CQC is very keen to show its growing teeth, explaining that 7% of inspections have resulted in enforcement action (compared with 4% in 2013/14). This action itself – and often the resulting publicity – can act as a drive for change. The CQC boasts that in half of cases, those services inspected improved after six-months. Depending on your viewpoint this is either a success or a failure.
Failures don’t come much bigger than that of Addenbrooke’s Hospital in Cambridge. Once rated one of the safest in the country, a recent CQC inspection and inadequate rating has catapulted the hospital into the public eye for all the wrong reasons.
The role for the CCG in Cambridge and Peterborough is one of collaboration, as Jill Houghton, director of quality, safety and patient experience at the CCG explains: “We are working with each of our providers following their CQC inspections to improve services and the quality of care provided.”
CQC inspections, and high-profile failures may make the headlines, but they don’t tell the whole story, with Houghton keen to point out that Peterborough and Stamford Hospitals NHS Foundation Trust appears as a positive case study for change in the report, illustrating the capacity for health services to improve with the support of a strong local commissioner.
For Cambridgeshire and Peterborough at least, the report isn’t likely to say much they don’t already know, and more importantly already doing something about. As Houghton explains: “We have plans in place to support local hospitals and other providers moving forward; most significantly this includes our urgent and emergency care vanguard.”

Money matters
In Cambridge and across the country, the desire for change must be tempered with the capacity for change. Houghton is understandably cautious, noting how “the report reaffirms the imminent national financial pressures” facing NHS organisations.
Finance looms large within the CQC report, with the state of care often linked to the state of budget. The report is careful to position its findings within this context, noting the significant financial challenges the health service faces. It’s particularly frank about the issues within the social care sector, emphasising a drop in funding of 37% in real terms over the past five years.
The lack of finance means that commissioners are having to approach the challenge of integration in a different way.
The CQC report offers some examples of good practice, including one in the London borough of Tower Hamlets. Using new technology – and the support of North East London CSU – the CCG is helping to reduce the demand on acute and social care through greater integration of systems, and the sharing of data across organisations.
Julie Dublin, transformation and integration manager at Tower Hamlets CCG explains: “The idea of information sharing isn’t new, but the IT system we have is the key enabler. The information we need already exists within the multiple providers but we needed some sort of middlewear (software that bridges the two systems) to see the information in one place.”
The CCG is now able to link data sets between primary and secondary care enabling primary care clinicians to see which patients are in hospital. Using information from both general practice systems and SUS (secondary uses service) data, the tool allows the prioritisation of clinical interventions by determining whether patients are eligible or enrolled with the integrated care programme.
It’s not an isolated example of integration, in fact across the capital CCGs and other health organisations are working more closely together to help improve the health system. Dublin outlines how the CCG has worked with neighbouring CCGs in Waltham Forest and Newham as well as Royal London Hospital to share information and improve the flow of patients to and from acute settings.
In managing change, the CCG is benefitting from the support offered by the local CSU, challenging and encouraging the provider to innovate.
Ryan Meikle, head of technology and delivery, at North East London CSU is positive about the relationship the CCG and the outcome. “The project is a really good example of where our CSU has brought innovation to the table.
“The commissioner was clear with the problem that they faced, and we worked together to design a solution that works for us all. It’s all about adding value.”
As the CCG/CSU relationship begins to rest on firmer foundations it’s likely that CSUs will fill a greater role in the planning and delivery of care, so this relationship is likely to grow and improve. Dublin says: “They [CSUs] have specific expertise and skillset and we have benefitted from that.”

Taking the lead
Leadership – or rather the lack of it – is troubling the CQC. It notes a number of examples where leadership has failed, leading in some cases to safety concerns with quality of treatment.
In Rotherham, there has perhaps never been a more important and pressing issue than tackling child sexual exploitation, a story that has shocked the nation and cast a dark shadow across the region. In tackling this complex problem, the CCG has used its role as a leader in the health community to face it head on.
Sue Cassin, chief nurse NHS Rotherham CCG explains what they are taking from the publication: “For us, the focus of the report is on safeguarding children, where we must remain focused on continuing to make improvements.”
The CCG has led a transformation not only of care provision but also of culture. Cassin explains: “We have a safeguarding golden thread that runs throughout the organisation, featuring heavily in our commissioning plan for Rotherham.”
The organisation is showing how bold leadership can help a health community overcome a major challenge. The strong leadership is supported by strong and robust systems, and a cultural change that puts the patient at the centre of care.

Lasting change
Reading through the report it’s clear that the CQC is keen to paint a realistic portrait of the health service as one that is struggling financially. It is also able to recognise that in many cases the causes of issues it raises are structural and systematic, which can mean that commissioners at a local level are limited in what they can achieve.
While providing useful guidance and some encouraging examples, commissioners will already be aware of local issues and taking action to deal with them. They will also have spelt out their local priorities in their five-year plans, which have been submitted to NHS England, and won’t be rushing to alter them.
Despite its failings, the report makes interesting reading, but given its length it’s unlikely that many commissioners will find the time to do so. A spokesperson from Cambridgeshire and Peterborough CCG sums up the views of many: “The level of pressure in primary care at the moment is making it difficult to get the required head space to think differently.”
It will be interesting to see how things develop in the health service and just what impact the new CQC regime will have in driving change. With the regulator itself coming under increasing scrutiny, the state of care next year may have changed more than the CQC could have imagined.

Lawrie Jones, freelance health reporter.