Hospital ratings will set the regulator up to fail

The recent media storm over the Care Quality Commission should make the Secretary of State for Health think again about hospital ratings. They will not give the public the infomation they need and will be used to discredit the regulator should future poor care be identified in a so called 'good' or 'excellent' hospital.

In all the furore over the Care Quality Commission, my thoughts are with the current staff. Between the legal challenges that providers jump to if regulatory action is taken and the public outcry if the opportunity for action is missed, there is no room for manoeuvre. They are damned if they do, damned if they don’t. Sir Robert Francis said in his radio interview on the Today programme on Monday (24 June 2013) that ‘healthcare is never going to be perfect and it is not productive to think it can be’. Similarly, the regulator can never spot every instance of poor care and it is not productive to think it can. It is a shame that the media and politicians pretend otherwise.

In the climate of criticism and blame we have seen in the recent week, one wonders why the Secretary of State for Health is pushing for recreation of hospital ratings. It was already hard to understand because every other initiative in the NHS at the moment is about moving care away from hospitals. A hospital rating reinforces the idea that healthcare equals hospitals.

Now maybe he will also see that he is setting the regulator up to fail. If any hospital is given a rating above satisfactory or adequate, the ‘rater’ will be sitting on a ticking time bomb. It is inconceivable there will not be a future story about poor care in any hospital, whether just one individual receiving poor care by act or omission, or a more systematic failure. Even great hospitals have poor departments, even poor hospitals have great departments. In my own field of paediatrics, I can recall Child Health Departments where some subspecialties were fantastic, others good enough and very occasionally, one where you need to take rapid action to turn it around. Will there be enough capacity to drill down to the kind of level that has meaning for a family seeking care for a specific condition?

I am not saying that it is not good to be recognised for achievement over and above minimum. We should always be striving to do better. I am just saying it is not the role of the regulator to do this. Now, more than ever, the regulator needs to focus on regulation, on how it forensically seeks out poor practice including responses to alerts about possible and actual poor practice and takes regulatory action. The Care Quality Commission was set up in 2009 and had to implement a completely new regulatory system by early 2010. It is only just completing the third year of operation of that system and it is, rightly and as expected, continuing to improve and refine both the design and the operation. The BMA and others, including Sir Robert Francis, have all commented on the impact of the frequent change of the regulator and also the change in the regulator’s functions. Why add a whole new design and implementation challenge to an organisation under stress? The Nuffield Trust strongly cautioned against an aggregated hospital rating as oversimplistic and unlikely to be useful in spotting lapses or giving the public the information it needs.

Maybe there is another factor. The star ratings system of care homes developed under the previous care regulator, the Commission for Social Care Inspection, were a by-product of their risk based regulation. If a service or home was deemed low risk it was not scheduled for reinspection for a longer period of time than one deemed higher risk. This was portrayed as star ratings to make it easy for the public to understand. Those star ratings were then used by others as the basis for setting and paying differential fees. So a regulatory process ended up creating a financial one. When the star rating system was suspended, one of the biggest arguments at the time was the loss of ability to attract higher fees.

I can’t help wondering if the desire for hospital ratings has a similar underlying intent. It makes no other sense.

Note: I was a Director at the Care Quality Commission from 2009 to 2011.

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