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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE
To be published as HC 592-i
House of COMMONS
TAKEN BEFORE the
ANNUAL ACCOUNTABILITY HEARING WITH THE CARE QUALITY COMMISSION
Tuesday 11 september 2012
DAME JO WILLIAMS DBE and DAVID BEHAN CBE
Evidence heard in Public Questions 1 - 140
USE OF THE TRANSCRIPT
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Taken before the Health Committee
on Tuesday 11 September 2012
Mr Stephen Dorrell (Chair)
Grahame M. Morris
Mr Virendra Sharma
Dr Sarah Wollaston
Examination of Witnesses
Witnesses: Dame Jo Williams DBE, Chair, and David Behan, CBE, Chief Executive, Care Quality Commission, gave evidence.
Q1 Chair: Can I begin by welcoming you to the Committee, both Dame Jo Williams and David Behan? I do not think either of you need introducing to the Committee. You will not be surprised to hear that there is a broad of range of subjects the Committee wants to cover this morning; issues that have been raised by your board member Kay Sheldon-
Dame Jo Williams: Indeed.
Q2 Chair: There are more general issues of whistleblowing and other specific issues in the performance of the CQC but, rather than going into those at the beginning, we would like to start by standing back. The organisation has been subject to extensive criticism over quite a long period from this and other parliamentary Committees. There has obviously now been the change in chief executive and there is the imminent change in the chair. The Committee would like to begin by asking whether you believe the organisation has understood why it has been criticised. What is your view about why it has been criticised and what has been the reaction of the organisation? The key question is: can the public now have confidence that the CQC is fit for purpose?
Dame Jo Williams: Thank you very much, Chairman. There are a lot of questions there. Perhaps I should begin by saying that I think the CQC has had a very tough year but during that year has made significant progress. To illustrate my point, I would say that last year we conducted 18,000 inspections, largely unannounced. Our processing centre in Newcastle received well over 200,000 calls. Over 90% were dealt with within 30 seconds. But, of course, the real issue is: what about the impact of those calls, those communications with the CQC? It is clear that we are following through, auditing and looking at the impact of those calls. We have done a lot of work in preparing for primary care registration. We have had great involvement with the sector and are confident that those processes-we have learned from what has gone before-are fit for purpose. In addition to that, we established a team in Newcastle that would respond to whistleblowing calls, people raising concerns, and we have had significant numbers-500, on average-a month.
What do I believe about the CQC now? I think it is an organisation that recognised last year that there were many things that had to change. We put in process the means of doing so. What I have tried to illustrate in the last minute or so is some of the ways in which we have made progress. That is not to say we are complacent. There is still a great deal to do.
On the appointment of David Behan as the new chief executive, we put out last week a consultation document looking at our next three years. We have begun to be much more future-focused. The feedback from organisations that we work with is that the foundations are now there and we have to move forward. Within our strategy, we are quite clear that we are part of a system that requires commissioners, providers, other regulators and the public to work together to make sure that services are safe and of an appropriate quality.
My reflection is-and, as you have said, I will be going when my successor is appointed-that the CQC had a very poor start and was probably given a task that was almost impossible. The preparation and the foundations were not properly in place. When I look back, I probably underestimated the challenge and the task, but over the three or four years that I have been involved, we have got to grips with that. We understand our part and our purpose now and I am certainly feeling that we will move forward. We have a work force central to what we do who are as passionate as David and I are about bringing about safe, quality services for everyone who uses them, whether it is in a hospital or in a care home.
Q3 Chair: But you used the phrase, Dame Jo, "We know what we are there for." I am not quoting you directly, but, "We know what we are there for." In response to the question, you talked about the call centre, the processes and about unannounced visits. What I still do not get is a clear single answer to what is the CQC there for? Why does the public pay £150 million a year for the CQC?
Dame Jo Williams: It is there so that we play our part in driving improvement in health and social care services. We do that through regulation, using our powers and, where necessary, taking action against those services that do not measure up to the essential standards.
Q4 Chair: But there is a tension, even in that, isn’t there, between a regulator who provides a minimum standard-
Dame Jo Williams: Yes.
Q5 Chair: -and a responsibility for standards above the minimum, driving towards better care. Where does the CQC sit in that? Is it a guarantor of the minimum or is it a mechanism for driving quality higher?
Dame Jo Williams: They are essential, not minimum and we believe and know that those standards will change over time as people’s expectations, and services, change. So they are essential standards. Our interventions in a variety of different ways certainly are about making sure that those essential standards are maintained, but, importantly, through working with the sector, helping people. Increasingly, the central platform of our strategy for the future concerns being clear about highlighting for people what works well and how they can learn and encourage. David, do you want to come in on this?
David Behan: If I may, Chair. It is a hugely important question and too often we have seen this as an "either/or" debate. Of course, the truth is that the 2008 Health and Social Care Act, which gives us our power, says that our job is to measure whether people are meeting these essential-as Jo said, not minimum-standards. That is an important issue. Then it goes on to say that we will do that for the purpose of encouraging improvements in services. So the very legislation that created the CQC gives a function which is to encourage improvement in the way that services take place. Holding up the light to services and saying, "This is how you compare to the standards that are set and this is where we issue warning notices," is an indication of where services need to improve and, of course, if services do not improve, we will take further action.
The other area where I think improvement takes place from the functions that the CQC is required to undertake through the legislation is in some of the reports we have produced. In the "Dignity and nutrition for older people" inspection report, which was published last year, one of the phrases that I came across during my induction in the CQC is "the bow-wave effect". What that means is that by publishing this report, those people not subject to an inspection are clear about what some of the essential standards are as to dignity and nutrition and have been able to take action on this.
This was illustrated quite vividly as part of my induction. I went on an unannounced "dignity and nutrition" inspection to a hospital here in London. We knocked on the door and said, "We are from the CQC. We have come to speak to you about dignity and nutrition." The hospital handled this very well, if I may say so. What was absolutely clear was that the director of governance in that hospital had already carried out some audit work based on the dignity and nutrition standards to check that it was meeting the standards we had set out in the "Dignity and nutrition for older people" report. So without the CQC going in to inspect, that organisation, which is a good organisation, had begun to act on the standards that had been set. That is an example of how, through our reports, we can drive improvements.
Indeed, I was flicking through the evidence that has been submitted to you, which your Clerk very kindly sent through to us last night. It was interesting to note the number of times the stateofthemarket report was commented on favourably by those people submitting evidence-there were other comments in there as well-as being a platform, a potential, to drive improvements more broadly across the sector. So I think we do it specifically in individual services through our regulatory activity and we do it through the reports that we publish which allow others that have not been subject to the inspection to consider how they compare against those essential standards.
Q6 Chair: One of the questions I remember asking Dame Jo some time ago was the extent to which your service, support and information are sought by the commissioners in the system who are supposed to be the people responsible for driving standards in their particular locality. Can you tell the Committee where that process has got to, in your view?
David Behan: Yes, and it is important. It is not only the commissioners of service, I would argue, Chair, but also the providers that have a direct impact on quality. The information that we possess needs to be sought by both as we begin to go into an environment, a landscape, a context, which is changing quite dramatically with the advent of the Commissioning Board. One of the things I reviewed this week is the draft memorandum of understanding between the CQC and the Commissioning Board. One of the first three areas identified for priority activity is exactly this issue about the exchange of information to ensure that the information that we possess is shared with the Commissioning Board and the information that the Commissioning Board has is shared with us, so we can build that. As you are aware, Chair, it has also taken on the responsibilities from the National Patient Safety Agency, which is a valuable source of information to the CQC. We are keen to ensure that that information is available to us so we can prioritise the work that we do in terms of the inspections and use that to inform the way that our inspections take place and move forward.
Q7 Valerie Vaz: I have a quick question about the past and then we will move on to your future strategy. You probably know that the Committee criticised the fact that you focused on registration.
Dame Jo Williams: Indeed.
Q8 Valerie Vaz: Can I put it to you that you got it wrong and that mainly you were registering dentists to get income in because you get £50 million grant in aid but £90 million from registration? Could you explain to us-because we have not had an opportunity-why you focused on registration?
Dame Jo Williams: We focused on legislation because-
Valerie Vaz: Registration. You said legislation.
Dame Jo Williams: I am sorry. We focused on registration because without registration it is not possible for us to regulate. So, if you like, registration is a licence which enables the provider to stay in business, to do business. The process is required within the law and we cannot follow up and look at whether or not the standards are being met unless that licensing, or registration, process has taken place. It was not about gaining income for the CQC. This was about carrying out our statutory duties.
Q9 Valerie Vaz: So you accept that you did not focus on inspection at the time?
Dame Jo Williams: At the time, we had to register in order to, as I say, carry out our regulatory functions. With hindsight-and this is certainly an issue that has been discussed many times-the emphasis, the way in which we set that process up, meant that we were not following up and doing the inspections that our work force wanted to do. That, if I might say so, was out of kilter. It has completely shifted and changed this year, but also last year.
Q10 Valerie Vaz: What is the current vacancy rate at the organisation?
Dame Jo Williams: I beg your pardon?
Valerie Vaz: The acoustics are not very good and if you do not mind I will talk loudly and slowly. What is the current vacancy rate at the organisation, because I think that was one of the criticisms?
Dame Jo Williams: We have details of our vacancy rate and I will hand over to David.
Q11 Valerie Vaz: Is it better than previously? It was an issue.
David Behan: Yes, it is. Really good progress has been made on this. There was an additional £10 million made available to the CQC from the Department. That was resource sufficient for an additional 255 inspectors. As of Friday afternoon, we currently have vacancies of 49 inspectors and 75 interviews are booked to take place over the next few weeks. All those inspectors, once selected, will go through an eightweek induction programme. So we are, from offer letters going out, eight weeks away from people starting being productive. But it is absolutely essential, Chair and Members, that we make the right decisions about selecting people, that we are clear about the standards we want. Therefore, there is a balance to be struck here about the speed at which we recruit to those vacancies and ensuring that we get the right people in.
We had 194 vacancies in April of this year and, as I say, as of Friday afternoon it was 49 inspector vacancies, predominantly in London and the southeast of England, interestingly enough, but we have a programme to get through that. I would calculate that by the end of this calendar year, we would be in a position where we have offered all those roles. We have about 4.5% turnover so there will be some attrition during that-it is a bit like the Forth Road Bridge in that as soon as you have it to full establishment some people will leave due to retirement, etc.-but that is where we are and we are making good progress in relation to that.
Q12 Valerie Vaz: Could you touch on this bank of 100 national clinical advisers? Who are they and what is it?
Dame Jo Williams: We have recruited people from a variety of different backgrounds and David is looking for the detail of it as I speak. They are a resource to our inspectors. If, for instance, an inspector believes that they are in a situation where they need advice from a nurse or a doctor, they can tap into this. They are people who have put themselves forward because of their expertise, and we can draw on that list. I think we have the complete list of what their backgrounds are.
David Behan: Yes, we have about 100, Valerie, and we went live with this in July. We have about 42 general nurses, nine nurses with expertise in mental health and learning disability, 14 midwives, nine doctors and two GPs. Interestingly, in terms of your question about dentists, we have 10 dentists, five allied health professionals, 12 social care people, four executives who are experts in QA systems and two clinical scientists for the laboratory work. In addition-and I think this is important-we have 300 experts by experience, people who use services, who have accompanied inspections.
On the dignity inspection I referred to earlier that was part of my induction, I was accompanied by an expert by experience who spoke to the people in the hospital and asked them how they were treated and who was, I have to say, a fantastically invaluable member of the team. We were assisted by a nurse from elsewhere in the south-east who added real professional value to the inspection. That is beginning to get traction in the organisation.
Since July, there have been 16 requests for advice and seven of those people have accompanied inspectors on routine inspections. It is a resource, a reservoir, which is there to be drawn on appropriately. Clearly, I would be looking for a greater traction in relation to that for inspectors who are going in where their own background is not of that particular service area either to speak to people before or perhaps be accompanied.
Q13 Valerie Vaz: If I could turn to this document, your next phase, you mention at page 15 "Building the evidence base". Could you explain about this evaluation, what it is about, how much it is going to cost and why you don’t appear to have that information already within the organisation?
David Behan: We do have some of it already and I think what is important, Chair, is that if you look across the world at the literature of what regulators do-whether you are looking in America, Australia, Canada, New Zealand or the Scandinavian countries-what is clear is that there is too little evidence internationally as well as nationally about what is effective in regulation. So I don’t think we should beat ourselves up. I am certainly not beating myself up, coming to this job, about whether we are missing international evidence about what is effective in regulation. If that evidence, that research, is not there, then we need to create it. There needs to be a debate about what academic research we need in relation to the evidence about the effectiveness of regulation.
We also need to be clear about the way that we operate. What we are setting out in the strategy, quite importantly, in my view, is a clear statement that we want what we do to be based on the evidence of what we know works. One other question is that I had a positive feeling that the expert by experience really added value to the dignity inspection that I went on, but what is the evidence? Do they add value to everything that we do? If they do, should we be extending the way that we use experts by experience in what we do? Where we have outside experts assisting teams, what is the evidence of what difference they make, what value do they offer and should we have more or fewer of those? What we are setting out is a clear approach to generating the evidence ourselves in terms of what works and using that to inform the work that we do going forward.
Q14 Valerie Vaz: How much is it and when will it come to an end?
David Behan: We will do that from within our current resources. We are working with Professor Kieran Walshe from Manchester university who has some knowledge and expertise in these areas and he will provide that link to the academic and research world, although he will also actively get engaged. I can write to you, Chair, if you want, as to what those original costs will be, but this is an ongoing programme. Being clear about what we do that is effective is something we will do year on year and not a oneoff event that will come through. It needs to be part and parcel of the way that we become a highperforming organisation.
As to your question earlier on whether we have listened to what people have said in terms of your recommendations last year, the Public Accounts Committee, the NAO and the Department’s own capability review, I have to say that coming into the organisation I have been impressed by the openness with which the organisation has demonstrated its receptiveness to the challenges that it has received. It is perhaps the most scrutinised public service organisation in the past 12 months.
The scrutiny review-there is a copy of that review and an update on progress on our website-has been used to drive the evaluation process that Valerie Vaz is raising with us now. I hope what we are doing in that is demonstrating that we have listened to the comments that have been made. One of the queries that was made in relation to effectiveness is whether we should regulate in exactly the same way a small threebedded care home for people with autism, a dental practice and a multisite multimillion-pound teaching hospital here in London. Perhaps the same values and principles can be used, but a number of people have said to us that you cannot use exactly the same evaluation process.
Q15 Valerie Vaz: The differential regulation.
David Behan: We need to differentiate. We want that differentiation to be based on the evidence.
Q16 Valerie Vaz: Absolutely. I want to move on. Thank you for that very helpful answer. One of the key areas you said you were going to look at in the future is how you are going to deal with other organisations, say, for example, Monitor. Some of the evidence that we have in, particularly from the Foundation Trust Network, said that clarification is needed on the role of Monitor and you because there is an overlap, isn’t there? There is a case where Monitor stepped in and found out there was something wrong and you didn’t pick it up. The Relatives and Residents Association has said that some local authorities and other commissioners undertake their own inspections because they have no confidence in the CQC’s rigour. Could you address those two points about Monitor and why other regulators have to step in?
David Behan: Yes. This goes back to the Chair’s question, I think, of whether we have listened to what has been put at CQC’s door over the past 12 months. I believe we have. In the past four weeks since I began I have had regular conversations with David Bennett at Monitor. I have described the memorandum of understanding that we are developing with the Commissioning Board. We will have similar MOUs with Monitor so we and it can be absolutely clear about what its role is. It is moving into a new space and developing its new role as a result of the Health and Social Care Act.
As I said, I read the submissions that you had kindly shared with us yesterday evening. There were no antibodies in relation to the issues that were being raised by the Foundation Trust Network or by the Relatives and Residents Association. We need to embrace some of those comments. What you will have seen earlier this month is the publication by the National Quality Board of a document which Dame Jo has signed on behalf of the CQC, David Bennett, I think, has signed on behalf of Monitor, and other key actors and players in the system have signed, which is a clear statement of their roles. As a beginning, it will set out what the distinct and unique contributions are that we all make. I think we have a unique contribution and I think this plays, Chair, to your question to Dame Jo at the opening. What we do that nobody else does is check that people are meeting those essential standards. Nobody else in the system will do that. In order to do that effectively-and I think this goes to the heart of your question, Chair-we will need to share information with those organisations and they will need to share that information with us.
The case you were referring to is that of Morecambe Bay, and one of the issues in Morecambe Bay is whether the right amounts of information were being shared at the right time. The CQC has been very open about that and we are setting out very clearly in our strategic review that our ability to be the independent regulator of quality in the system-so we can arrive at independent judgments about the quality of services-means that we have to be interdependent because we will work with others to discharge those responsibilities.
Q17 Valerie Vaz: Finally, is there any reason why Monitor and HFEA have been left off your list of participating organisations?
David Behan: You need to draw a line somewhere otherwise you end up with a very long list. What we are doing is drawing a distinct difference between the organisations which we know now we have to work with-and we are calling those strategic partners-Monitor, the professional regulators, but the consultation is still out in relation to HFEA. That matter has not been determined by Government. In fact, we have not yet set out our response.
Q18 Valerie Vaz: I am talking about your document and list of participating organisations. Could it have been an error? Monitor is keen and you have been having a chat with them. I wondered why you drew the line and left those two important institutions aside.
Dame Jo Williams: It must be an oversight. Quite clearly-
Q19 Valerie Vaz: That is all I wanted to know.
Dame Jo Williams: If that is the case, I am sorry about that.
Q20 Barbara Keeley: Can I take you back, Dame Jo, to what you said about this question of "essential, not minimum" standards? You said a curious thing, I think. You said that "this will change as people’s standards change." I have to tell you, as a constituency MP, that it is not unusual to find family members and carers who have had very bad experience over the last number of years, for instance, and particularly in things like using nursing homes for respite care, to the point where a family member would remove somebody halfway through a respite care week because the standards of a home that you had passed as being acceptable were so poor. That is where we are.
It is not a question, I think, of looking forward to a future where people will start to expect higher standards. In my experience, in my constituency, people are unhappy with standards now. This is particularly borne out in the written evidence from the Relatives and Residents Association. Focusing quite a deal on care homes, it says that the CQC does not have sufficient expertise in the care-home sector, and your focus on selected standards only is negligent. It makes the point that, differently from registering dentists and the other things we have been talking about, care homes are places where people live. You are not just there for a couple of weeks. If the standards are low, this is the quality of your life all of the time, 24/7 all year round. I would like to take you back to that because I don’t think we are in a situation where we are looking at people currently thinking standards are acceptable but that they might go higher. That is not the case.
Dame Jo Williams: I do not wish in any way to deny anything that you have said. I absolutely agree that if someone is experiencing a care service, it should be acceptable to them. We all have individual standards but, basically, it must be acceptable to that individual and their family. The essential standards which we operate against are the means by which we are able to say whether or not a service is compliant. We are increasingly focusing on what has been the experience of people living in that environment: how have they experienced it, are they happy with the way in which they are treated as an individual and the services they all receive? If there is additional information that a service is not meeting the needs of an individual, we would wish to know about that and follow up.
Q21 Barbara Keeley: Before you go any further with that point, let me say that I am not talking about exceptions. I have, on occasions, sat down with a group of carers at a carers’ dropin, who would run through the list of nursing homes we have locally and find only one or two of them of an acceptable standard. That is where we are. When they are trying to find a nursing home following the deterioration of a loved one and their increasing need for care, people are horrified at the existing standards. This is a crucial point.
I am talking about my local experience, but the Relatives and Residents Association gathers a lot of experience in from its members. It is saying that in terms of purpose and where you are going, its belief is that you do not have sufficient expertise; you are focusing, negligently, only on selected standards; and that you are not doing an adequate job in terms of inspecting care homes. That would entirely tie in with my experience of talking to people in my constituency about their local experience. It is not always a question of saying that at some point in the future standards have to improve. This is an issue now. As we discussed, Chair, on the purpose of the CQC, it is important that you recognise and accept that. If you do not, there is an issue.
Dame Jo Williams: I would not wish to say in any way that we wouldn’t take seriously what you have said. I know from my own experience that it is very variable. If there are significant shortcomings in the service, we must know about that and we will follow it up. We have been working with the Residents and Relatives Association very closely, asking it to pass on information. Since the beginning of this financial year, we have had an agreement with it. The information that it has passed to us is very limited. That is a matter that we must take up with it. We have only had, I think, somewhere in the region of 35 direct referrals. We need to hear from you and from the public about those unacceptable services and standards. It is our job to go in and regulate against those standards. Quite rightly, people’s expectations should change. My point about standards improving is not to deny that we must make sure, right now, for everyone experiencing services, that those services meet with those standards.
Q22 Rosie Cooper: Dame Jo, please let me ask this and I am sorry to interrupt. I heard what you said and there will be people agog at it. When you last gave evidence you talked about minimum standards. This time, you are talking about essential standards. You are saying that, when alerted, you will go to it. So what happened at Winterbourne View? What happened at Mid Staffordshire? You were alerted many times. We have had people here giving evidence. If what you are saying is true, why didn’t it work then? Why did you fail so miserably on so many occasions?
Dame Jo Williams: First of all, may I say that if I did talk about "minimum standards" rather than "essential", I am surprised by that and I apologise. It has always been "essential standards". We have looked long and hard at what happened at Winterbourne View. As a result of that, we have made very significant changes within the CQC. We carried out our own internal management review and contributed to the serious case review. It was an extraordinarily painful process for everyone concerned and horrifying to see and understand that people were in that situation. But what the serious case review author said was that the CQC had been refreshingly honest in looking at what had gone wrong and putting in place measures to move forward. That is my point, that we have absolutely listened to, understood the messages and taken steps to improve.
Chair: Rosie, we are coming back, if I may say so-
Q23 Rosie Cooper: Winterbourne View was a while ago. What happened to Morecambe Bay? That is recent.
Dame Jo Williams: As David has said, we have looked at that. In fact, we have established a further investigation into that. We want to understand why we made the judgments that we did.
Q24 Grahame M. Morris: My point essentially follows on from a point that was originally put to you, Dame Jo, by my colleague Valerie Vaz in relation to the dissemination of information following an inspection and how the information that is collected by the CQC is made available to the general public and to other stakeholders. We have received evidence from individuals documenting their concerns. Without mentioning those specific cases that colleagues have already referred to-just in the generality of it-could you clarify for my benefit, what happens in the case of a private care home where the CQC does an inspection and finds that the services that are delivered do not meet the required standard? If that was a local authority care home, the CQC would share that information with the local authority and it would be in the public domain, but if it is a private care home, those individuals who fund their services privately are not notified of it, are they? Why is that, in terms of what do we do with the information that the CQC collects?
The other question related to that is, when we are talking about private care homes-and often private care homes will be part of a group-if there is an indication of a problem within the group or there is an indication that directors who own these companies are involved with other companies where there are similar failures in standards, does the CQC make that information available on its website so that people can make a judgment about where their relatives should be looking for the best standards of care?
Dame Jo Williams: Your first question was about what we do if we find that a service is not compliant: that could lead to actions such as a warning notice, and that would certainly be published on the website. I take the point that you have made about would we go and talk to those individuals in the home. If it was significant and we felt that they were significantly at risk, of course we would work with the local authority whose responsibility it would be to make sure that they were kept safe and that alternative arrangements were made for them. That is a reflection of, yes, how do we do more to safeguard individuals who themselves are limited in the way in which they are not supported, if I can put it that way, by a local authority?
As to the question about large corporate organisations, we do recognise that. Particularly relating to issues to do with learning disability and Winterbourne View, we are looking at how we can work differently with the corporate organisations and what we can legitimately say to the public about that. That is a partial answer, I think, to the point that you are making.
Q25 Grahame M. Morris: Where there is a serious failure, would the CQC determine that, say, the director of a company where there is a history of this, or where there is a failure to comply, is not a fit and proper person to run such an establishment? When would you reach that point?
David Behan: If I may, Chair? This is an important question and I think you yourself have raised it at other times.
Chair: I have.
David Behan: It is a hugely important question. The Government have published a document on the operation of the market and this was very much post the events at Southern Cross. One of the issues that came out of that consultation was exactly this issue about how you determine fit and proper people. It was a question that was asked in the document and the Government have committed to publishing a further document in the autumn of this year. One can anticipate it any time soon, I suppose. I hope that will be the basis on which a further debate can take place about this important question that Grahame Morris is raising. At the minute, the CQC does not have power to act in that way around "fit and proper people" tests and therefore that is something on which there needs to be a broader debate and it is an important issue for members of the Committee to continue to raise.
Q26 Mr Sharma: Following on from Barbara’s initial question, do you act only when the whistleblower or a family member of those residents in the care homes makes a complaint? You do not have any mechanism to visit and question.
Dame Jo Williams: Indeed we do. Each inspector will have responsibility for a number of services. They are looking at those services for which they have responsibility. They will be talking to the local community, possibly local LINks, but they will be looking at local newspapers. If it is a care home, they may be talking to local nurses, gathering the information, sharing information with the local authority, making a judgment about that information and then deciding to make an unannounced inspection. On that basis-
Q27 Mr Sharma: How long is that period?
Dame Jo Williams: If we received very worrying information from a particular source that suggested there was high risk to those people, we would act very quickly. Every inspector is looking at their responsibilities. If I could put it this way, they are doing a risk assessment on the basis of what they know-when they last visited and what others are telling them-and determining at what time they should go in.
Q28 Mr Sharma: Then why-and I am not going to name the places at this stage-even in my own constituency, has it taken years, not days, weeks or months, but years, before the CQC came to the decision to close down the care home when all that information was publicly available? The local authority was involved, a large number of families were directly involved, whistleblowers had provided the videos and all that information, but it still took years and many residents suffered and later the families suffered during that investigation. Is it the failure of the CQC, or do you think there is something else? And what actions would you take against any inspector who was responsible in that investigation?
Dame Jo Williams: If I might say, I would be very pleased if you would perhaps give us information outside this Committee.
Q29 Mr Sharma: It is an old case, now closed. I am asking why it has taken such a long time when that information was available and if the organisation was, as you say, so effective.
Dame Jo Williams: I obviously cannot respond to your particular point or example, but most certainly, if we learned that people were at risk, we would take action to make sure that they were safe. If it is not of that high risk but there are difficulties and noncompliance-if it were of such a nature-the first thing we would do would be to talk to the provider of the service about what they were going to do to put it right. We would follow that up. If they were not putting things right, we would determine what would be a suitable action. It could be that the first stage would be a warning notice. The point you ask about is, from that stage, how long does it take to bring about closure? It is a legal process and of course it doesn’t happen overnight, but throughout that legal process our responsibility is to make sure that individuals are safe.
David Behan: If I may add to that, Chair, it is an important question. The CQC has been publishing on our website performance data and one of the changes that have been made from this time last year to now is that we are trying to provide data as part of that. It is published on our website and anybody can go on and see it. The period to July is on the website now, but I want to check that. One of the pieces of information that we are putting out there is the length of time it takes us to complete certain activities. Then it is out, open and public and people can come back and challenge us in relation to it.
Obviously, the devil on all these cases is in the detail and not in an aggregate set of numbers. Your challenge right at the beginning was "What have we learned?" One of the things we have learned is to be much more open about the way we are publishing data on our performance, being much more transparent and allowing people to come back to us in relation to that. As I say, I commend the information that is on the website. The last period is period 4, to July 2012. We hope that information is accessible and presented in a way that people can make sense of in terms of our own performance. A huge amount of work has been done-to pick up on Grahame Morris’s question-on improving the website, so our reports are there and available for people to read, whether that is public or private-sector organisations.
There is more still to do. We are not satisfied with the website. There is an active programme of engagement and I think, in terms of Virendra Sharma’s question-and I think this plays to Rosie Cooper’s challenge as well-we are getting about 500 whistleblowing referrals each month. Rosie herself has been up to look at the work that we do in Newcastle, and thank you very much for making yourself available to do that. It speaks well of your commitment to making this a system that is one that people can have confidence in.
We are also carrying out audits of the way those whistleblowing referrals come through. In our second audit-we are about to do one in September-we looked at 40 cases. Of those 40 cases, 22 were referred to local safeguarding teams and 17 triggered responsive inspections. That is an example of where people do blow the whistle, the information comes through and you are beginning to see us changing the way that we operate based on that information coming through. As Jo said right at the beginning, we are not complacent about any of this. This is a significant change in the way that we operate, but I share that information and the statistics that are behind that in a way that I hope enables you to begin to develop some confidence that this is an organisation which is changing, learning, growing and developing. We are determined, as an organisation-I am determined-that we will discharge our responsibilities in a way that people can have confidence in.
Q30 Chair: We would all welcome that, but perhaps you will understand the scepticism on the part of the Committee, and indeed beyond the Committee, given that this is not an old quote-or not that old, it is January 2012. Your director of operations Amanda Sherlock described the inspection of the Morecambe Bay Trust as a "robust piece of work". We do not understand, frankly, how the director of operations can describe the inspection of that trust as a robust piece of work given what happened following that inspection.
Dame Jo Williams: Chairman, I have already said that we are looking back. We set up an independent review of what happened there and that information will be with-
Q31 Chair: It is a pity, isn’t it, that the director of operations describes it as "a robust piece of work" before the review takes place?
David Behan: It is important, Chair, to draw the distinction between the registration of Morecambe Bay, which is where some of the concerns come from, and then the subsequent inspections in Morecambe Bay. The issue that sits at the heart of the Morecambe Bay case is whether we got the initial registration right and whether all the information-
Q32 Chair: With great respect, I doubt whether that distinction between registration and inspection would tell very strongly in the eyes of patients.
David Behan: No, that is absolutely right. One of the consequences of, "Did we get it right in Morecambe Bay?"-one of the things I have agreed with Dame Jo-is that we should get an independent review. I have asked Grant Thornton to lead a review of that work, which is completely independent. Then, as to the issues that you are quite rightly raising, in the eyes of people using services in Morecambe Bay, I hope they will see that there is some element of independence in the review of the work that we did and the engagement that we have had. That is probably the most appropriate way to try to respond to those allegations, Chair.
Q33 Rosie Cooper: Mr Behan, how can the general public have great confidence when-and it is the point I was trying to allude to before-organisations get either a clean or reasonable bill of health and then later the most horrendous situation is found to have existed? It is not that you were not alerted to it. You were alerted many times and, as the Chair has described, Amanda Sherlock did say that that report was robust. I hear you saying repeatedly, "We are learning," but the public out there are screaming, "How long will it take?" How many people have to suffer before we start to get this right and we can trust that when you say it is robust, we don’t need to go to Grant Thornton because we know it is robust? That is the bit by which you will be judged.
Perhaps I can also say something in your mitigation that I think is true as well. There is confusion in the hearts and minds of people outside because you say, "Please bring us your concerns. Please bring us any detail you have," and when people do give it to you, the immediate response is, "We are a regulator, we are not a complaints mechanism. Therefore, we will not investigate that complaint and get back to you." There is a complete mismatch between what you are asking people to do, what they think they are doing and what you are delivering. They want you to look at the complaint and you are saying, "Thank you very much for that information. We will feed it into our system." The fact that the Health Service has such an appalling complaints system often means that people feel that their complaints are not dealt with properly. You, the regulator, become the point of last resort and when it all goes wrong, you have allowed it to happen. So there are other parts of this system which are wrong as well, but the truth is that you are the regulator, you are the backstop, and people’s lives depend on you getting it right.
Dame Jo Williams: I appreciate where you are coming from and absolutely understand the points that you are making. One of the challenges for the CQC, but maybe also for the way in which the whole system is working, is the expectation that there is some mechanism, a silver bullet, a magic, that will ensure that in every situation everything is going to be all right. The real issue for us, as a regulator, is making sure that we understand and work with, in an interdependent way, people who provide services, people who commission services and the public. The challenge for us is to get that right, to use that information judiciously, to use it in a way that will enable us to take appropriate, timely action, as quickly as we can. That is a hugely challenging proposition.
We are saying to you this morning that we recognise what you are saying about public expectation-we are a backstop-and we are determined that, through analysing what has gone before and looking across the world at what is happening, we can play our part and improve in our role as the regulator. The health and social care system is extraordinarily complex and nowhere that I know of has got that absolutely right. If they had, we would take that off the shelf and take it away.
It is a very important challenge that you make and we do not underestimate what you are saying. The public, as you say, are entitled to feel that the regulator can make everything right and the truth is that we need to, as a robust, highperforming organisation, play our part. That is what we are determined to do as we move forward.
Chair: Chris Skidmore wants to ask a quick question and then I want to move on to the specifics of Kay Sheldon.
Q34 Chris Skidmore: I want to ask about David Behan’s point as to the differentiation between registration and inspection. Going back to Morecambe Bay, the trust was registered in April 2010 and then you had an unannounced inspection in June 2010. Obviously, inspections are unannounced, but is the process of registration itself unannounced?
David Behan: No, but-
Q35 Chris Skidmore: Do you not think that, rather than create the kitemark of a standard through registration, and then have unannounced inspections later on, the very process of the registration erodes confidence in the CQC if the CQC registers an organisation which then turns out to not live up to the standards of care that should be expected? Shouldn’t the process of registration follow similarly the process of inspection in that there should be some form of unannounced process by which, when you turn up to register a trust and talk to providers, they cannot sweep anything under the carpet?
David Behan: It is an interesting proposition, Chair, as to what degree of, in a sense, spontaneity there is about the registration process. Clearly, the system is set up at the present time such that it is a licence for people to begin to be a provider.
Q36 Chris Skidmore: There is that bond of trust by handing over the registration process.
David Behan: Absolutely. These issues about trust are hugely important. I see my job with the board as driving forward the CQC so that the public can have trust in what we do and the judgments that we make. I feel that as a personal mission. I think that is how I should be judged in doing this job and that is what I am determined to do.
What we are doing in our documents-our forward strategy-is asking questions about what the best way is to do it. It is not only that we are learning from the past, Chair, but that we are trying to find a way forward, and this comes to the points made by you and other members of the Committee about whether we have the right direction, and whether we are being clear about our purpose. What we will do between now and December is ask people whether we are asking the right questions and answering these in the right way. What we must do in December is bring this not only to a conclusion-this is not a seminar-but to a decision and that should inform what we do. That is key to building this bond of trust that Members have said is so important.
I have one last point on the trust, if I may. We got 1.7 million visits to our website last year. We got 685 completed "share your experience about care services" forms coming in. So a mixture of whistleblowing, hits on our website and sharing experiences gives us some of the intelligence that we are using to drive forward. It is not everything, but they are some of the things that we are doing differently that allow us to position-
Q37 Chris Skidmore: You would look at changing the registration process to possibly reflect an unannounced inspection. It is part of the-
David Behan: What I would like to do is take that away, if I may, Chris, and have a look at it: is it possible to get spontaneity into, effectively, a licensing process?
Chair: Could we spend some time on the important, serious allegations being made against the CQC by Kay Sheldon? Rosie, you want to lead on that.
Q38 Rosie Cooper: I would like to start by asking about when you first became aware of Kay Sheldon’s concerns, what they were and how they were addressed. I have a number of questions to follow, but perhaps you could walk us through from the original concerns right through to today, as that may answer some of these other questions as well, please.
Dame Jo Williams: Perhaps I can begin by giving a little bit of context, if I may. Last year, the CQC was well aware that there were matters of concern. The board was, quite rightly, sighted on those concerns. You have mentioned some of them this morning. We were a very small board. In fact, one of the commissioners indicated in September that he would be leaving because his work location had changed. So we were a board of five, myself and four commissioners. On the issues that were being raised, which we understood and needed to be addressed, every member of the board had a different perception, a different view. We were, together, taking our responsibilities very seriously, looking to work effectively as a corporate board tackling those problems and looking to solutions. When Kay Sheldon, for instance, began to raise her concerns, what we felt as a board was that, yes, these were reasonable but there is a difference between raising a question, raising a concern, and expecting that, having raised it, there is immediately going to be a solution. That was the difference between Kay Sheldon and the rest of the board. To be specific, she had concerns about the regulatory model and about the culture of the organisation.
Q39 Rosie Cooper: How would you handle the procedures for assessing the performance and abilities of board members? Do you think that worked well in this case? I will come back, if you like, to your or the executive team’s control in determining what board members may or may not do. Let us go to procedures. How do you establish how your board members are doing?
Dame Jo Williams: How do I establish-
Rosie Cooper:-the performance and abilities of your board members?
Dame Jo Williams: I beg your pardon?
Rosie Cooper: What are your procedures for establishing the performance and abilities of your board members?
Dame Jo Williams: There is a process that was driven by the Appointments Commission but now is driven by the Department of Health. It is a formal process of analysis on an annual basis, looking at how individuals have contributed and the way in which they have carried out their functions as board members. For instance, at the very basic level, are they apprising themselves of what is going on in the organisation, what are their specific skills and how have they been able fundamentally to add value to the organisation?
Q40 Rosie Cooper: How did that work in relation to Kay Sheldon, both before and after her wish to appear at Mid Staffordshire?
Dame Jo Williams: I need to explain some of the issues that had happened during the autumn of last year. We were going through an exercise in late September, building and developing the board, quite rightly, and we will continue to do that this year. It was at that meeting that Kay told us that she was embarrassed and ashamed to be a member of the CQC board, which was very concerning to all of us. Following that, she left the meeting and was subsequently found to be in considerable distress. It is true to say that throughout the autumn I spoke with Kay and expressed my feeling that I believed I had not only a duty to ensure the board worked effectively but a duty of care to her as a board member.
Subsequently, as you well know, it was her decision to go to Mid Staffordshire. Following that-again it is in the public domain-my colleagues and I felt that there was a breakdown of trust in what had been a small group of people working together with common purpose doing what we believed was everything possible to bring about change and address the issues relating to the CQC. You would not be surprised to hear that, following that-and it is quite clear that that action led to a significant change in the relationships-it has not been possible to reach agreement with Kay Sheldon about when she and I would sit down and have that appraisal.
Q41 Rosie Cooper: You said your colleagues had agreed there was a breakdown of trust. Who constitutes "my colleagues"?
Dame Jo Williams: The other commissioners.
Q42 Rosie Cooper: So you had a meeting. Was Kay there?
Dame Jo Williams: No.
Q43 Rosie Cooper: Was this the purpose of the meeting, to discuss Kay’s actions?
Dame Jo Williams: What I should say to you is that when Kay made her decision to go to Mid Staffordshire, the response from us was huge shock. We had been working together as a group of people wishing to address the issues. So there was huge shock. Therefore, the question in our mind was, "Were we able to work together, could we work together?" She made some very strong statements about individuals, both executives and myself as chair, and other commissioners felt that, reflecting on what her statement had been, their view was-and I wasn’t party to this conversation-they wanted to issue a statement of support for my leadership. But quite clearly, in my conversations with them, we were shocked and we did believe that trust had broken down.
Q44 Rosie Cooper: Dame Jo, I am not sure from your responses there whether this just happened or there was a meeting where you, without Kay Sheldon-a group of you-decided there was a breakdown of trust and therefore actions should follow. What you are actually saying there is if there is real dissent that goes to the core of it, you are going to be cut adrift by the board. Is that true?
Dame Jo Williams: Your proposition is that if there is real dissent-
Q45 Rosie Cooper: I have chaired organisations. I have dissented more than enough and I probably would have found myself out in the Irish sea or perhaps up in Antarctica by now. Dissent is absolutely to the core of everything. You sort it out. You don’t suddenly say, "Just because you disagree with me, we are going to cut you off." I don’t understand how you can go into a room and make that decision.
Dame Jo Williams: It is not my intention in any way, Rosie, to mislead you. It absolutely was not like this. This was a period of time over several weeks and months when my belief was-and other commissioners believed this-that we were addressing the issues and the concerns. That was our purpose. As to dissenting voices, you are absolutely right that you cannot expect a group of people who are doing a job like this always to agree. If we were all agreeing, we would be in terrible trouble, so that was not the point. The point was that, without discussing with us her determination to go further, she went to talk to the National Audit Office and then to the inquiry. There are processes and procedures that we have within the CQC that she did not choose to use. She could have gone to the Secretary of State, a Minister, to express her concerns. We were not in any sense underestimating anyone’s concerns within that board. The point I am making is that what she did-it was not that she should not and is not entitled to raise matters that concern her so deeply but that she was working as part of a group-was to choose not to let us know that that was her course of action, nor did she follow procedure.
Q46 Rosie Cooper: Can I ask you a question then? Was Kay Sheldon told by the deputy chief executive that she could go to Mid Staffordshire as an observer? Is it your knowledge that she was told she could go as an observer but not to give evidence?
Dame Jo Williams: I would have to come back to you on that. I do not know of an occasion when that question was asked. Is the proposition you are making in terms of our original evidence? I do not know the answer to that. I will come back to you.
Q47 Chair: Can I clarify that, Rosie? Kay Sheldon says very specifically that she told Jill Finney she wanted to give evidence at Mid Staffordshire and was told by Jill Finney that there would be an official giving evidence. We were further told by Kay Sheldon that the official had not at that stage agreed to give evidence and was told to give evidence by Jill Finney following her interview with Kay Sheldon. Is that true or not?
Dame Jo Williams: I do not know, Chairman. I received the information that you received late yesterday afternoon and I will need to come back to you on those specific points. I do not know. That is the situation.
Q48 Rosie Cooper: Could you come back?
Dame Jo Williams: Of course.
Q49 Rosie Cooper: Could I also ask how many compromise agreements have been signed in the time that the CQC has been operating and how many of those contain gagging clauses?
Dame Jo Williams: While David looks for the detail of that, can I also say that even though we did include compromise agreements-and I know they are now called gagging clauses-it was quite clear in every case that that would not preclude public interest disclosure.
Rosie Cooper: I am going to end my comments by thanking you for the information you have given us. We will look to get some more information, but I think that, David, as you take this organisation forward, a board member does not need the permission of other board members to do their duty.
Q50 Andrew George: In terms of the organisation itself, being the Care Quality Commission, obviously you want to be setting the highest possible-
Dame Jo Williams: Absolutely.
Q51 Andrew George:-quality standards, including in the area of medical ethics. That will of course include patient confidentiality and patient consent. In those circumstances, why was it that without Kay Sheldon’s knowledge you were seeking an independent medical assessment of her?
Dame Jo Williams: The situation was this. She wrote to me asking for an assessment. She said that-I do not have the exact words in front of me-because she was a disabled person with a mental health issue she was seeking an assessment. When I received that request, I was genuinely pleased that that was an opportunity to move forward. My initial response to that was to believe that the occupational health department-we had a contract with an organisation-would be the appropriate place to seek that advice. I notified Kay Sheldon that arrangements were being made for her to have an appointment.
Q52 Andrew George: That was done collaboratively because she was saying in her evidence that-
Dame Jo Williams: I wrote to her to tell her that was the case.
Q53 Andrew George: You told her.
Dame Jo Williams: What I did not do-and I am disappointed in myself that I did not do this and this was wrong-was send her a copy of the referral that I made. But I did let her know that that appointment was being made.
Q54 Andrew George: She says in her evidence that she had requested this.
Dame Jo Williams: Indeed.
Q55 Andrew George: Therefore, I think it is reasonable to expect-as she had made the request-that that should be done with both sides consenting. In other words, there should be a collaborative approach rather than you unilaterally going to Medigold and simply commissioning something, and not only commissioning something but commissioning it in a manner which did not fully consult her or she was not fully aware of.
Dame Jo Williams: I take the point you are making. As I say, at the time I felt this was an opportunity to make progress. It seemed to me that our occupational health contractors were the right people to approach. What I did not do was to talk through with Kay the making of the referral I made and send to her a copy of it. I agree that that was not the right way to move forward. Subsequently, when it was made clear to me that, in Kay’s view, she was asking for something different, we then did collaborate and look at what would be the most appropriate means of getting that assessment.
Q56 Andrew George: You are content that the person who was commissioned to undertake this work was qualified to undertake a mental health assessment. Are you satisfied that when you received a report-I understand it was a threepage letter-that, as you say, should be shared in a collaborative way? When that report came in, did you make any effort to show it to Kay Sheldon and to consult her about that report?
Dame Jo Williams: No. First of all, it was a record of a telephone conversation. It was not an assessment in any sense. My understanding is that the purpose of that conversation was to determine who would be the most appropriate practitioner to undertake an assessment. That was the whole purpose of the discussion on the telephone. Subsequent to that, the doctor who had had the conversation wrote the letter describing that conversation.
Q57 Andrew George: This communication included a number of comments about Kay Sheldon herself from someone who is not qualified to make assessments, saying that she is likely to have one of the conditions that involve paranoia. There were a number of other comments including that it was really important that she be "assessed or else removed from her position" and comments of that nature. Those comments were not shared with her at that point.
Dame Jo Williams: That is true.
Q58 Andrew George: Kay Sheldon, in order to find out what had happened, could only obtain that information through Freedom of Information requests-through a Data Protection Act request for that information. That is a very unsatisfactory situation, isn’t it?
Dame Jo Williams: It is unsatisfactory. I want to say two further things. In my duty of care and concern for Kay Sheldon, there were two issues that I want to draw to the attention of this Committee. First of all, at the end of September, when we had the meeting when she told us that she felt ashamed and embarrassed to be a commissioner, she disappeared from the room for a considerable period of time and it took us possibly well over an hour, an hour and a half to locate her. I was not there myself, but two senior members of the executive found her. She was very distressed. She wasn’t recognising her own name. She was in a toilet, there was water everywhere and she was completely wet through. There was genuine concern on my part for her wellbeing. Subsequently, later in the autumn, she told me that her reality was that when she walks down the street she believes that everyone is talking about her. So I had concerns about her wellbeing. That doesn’t in any way answer the question that you raise and you are quite right that-
Andrew George: Not only does it not answer the question, it reinforces the assessment she has made herself. Here we have a letter which was kept from her which-
Q59 Chair: The question, if I may say so, Andrew, was, is it appropriate for this assessment or preliminary opinion about Kay Sheldon’s condition to have been passed to you and not been shared with Kay Sheldon? Can we confine ourselves to that question?
Dame Jo Williams: Indeed, okay. Thank you, Chairman.
Q60 Valerie Vaz: I am sorry, but I have to say that you are making comments about someone who does not have a chance to speak against them. They are very personal comments and I feel incredibly uncomfortable that you should sit here in a public forum and say those things, which is just your word. No one has a chance to answer back. Please withdraw those comments now.
Dame Jo Williams: I will do. Chairman, I understood that in this arena I was at liberty to answer the questions put to me.
Q61 Valerie Vaz: You should not be making personal comments about someone who does not have an opportunity to put the case herself.
Dame Jo Williams: I withdraw.
Andrew George: The question I was asking was based on the evidence that was supplied through the-
Q62 Chair: The question you asked was a very narrow one, which is whether it was appropriate to share that letter.
Dame Jo Williams: Yes. It was not. I should have shared it with her.
Q63 Andrew George: It was not appropriate.
Dame Jo Williams: I beg your pardon. It would have been appropriate for me to share that with her.
Q64 Andrew George: It would have been appropriate.
Dame Jo Williams: Indeed.
Q65 Andrew George: You announced, two working days ago, your resignation. Was this episode anything to do with the basis on which you have decided to resign?
Dame Jo Williams: It is quite right that over the last 12 months or so it has been extraordinarily complex and difficult to make sure that the CQC board is working effectively. What I said when I told the Secretary of State that I was stepping down was that I was pleased that David had moved into the job, that I was confident that, with our new document and the strategy moving forward, there was an opportunity for us to move from strength to strength and a chance for me, having done four years with the CQC, to step down and step back. Of course, it has been a tough job, of which some of the things we are talking about this morning are a dimension. But it has been a tough job for a whole range of other reasons as well.
Chair: Can we move the discussion on, therefore, from Kay Sheldon’s case to the broader issue of whistleblowing and how that is dealt with by the CQC?
Q66 Dr Wollaston: Dame Jo, to make that link, can I quote from your letter to Kay Sheldon, in which you say, "your decision to place information into the public domain are not formal ‘whistleblowing’ but a self created opportunity to criticise decisions with which you do not personally agree." Isn’t that the excuse, if you like, that is made by all organisations to silence whistleblowers? Would you agree that that is true?
Dame Jo Williams: First of all, at that stage the concept of Kay being a whistleblower was not the point I was making there. As I have said earlier this morning, we were functioning, working together, trying to resolve difficulties and issues. The lifeblood of the CQC is receiving information, matters of concern, from people who may be working in an organisation. In no way would I wish the CQC to be seen as an organisation that didn’t support people and want them to speak out.
Q67 Dr Wollaston: Can I make the point perhaps that a care home, or indeed a hospital board, could make the same argument? They could say, "Look, we recognise we have troubles in our organisation and we are working together as a corporate body to address that. Therefore, what you are doing is undermining our brand or the corporate body and the board." It is a way in which whistleblowers are always sidelined, by accusing them of not acting with other board members to deal with the problem, even where that is in the public interest.
Dame Jo Williams: Yes, that is true, but I think it is also true to say what I have said before. There are processes for raising concerns and those processes weren’t followed. There is a duty when you, as a person who is called a whistleblower, raise a matter of concern to balance that against the potential impact on the organisation, thinking through what that impact will be.
Q68 Dr Wollaston: Surely if you took any private provider, for example, you could argue the same for them. Of course, it is going to have an impact on any care home or provider if somebody blows the whistle, isn’t it?
Dame Jo Williams: I can only say to you that, at the time that this occurred, I was trying to balance the CQC and our role in offering a very important service to the public.
Q69 Dr Wollaston: Would you do the same again?
Dame Jo Williams: I have learned a great deal over the last few months. If I had the opportunity again, of course I would want to do things in a slightly different way. I have already talked about the matter of engagement. But my fundamental concern was that the CQC should move forward with a board that could be effective. I did not believe at that time, because there had been a breach of trust and a relationship breakdown, that we could effectively work as a board and move forward.
Q70 Dr Wollaston: Even though, ultimately, her allegations turned out to be correct?
Dame Jo Williams: Her allegations?
Q71 Dr Wollaston: I mean her concerns about the CQC and the points she raised.
Dame Jo Williams: Some of the concerns did, but some of them remain unsubstantiated.
Q72 Dr Wollaston: Right. So, moving on to the wider point perhaps, the issue for whistleblowers is how do we support whistleblowers in organisations like care homes who want to make allegations? We know that professional bodies often support members who make allegations, but if you are a care worker in a care home without that professional body of support, how can you feel confident that your allegations will be taken seriously and you will be supported?
Dame Jo Williams: It is a very fair challenge and I am not sure that there is a simple answer to that. We are the regulator. When people pass information to us, if they choose anonymity, we can make sure that that is respected. But we know that, at the end of the day, it is our role to try to bring about that change, not directly supporting the whistleblower but bringing about the change so that the service improves. Good organisations now have very clear whistleblowing policies. That is one thing that we can look at as a regulator: what are the policies and support mechanisms that are in place? You are quite right that in some very small provider organisations they are less than robust, yes.
David Behan: May I supplement what Dame Jo has said? One thing that I have seen since I joined the CQC is the development of a policy with NHS Employers on whistleblowing to create this climate that Jo has been talking about. There has already been published a set of joint principles with, among others, the BMA, RCN, GMC and the Nursing and Midwifery Council in relation to these issues. The volume of whistleblowing referrals through to the CQC has gone from 50 after Winterbourne View up to about 500 a month and a dedicated team is now established at our call centre in Newcastle, which is dealing with these referrals as they come through. As I have already indicated in an earlier answer, Chair, there is an audit process of that work going on to make sure that we know where those whistleblowing referrals are going.
If you depersonalise "What have we learned since that?" and make it "What has the organisation learned?", then I offer that as evidence of some of the changes that have been made to try and raise the CQC’s performance in relation to whistleblowing. There is still much to do, but I think that is some sense of a signal about how we want to take whistleblowing seriously and respond.
Q73 Dr Wollaston: You started with a team initially of six people to handle the whistleblowing call centre. How many people now are manning that team?
David Behan: The number is still about six. They are managing to do that well. They are the team that receive them. They then pass them on to our inspectors and that is the process that goes through. I don’t particularly like this word, Sarah, but they are the "field force" that would then go out and make those investigations that take place. The team of six are acting to receive these and respond to them. I referred earlier to the fact that we publish the times, meaning the length of time it takes for us to respond to those claims coming through. The issue is not the time it takes us to respond to them-that is important-but what the outcome is.
That is why I mentioned earlier that the audits, and what we know of those audits that go through to safeguarding teams, are those which trigger responsive inspections. I am not saying that is a definitive answer, but I offer it as some evidence of changes which are taking place as a consequence of the challenges relating to whistleblowing that have been made which sit underneath the answer that Jo has shared with you.
Q74 Dr Wollaston: Those whistleblowers would receive feedback as to what had happened to their complaint?
David Behan: Can I come back to you on precisely what that is? This is one of the difficulties, isn’t it? I say yes and then you have a case of somebody that did not get feedback. Our principles and standards are that people do know what happens to those referrals that come through. I would like to think that all of our practice meets those standards. Rosie Cooper is busy nodding as I am saying this.
Q75 Rosie Cooper: I was there.
David Behan: I know you observed this, Rosie.
Q76 Rosie Cooper: Absolutely. If the calls are not anonymous, then they do go back to them. That was exactly what I saw.
David Behan: Yes.
Q77 Chair: Does the CQC regard the report of a whistleblower from a particular provider as evidence that the culture within the provider is wrong? Surely the proper course of action in a healthy healthcare organisation is for the concern to be raised and dealt with through the local channel and the professional regulator. Almost by definition, if somebody feels the need to report as a whistleblower to the CQC, it is evidence of something going wrong within the provider, isn’t it?
Dame Jo Williams: That is a very fair point, Chairman. I do not dispute that. That should be a trigger in itself, but I think we are also recognising that some of the calls we are getting are very highrisk situations, so it may be, for instance, there is an issue of safeguarding an individual. But you are quite right that if an organisation is not dealing appropriately with people that are raising concerns, it is an indicator.
Q78 Chair: By extension, if an inspector goes to a provider, do they ask for the evidence of concerns that have been raised locally and what has been done about them? Also, how would they react in the case of a provider where the answer was, "We had no concerns raised"?
Dame Jo Williams: I am not sure that I am able to answer that question, Chairman.
David Behan: One way we have-and again apologies for using jargon or technical language-is a quality risk profile, which is, in a sense, an intray in which information about a particular service is received, whether that comes from a member of the public, a member of staff or another organisation. It is that which inspectors are using to inform their judgments about where to prioritise inspections and what are the kinds of issues to be raised. I am currently signing all the letters of response that you and your colleagues here in this building send to us. One thing that we are trying to do is make sure that we give both you as MPs and individual members of the public feedback, if it is not an issue that we can help with, about where to get that help and how that might be resolved. The reason for this is so that we can both collect the information and ensure that people get some feedback.
What we are trying to do, Chair-and I am deeply committed to this-is have it so that we should view complaints information about us and whistleblowing information about services as free intelligence. We should be open to use it in a way that allows us to ask questions when we visit such as, "Is this true? What does this mean? How do we move forward?" The creation of that approach is one that I remain committed to. The organisation is committed to it. Jo has been indicating that in her answers as well. Yes, there have been challenges about the way we have responded to allegations generally about whistleblowing, but we, I hope, are setting out through the strategy what we intend to do about that and how we intend to move forward.
Q79 Chair: The reason I raise the question in the way that I do is that it seems to me that the ability of a healthcare provider or care provider to respond to concerns raised locally is a very good proxy for the culture within the organisation. My answer to my own question, "Is it plausible for any but the tiniest provider to have no concerns raised between inspections?" is that it isn’t plausible and that if the answer from a provider is, "We have had no concerns raised," it is prima facie evidence of the culture being wrong.
David Behan: Yes.
Q80 Chair: To be honest, that is the answer I was hoping you would give me.
David Behan: Thank goodness this is not the interview, but I think you are right. There has always been this debate, hasn’t there, about whether a number of complaints are evidence that a system is working effectively, because it is encouraging people to feed back and the organisation to learn from that, and that an absence of complaints is not a signal that this is a good service but indeed a signal that this is a service that might be not encouraging that kind of feedback and moving it forward? I apologise for misunderstanding the question, Chair, and can I say I agree to your answer to your own question?
Q81 Rosie Cooper: Do those answers reflect your view of the CQC as well? In terms of Kay Sheldon and people who were having a view, or complaints, why did you not see that as almost a mirror on the culture of your own organisation?
Dame Jo Williams: I do take the point that you make, of course. What I tried to do this morning, particularly in relation to the evidence that you have been given, was explain the context within which I was working, and I can say no more.
Q82 Andrew George: I have a brief question, but preface it with congratulations to the CQC for a recent case that I referred and the very appropriate manner in which the CQC spoke to and referred to whistleblowers in that particular case. That was a recent case, so I want to say that, obviously, the procedures were satisfactory.
Following on from Stephen’s question, I want to ask about whether and to what extent you see a pattern of the most serious cases which have been raised by whistleblowing being by those whistleblowers who have failed to use internal processes within organisations, or the extent to which internal and organisational processes for concerns being raised have been fully utilised and yet still the whistleblower remains frustrated and disappointed by that response. Is there a pattern? Can you draw anything from that?
David Behan: That is a good question.
Dame Jo Williams: It is a very good question. My response is that I do not think we have differentiated in that way. As David has indicated, there will very soon be an audit looking at whistleblowing calls. We should consider that and think about whether or not there is some learning to be had from the very point that you make. Thank you.
David Behan: We will build it into the audit, Chair.
Q83 Barbara Keeley: In many cases, the families of people using health and social care services have an intimate understanding of the services and would be the first to see if people are left soiled, undernourished and that sort of thing. Are their concerns about a particular service or an organisation going to be treated in a similar way to those of whistleblowers? Can they be? Is there one process for staff whistleblowing and a different process if it is a family complaint? Do you see them as different things? You said, David Behan, that you see them as free information that can be used, but I think it is very important to people how what they say about a service and what they have found of it is treated.
David Behan: In a strict legal sense-and far be it from me in this building of all buildings to comment on this, but you would know that-personal interests disclosure legislation does set whistleblowers apart from others, but-
Q84 Barbara Keeley: But the way you handle it is the important thing.
David Behan: But, in a sense, you talked about procedures. I want to make that distinction so I am not avoiding the question, Barbara, and you have done as much as anybody to champion issues around carers and how their voice should be listened to. It is our determination that we should treat people with compassion and see services that treat people with compassion as well. So yes, we do need to listen to what people are telling us about services and begin to incorporate those comments. Andrew George’s point about detecting any patterns in what people are telling us is one way that I think we need to develop in the work we do over this next period of time.
What are the trends? Valerie Vaz began the question about the evaluation-and this is exactly the point-and what do we know and what is important about what we do. For proper reasons, Chair, Members have raised issues of concern about us. I am grateful to Andrew George for raising issues about where we have got things right, and you have been able to see those things have been got right and that improvements have taken place. We need to listen to these bad cases and also learn from our experiences of what goes well. It is important that our learning goes right across the spectrum and does not only go on the cases where we have not been as successful.
If you look at the volume of activity that the CQC goes through on a daily basis-let alone weekly, monthly or yearly-we come into contact with considerable numbers of members of the public and it is important that we listen to them. But we are in a legal process, so when we take action we need to ensure that we have the evidence that would stand up to challenge when it is placed in those formal processes. Also, quite properly, people have a right of appeal. In answer to Virendra Sharma’s question about delay, collecting the evidence which can resist any challenge in a legal process will take time. Our job is to ensure that we do that as speedily and quickly as possible for those urgent cases and we are committed to doing that and improving. We will listen to both complainants and whistleblowers on what they tell us about our effectiveness and build that in.
I do a newsletter. We got a tweet back saying, "Your whistleblowing number is not prominent enough on your website." One of the things we will do is make sure the whistleblowing number is prominent on the website so that people do not have to go looking for it. It is a small bit of feedback which has led to a decision and an action which will make the number more prominent.
Q85 Barbara Keeley: Can we go back to the care-home sector? I made the comment earlier from the written evidence from the Relatives and Residents Association that it thinks you do not have sufficient expertise. There is also the question of the volume of inspections. Given that 62% of adult social care locations were inspected last year, and in fact the inspection regime almost ground to a halt the year before that, can you tell the Committee how many adult social care locations have not been inspected? You had a year when it ground to a halt. Last year it was 62%. How many have not been inspected?
David Behan: I did not anticipate that question, Chair. Where are we up to in terms of our inspection programme? I will get the exact figures. We have 35% of all NHS inspections carried out.
Q86 Barbara Keeley: You do not have a breakdown for social care.
David Behan: Can I come to it, Chair? We plan to hit that target, so it is green rated at the minute on our risk register. For adult social care, we have 27% of all adult social care inspections which are completed. That is, more interestingly, behind our plan. That is amber rated. I am now receiving weekly reports so that we can make up the ground to deliver on our plan. We are aiming to complete that plan and working hard to do that. In relation to independent healthcare, dentists and ambulances, we are behind our plan. They are red rated and, again, there is action in place to make progress.
Q87 Barbara Keeley: Let us stick with social care for the moment. It clearly has been demonstrated that large case loads for inspectors adversely affect the overall quality of inspections. I don’t think anybody would be surprised about that. You have talked about numbers earlier and recruitment. Have you had success in reducing case loads and is that continuing to be an objective? Also, have you acted on the Committee’s recommendation to track staffing ratios, because there is a concern about the ability of staff to highlight risk? That is the key thing that they are doing now.
David Behan: Yes. These are all very good questions, Chair. In terms of the case loads that our inspectors carry, the average is 41 and the range is from 30 to 70. There will be some outliers on that and outliers at the top end where there are vacancies. We are going through the recruitment process and that was the answer to Valerie’s question earlier. So they are figures as of this morning. We are running these figures on a weekly basis. This Committee’s challenge last year was in relation to whether we have a work load planning tool. A considerable amount of work has been done on that. I was briefed on this last week, not because of this but because I was new to the job. There has been some excellent work in relation to that, if I may say so to my colleagues who have done that work. It is not yet complete. We need to do some further work.
Interestingly, some of the things we need to tease out-and again, Chair, apologies if this sounds too technical-are how do you benchmark with a homebased work force, who else has a homebased work force, how do you get a benchmark for key issues and how do you work that through in a way that is consistent? I was pleased to see in the trades union evidence to the Committee that they acknowledge that those conversations are going on. This is a conversation we are having with staff representatives as well as staff to try and get this right. I am encouraged by that work rather than thinking it is completed. We need to run that on an annual basis, Barbara, in relation to how that informs our annual business plan to make sure that, of the tasks we have, we have the resources there.
As Jo said earlier, we have moved from a period of the CQC being set up, where you have to go through this registration process and these huge numbers of services being registered for the first time, and are now into what we have called the forward strategy, "The next phase". It is clear that having registered those services we are now in this inspection period where, in a sense, we are going to go through, refine and develop our inspection methodology. We need a work load which reflects the next phase of our development, which is much more about inspection than it is about registration. Good progress is being made and we will continue to be open in the way that we discuss and take these issues forward.
Q88 Barbara Keeley: Would you say there is a lack of consistency across regions because providers are concerned that there is inconsistency between regions?
David Behan: Yes.
Q89 Barbara Keeley: You mentioned finding difficulty recruiting in London and the south-east. Could you touch on how inspectors understand which standards apply in different cases and is there central coordination? Clearly, we do not want a situation where there are different standards applied or where you are so short of inspectors in London and the south-east that you cannot maintain the same standards there that you do in other parts of the country.
David Behan: That is absolutely right.
Dame Jo Williams: We have established our own internal quality assurance team to address the point that you make, making sure that there is, as far as possible, consistency in the application of those standards.
Q90 Barbara Keeley: Do we accept that at the moment there is inconsistency and a regional problem?
Dame Jo Williams: Yes.
David Behan: I am not saying that I think that is linked to the amount of resource, Barbara. I think it is important to agree with you about the issue of consistency. From being appointed to taking up post, probably the most oftenquoted issue to me saying "Please sort this out, David" was consistency, particularly from the larger providers that provide in more than one area.
Again, as Jo has said, at both a national and a regional level there are arrangements put in place to assure the consistency of our decisions, so it is something, again, that the organisation is trying to respond to. It is a desperately difficult issue to deal with, as I think members of the Committee will know. How you can get consistency on a multiplicity of interventions going on nationally is very difficult. What we need to ensure is that the organisation is performing to meet the standards it has set for how it should perform. Where we want inspectors to make judgments based on their professional background-and I think that was in the evidence you have received-then you are going to get difference. I am looking at Dr Wollaston. Not all GPs determine things in the same way, as not all inspectors will determine things in the same way. I am not making a frivolous point here. You have audit as a way of ensuring consistency with standards and I think that is exactly what the organisation has done. It has introduced some systems to try to assure consistency in our approach. It is an absolutely legitimate and appropriate challenge.
Q91 Barbara Keeley: Have you measured the impact removing the central investigations team had on the quality of investigations and the level of expertise you were left with to deploy into the more complex and challenging situations?
David Behan: Personally-and this is week four-no, I have not.
Q92 Barbara Keeley: Will that be done? It sounds like it should be.
Dame Jo Williams: Part of our strategic document is very much looking at the whole issue of differential regulation. I think David talked about that earlier. We have also recognised, by having the register of associates-professionals-that that strengthens the inspectors and they are available to them to use if they believe that they are in a situation where they need additional expertise. What we have done to date is recognise that that is a way of strengthening an inspection, but we hope, through the consultation process, that we will hear back from those who are directly involved in our work, and we will need to consider those reflections. If necessary, we will, over time, change the way in which we regulate. As David has said, we want to use evidence, want to look at what is happening around the world to inform the best way to carry out inspection in England.
Q93 Andrew George: Do you believe that you have all the powers you need in order to fully interrogate and to complete inspections?
David Behan: That is an interesting question, if I may say so, Chair.
Q94 Andrew George: I can give you an example if you want. The example is, in the case I was referring to earlier, that the CQC indicated to me that it did not have the powers to forensically interrogate some crucial information in a callhandling system, to find out whether there had been any manipulation of the data. It didn’t have the forensic powers to go that step further to interrogate and to satisfy itself that the information it was being given was robust and accurate. If that is the case, to what extent are you undertaking an inspection but you can only go so far and you get to a point where you do not have the powers to interrogate or crossquestion the information you are given?
Dame Jo Williams: There is a review of the regulations going on, so we need to take that point away and also talk to the inspectors on the ground about it because that is a very important question that you raise there. It is taking us into new territory, I think. The question in my mind is that we do sometimes refer to the police and I think it is about what would be our appropriate role visàvis another organisation. But we must take that away and consider it.
Q95 Chair: Could you write to us when you have had a chance to reflect on it?
Dame Jo Williams: Yes.
David Behan: The point I would want to emphasise, Chair, is exactly this latter one about the issue being not only about our powers but about how our powers sit with other organisations. You have previously encouraged us to work with others. Part of it is that, but, as Jo has said, there is an important conversation going on with the Department at the present time about the adequacy of the regulatory framework. I think Grahame Morris’s question about fit and proper persons is why I smiled when you raised the question about adequacy. It seems to me that the legal framework and the regulations always lag behind what we know about practice. Therefore, the issue is how that can catch up. It is important that we have this mature dialogue with the Department about where we need its help in terms of the framework that we operate in to actually move forward.
Q96 David Tredinnick: It seems to me, assessing what you have said this morning, that there is quite a range of areas where you are still thinking about what you should be doing and what resources you should be deploying, yet when you came before this Committee in June 2011, Dame Jo, you told us that you needed an additional £15 million. You also qualified that by saying that the CQC could fulfil its existing obligations without additional resource.
Going back to what I have just said, there seem to be areas where you are not very sure about what you are asking for or for what you want the money. Let us focus on the £15 million for a moment. Could you illustrate how the allocation of an additional £15 million to your budget will enhance your work, please?
Dame Jo Williams: We received an additional £10 million and our priority was to recruit additional inspectors. David, as he says, has only been with us a very short time and one question he is already raising is the extent to which we have an appropriate distribution of resources across the CQC. That will be work in progress, I think, over the coming months. It will be influenced by the response to the consultation document but, quite clearly, we have a number of people who are involved in analysis and data analysis. Do we have people with the right competencies, possibly in terms of management information? These are key questions that are appropriate for a new chief executive to bring in. But the fundamental issue for us was getting people on the ground carrying out the inspections.
Q97 David Tredinnick: The resource model point of information I have-you have agreed with the Department-includes 200 more fulltime equivalent inspectors and 20 more fulltime compliance managers than you had at what was then the present. However, last year you managed to meet your core inspection targets. What will you be doing in 201213 that you weren’t doing last year?
David Behan: More inspections, Chair.
Dame Jo Williams: It will be more inspections, but-
David Behan: We have more people on the ground, more inspections will be done and we will be publishing thematic inspection reports. We have completed the report on Winterbourne View and we have reports on "Dignity and nutrition" with over 250 inspections that we will report on.
Q98 David Tredinnick: You also told the Department that 580 other inspections had been forgone as a result of launching inspections into the termination of pregnancy services at the request of the Department of Health. Could you explain that a little bit? What does that mean exactly?
Dame Jo Williams: Perhaps I could help there, David. The point was that those inspections were completed but in a different timeframe. They were completed after the followup to the abortion clinics, the termination of pregnancy work. Having said that, what was absolutely clear was that if people were moving from one piece of work to another and following up on the termination of pregnancy work, we were not failing in our duty to follow up inspections where there was information suggesting there was high risk. Those 580 inspections were delayed somewhat.
Q99 David Tredinnick: Which is another way of saying, "We were unable to carry out inspections which we had intended to carry out because of the additional burden that the Department had put on us", and in a sense it was firing a shot at the Department, wasn’t it?
Dame Jo Williams: It was at a later time that they were carried out, yes.
Q100 David Tredinnick: So they were delayed.
Dame Jo Williams: Yes.
Q101 David Tredinnick: Were there any consequences that you are aware of? Did these delays result in unfortunate circumstances?
Dame Jo Williams: Not that I am aware of.
Q102 David Tredinnick: Do you think there are any inspections that should have been conducted that have not been conducted as a result of that situation?
David Behan: If I may, Chair, this goes back to Barbara Keeley’s question about where we are on the inspection programme. If I have the sequencing of this right, the issue that you are referring to was in the earlier part of this year, in March. Barbara’s challenge to us is where we are on the inspection programme. I can only do it on our progress against the trajectory to complete all of our inspections and, as I said, we are currently rating that as amber. We are at about 27% and we should be at about 35%. What I have asked for is work to ensure that we can complete our programmes by the end of the year. So in reply to your question-your proper question-about whether we have displaced any of our mainstream activity in order to do that, we should absorb that as we go through the year.
The additional inspectors are coming on through the year. As I said, in April of this year, we had 197 vacancies across the organisation-that is more than just inspectors-but now we have 49. As I hope I indicated, there are 75 interview slots which are set to take place. Providing people are of the right quality, I am optimistic that we have made considerable progress on bringing in the right calibre of people to be able to undertake the jobs which are supported by that additional £10 million from the Department which has allowed us to bring in potentially up to 250 additional inspectors. So I think, David, we are making up the ground.
Q103 David Tredinnick: So you say you are making some progress?
David Behan: Yes.
Q104 David Tredinnick: That is reassuring. This is my last question. We were talking in the briefing about your earlier request being for £15 million, but the discussion has focused on £10 million. What happened to the £5 million?
Dame Jo Williams: We asked and that is what we got.
Q105 Chair: I will remind you that the Committee did not back the £15 million request because we did not think it was substantiated last year.
Dame Jo Williams: We got £10 million.
David Behan: Hence the work load management system, Chair, and the planning tool which allows us to get to an absolute figure based on work loads.
Q106 Grahame M. Morris: I want a bit of clarification on a question from one of my colleagues a little earlier. You asked a rhetorical question, "How do you benchmark performance?" and you particularly mentioned the complexity of organisations, the homecare work force and so on. It is difficult, but what was your rationale-apart from criticism from the Health Select Committee and the Public Accounts Committee about lack of focus-for deciding to scrap the social care excellence awards? Wasn’t that a means of benchmarking or demonstrating performance?
Dame Jo Williams: It predates David, so I must pick up that question, if I may, Grahame. The rationale was that we were working to different legislation. The new legislation was very much about the essential standards and focusing on outcomes for people. It was about "Is this service compliant or is it not?" Our predecessor organisation had created the star ratings and we recognised that, for many people, they were proving to be valuable, but we weren’t regulating against the same regulations, so that was the rationale for it. Perhaps David will pick up where we are now because, within the social care White Paper, I think there are some proposals for moving that forward.
David Behan: There are. In a sense, the Department, in its White Paper, made some propositions relating to rating systems. Interestingly, some of the large corporate providers-I am not sure, but I think in your evidence pack there is information from Peter Calverley about ratings and I do not know whether his organisation is involved, but this was covered in The Guardian yesterday about the providers themselves taking an initiative to ask Ipsos MORI to do surveys of their own residents to demonstrate it.
Going back to earlier questions about what is our role and what is the providers’ role as to driving quality, I have to say I commend those providers for taking that initiative and publishing that in a public way because that is providers taking responsibility themselves for driving quality in their services. There are some interesting conversations for us to have around "How does that fit with the regulatory framework that we have?" But this fits with a bigger theme, which is, how does the information we collect go on to our website in a way that is accessible for people, to give them information about the quality of services?
I do believe some progress has been made. One of the interesting things is that there is a piece of development work going on, test work, as to whether we can link between our website and a provider’s own website so that people can go on to-forgive the name-"Happy Valley Nursing Home" and immediately click straight to the last inspection report to see what it said. That will give an immediacy of feedback. One criticism that comes through is people’s difficulty in finding the inspection reports, so how can we make that easier?
There are some developments we are going to make to the website, going back to your commissioning point, Chair, as to sorting providers by local authority areas, so then commissioners can see that. Interestingly for this place, we will be doing them by constituencies as well and then Members of the House may find it easier to find out what are the services in their areas.
Q107 Grahame M. Morris: It would be quite difficult as well, with a large public sector organisation such as an NHS trust that provides a range of services in a range of different locations, to rate it using a star rating or a trafficlight system overall for performance, as most of it may be excellent but there might be failings in a particular part of it. But in terms of the profiling-and we are waiting for the detail from the Government’s proposals-do you think there should be an element of, and you touched on it before, a complaints system like Trip Advisor? This is much more serious in terms of choosing, say, a care home for an elderly relative, but do you think, in assessing the criteria for the provider profile, there should be some element of feedback from complaints in there? I am only asking for your opinion.
David Behan: Yes, I do, and alongside-if I may go back to the job I have recently left-the White Paper there was an announcement on the day of the White Paper by some of the major providers, and I think Peter Calverley’s organisation was one of them, that they would agree to publish information, the score card, if you wish, of their organisations and that would include the number of complaints received. So the sector is beginning to change in responding to this and so is the leadership by those large national organisations. One of our challenges is how we can reinforce those initiatives so it does not simply trickle down but other organisations begin to respond in that way.
Q108 Chris Skidmore: Going back to the figures regarding inspections, I understand you have performed 18,000 inspections in total in the previous year, and that was with 750 inspectors, rising to about 900 now, say, so you have 50 vacancies still to fill. In our brief we have been told that the plan is for 31,000 inspections in 201213. I couldn’t see that in your document, but I wonder if you could confirm that that is the anticipated trajectory of rising inspections. Do you have any concerns about whether you will need an increased number of inspectors in the future? Obviously, it is a significant rise on the 18,000 the previous year, but can the 950 cope with doing 31,000 inspections when 750 to 900 did 18,000 before?
David Behan: That is an absolutely legitimate question, Chair, and it goes right to the heart of the line the Committee has been pursuing about whether we have a work force planning tool that allows us to do this. I said we would monitor and evaluate this, that we would do this on an annual basis. At the minute, I am being reassured by the teams that are responsible for this that they have a plan to bring us back to that trajectory. Can I come back to the Committee, Chair, on whether the absolute target number is 31,000? I would not want to commit to that without being reassured of it. We have plans in place based on the numbers, but I would want to come back on the precision of your question.
Chris Skidmore: Sure. Secondly-
David Behan: I am sorry-I do apologise-but we need to be more productive as well. I do not think this is only about absolute numbers. We need to be productive within that. There is an issue about our efficiency and effectiveness and how we move forward.
Q109 Chris Skidmore: In terms of the timescale of inspection, would that be a threeday or a week’s process? How long would an individual inspector be expected to take, from beginning to end, to put together a report? Going on the 31,000 inspections with 950 inspectors, that is roughly 31 to 32 inspections a year per inspector, but that is probably rising from maybe the 18 or 20 they are doing at the moment.
Dame Jo Williams: It seems to me that there is not a very simple answer to the question that you raise. The work force model will be working on averages but, quite clearly, if an inspector goes into a large institution, that is quite different from a small place and, of course, it also is influenced by what they find. Those are the kinds of variables which will affect the time scale.
David Behan: As to the benchmark information, on average an inspector is doing an endtoend process and it is about one every five days. The point is, can we bring some of that down to one every four days in relation to some of the simpler issues that Jo has raised? There will be more complicated issues-a multisite hospital is not going to be done in the same timescale as a dental practice or a threebedded care home. The figure we are going for is 31,915 at the end of the year.
Q110 Chris Skidmore: Another figure-I hope you do not mind me bringing it up-is that of the departmental underspend in the past two years. There is roughly, I see from the letter from Richard Douglas, about £13 million as a result of staff vacancies. Once you have then fully filled the vacancies, that underspend will disappear.
Dame Jo Williams: Indeed.
Q111 Chris Skidmore: If you have a £13 million underspend and you have vacancies, just off the top of my head, that means there will be at least a £2 million-
David Behan: Projecting the variance for the year end of this financial year, Chair, it is about £7 million. It is down from the £13 million last year. We do not have all the inspectors in, in the full year. That was my answer to Valerie earlier. Currently, as of my conversation with the director of finance yesterday afternoon, we are projecting a variance of £7 million at the year end-interestingly, in that there is over-recovery of income as well.
Q112 Chris Skidmore: In terms of registration fees, they are paid annually into the CQC?
Dame Jo Williams: If I could be clear, registration is a oneoff process.
Q113 Chris Skidmore: Does that not create a structural problem for the CQC as well, given that the large amount of your money, £92 million to £93 million, is in registration fees?
Dame Jo Williams: I am not intending to mislead you. Registration is a oneoff process but there is an annual fee.
Q114 Chris Skidmore: Yes. To reverse that, you are getting an annual registration fee. As you increase the number of people being registered, could you then be weaned off funding by the Department?
Dame Jo Williams: That is the idea.
Q115 Chris Skidmore: It has gone from £50 million to £60 million, but, obviously, hopefully, you could be selfsufficient.
Dame Jo Williams: That is right.
David Behan: We are on a trajectory, for our regulatory activity, of full cost recovery.
Q116 Chris Skidmore: When would that take place?
David Behan: We are about to publish a document for consultation on our fee structure which picks up on exactly the point you and Jo have been teasing out about what the annual fee is and how we determine the fee for services new to regulation, dental practices, GP practices and how you do it, by practice size, geography or by locations. How do you calculate an appropriate fee? There is a consultation document being developed, which we are about to publish, which will open up this conversation in exactly the way that you are referring to and allow us to explain the approach we are taking to full cost recovery and what fees will be contributing to in relation to-
Q117 Chris Skidmore: To refresh my memory, the scale of the fees at the moment still varies, doesn’t it, between various locations and practices?
David Behan: It does. It varies between locations and sizes. What we are trying to do is be absolutely clear and consistent in the way we are structuring that fee.
Q118 Chris Skidmore: In terms of registration, when do you anticipate full registration of services? I know that is obviously dependent on new services being opened-dentistry and everything together.
David Behan: The dentists are registered. We are currently on general practitioners. We have asked people to notify us. I think out of 8,000 there is something like about 7,500 that had notified us by last week. That is about 95%, we think. We are working with all the associations that support general practice in relation to that and, as of Friday evening, we had 60 people that had registered. It was interesting that Tuesday last week came and went and we begin registering GPs on the Tuesday of next week.
Q119 Chris Skidmore: And the current fee for GP registration at the moment is-
David Behan: Blimey. I will have to come back to you on that.
Q120 Chris Skidmore: There is the potential to cover costs and reduce reliance on the Department of Health, but you have yet to have an end point on which you will say, "We will have full recovery of our costs."
David Behan: Yes. We are on a trajectory, Chair, to full cost recovery, rather than being at it.
Q121 Chris Skidmore: When would you anticipate full cost recovery? That could then influence the level of the fee increase on GPs, couldn’t it?
David Behan: Yes, it does. That is the issue we are trying to tease out about what the combination is between the fee level and granting aid from the Department.
Q122 Chris Skidmore: Do you think you would be there by the end of the CSR, in terms of when the next settlement comes around?
David Behan: Why don’t we send you the consultation document, Chair, and I will be very happy, if you wanted a separate meeting on the fee structure and what that would mean on the trajectory, to come and see you and go through that with you?
Chris Skidmore: Okay.
Q123 Dr Wollaston: Can I follow up on the point about GP registration and how you are going to avoid duplication and unnecessary bureaucracy? Of course, the GP practices are already accredited by the Royal College and they are going to be registered by the NHS Commissioning Board. Do you think it is going to be necessary for the NHS Commissioning Board to register them in addition or could there be a process whereby you can streamline that?
Dame Jo Williams: If I could begin the answer to that-David may want to follow on-the point you raised about accreditation systems is very important and it doesn’t only apply to primary care. It is an issue that we say in our consultation document we do want to consider, how we can utilise accreditation schemes to inform and safeguard the public by recognising that certain schemes are very sound. So we are keen, as a regulator, not to duplicate. We want to go in where we believe there is a high risk. You are absolutely right. We are going to be talking. We have been talking with the sector about our respective roles and responsibilities. The difficulty for us at this stage with primary care is, of course, that we have never done it before. We will next year want to explore, through our inspections, what we are identifying as the risk issues and talking to, as you suggest, other organisations about how, together, we make sure that there is quality service.
Q124 Dr Wollaston: You touched on this point before, that one of the themes about wellfunctioning organisations is that they carry out their own accreditation and internal audits-
Dame Jo Williams: Yes, absolutely.
Q125 Dr Wollaston:-and how you can create that bowwave of encouraging good practice rather than only creating another whole raft of bureaucracy. So you are confident you are going to do that rather than-
Dame Jo Williams: What I am saying is that we are considering this. It is certainly one issue that we have identified in our consultation document and we will be interested in what people say in response to that, but it feels appropriate to me that, in terms of using our resources properly and targeting them on organisations where there may be difficulties, that is the right way to proceed. We should acknowledge those organisations that are getting to grips, as you say, quite rightly, with quality assuring.
David Behan: Briefly, if I may-and I know you want to move on-this is an important point. There was an advisory group that comprised the BMA, the Royal College, the Family Doctor Association and the NHS Alliance. They have overseen the work we have been doing on this. There has also been a provider reference group. That has involved, I think, GPs and practice managers to make sure that exactly the points you are raising about how this fits together are actually taken forward. Of course, we are going to learn from the way this goes. These are organised in tranches. It will be interesting to speak to these early adopters, these 60 that have already done it, got on with it and got their application forms in.
We are making contact with those practices that have not yet notified us. There are still about 5%, 6% or 7% of GPs that have not yet notified us. This is on a digital platform. We have tried to strip it out to make it easy and less burdensome. We have calculated that the application form takes no more than 90 minutes to complete, having taken to heart some of the challenges about what we have learned from our previous methodologies. I have to say, coming in and seeing this, I have been very impressed by the simplicity of the approach that has been taken.
The additional year that resulted from the discussion with the Department of Health about deferring registrations I think has been put to good effect by allowing exactly those conversations with the professional associations to make sure that the approach that is being taken is something that people are familiar with and aware of and we will spend time over the next period-and I will personally spend some time-going round meeting doctors’ leaders to discuss the effectiveness of the system.
Chair: We are going well over the estimated two hours. Valerie has a quick question.
Q126 Valerie Vaz: I have a quick one on that. As to outofhours providers, you register them separately, do you, and they are all registered now?
Dame Jo Williams: Yes.
Q127 Valerie Vaz: Have you inspected any outofhours providers?
Dame Jo Williams: We have indeed, and your colleague Andrew George, I think, was referring to an inspection that we carried out in Cornwall in relation to an organisation that-we heard from a number of sources-was not delivering appropriate care.
Q128 Valerie Vaz: That was after a complaint as opposed to one of your inspections.
Dame Jo Williams: It was, yes, that is absolutely right.
Q129 Valerie Vaz: Can I change the subject slightly? It is really to do with the HFEA and HTA. Whose idea was it to include them in the CQC? Was it the Secretary of State? Was it a political decision or was it something that came from you?
Dame Jo Williams: It certainly came as a consequence of a Department of Health review of all arm’s length bodies. The Government determined that the number of arm’s length bodies should be reduced and that there was potential for those two organisations moving into the CQC.
Q130 Valerie Vaz: Do you have the experience and the capabilities to oversee them and why?
Dame Jo Williams: There is a consultation document out at the moment. We will be discussing this at the board next week. It is proposed that the change would not be until 2015, but, as things stand at the moment-and we have talked over the last couple of years, and certainly this morning, about our determination to deal with what we are dealing with, and deal with it well-we will make it clear that, for now, we would not wish to take on HFEA and HTA. We have said that already to the Government but we recognise that if, at the end of the day, that is a Government decision, of course we will get on with it. But we would need to make sure that the expertise came in to the CQC. We have done a lot with them in terms of sharing backoffice costs and we are also very clear that where there is overlap we should avoid duplication and share data and information. That is taking place.
Q131 Valerie Vaz: Do you see any issue in relation to their remit over other devolved administrations compared to yours being only in England and Wales?
Dame Jo Williams: I think that indeed is an issue, yes. We are England and they extend beyond England.
Q132 Valerie Vaz: So nothing is going to happen until 2015 and obviously it depends on the consultation. If the consultation comes back and says, "No, we don’t think it is a good idea," you will not go ahead with it, or you will put the case for it not being incorporated.
Dame Jo Williams: We will be making the case that we want to focus on our current work load but acknowledge that if Government are so minded to make that decision we would get on with it.
Valerie Vaz: Thank you very much.
Q133 Chair: To be very clear, you are contributing to the Government’s consultation on this.
Dame Jo Williams: Indeed, we are.
Q134 Chair: You are arguing that HFEA and HTA should not become part of the CQC.
Dame Jo Williams: We are not saying it should not, quite like that. We are saying that we appreciated that no change is likely until 2015. That gives us time to strengthen our organisation and, as I say, if, at the end of the day, a decision is made, we would have to get on with it.
Q135 Chair: I will rephrase it. Your preference would be that they will not.
Dame Jo Williams: Exactly, Chairman.
Q136 Chair: Thank you very much. Could I ask a very specific question also about HealthWatch? Part of the CQC which perhaps comes up slightly less than instinct suggests it might in a hearing of this nature is HealthWatch. Could you tell us whether you are confident that that will have an independent voice and a sufficiently authoritative voice and perhaps that we have finally emerged from however many years it is of endless change of what started with the CHCs and has been through so many chapters that most of us have forgotten the ones in the middle?
Dame Jo Williams: Okay. I will begin by saying that, as you know, the chair of HealthWatch has been appointed. She is currently recruiting members of her committee. It will indeed be a subcommittee of the CQC, but already, through preliminary conversations and also through the way in which HealthWatch has been set up and public expectation, it will most definitely have independence of voice. There is no doubt about that. The CQC regards the development of HealthWatch as a real opportunity. We hope that, through its connections with local HealthWatch organisations, it will be an increasing rich source of information for us as we carry out our work. But we are absolutely committed to the chair of HealthWatch and her committee speaking out unfettered by the CQC. It is entirely appropriate that that is the case.
Chair: Thank you.
Q137 Dr Wollaston: I have one final question on the issue of your role in monitoring the operation of the Mental Health Act.
Dame Jo Williams: Yes.
Dr Wollaston: Do you feel that that is the appropriate place for that responsibility to sit?
Dame Jo Williams: It is a very good question and I think we have had some discussion about this before. We are, within our forward thinking, absolutely determined that we need to highlight the special issues relating to mental health. It is a service that we provide and one thing that is happening is that those people who are carrying out their commissioner responsibilities as Mental Health Act commissioners are increasingly working with our inspectors. I do not think we have capitalised sufficiently at the moment on that crossover of information, but, for the future, I think that helps us to do even more in monitoring what is going on in hospitals and keeping people safe.
Dr Wollaston: Thank you.
Q138 Chair: I also want to have a final shot, I am afraid, going right back to the beginning, to this business of what is the core function of the CQC and the balance between the assurance of essential services and the participation in the ambition we all share for improving quality. Do you think that the Government’s stance on the National Patient Safety Agency and the whole issue surrounding the guarantees of patient safety should be feeding back into that debate within the CQC? Doesn’t that reinforce the argument that, actually, from the patient’s perspective, from the service user’s perspective, the thing they really look to the CQC for is that the system observes the old rule "First, do no harm"?
Dame Jo Williams: You are well aware that the functions of the National Patient Safety Agency have been transferred largely to the NHS Commissioning Board. At the very heart of what the CQC is about are the people who use services. There is no doubt about that. That is what the work force, the board and the executive are committed to. In taking forward our purpose we have identified a number of priorities, not least making sure that we do work with others but also continue to keep our focus on people who use services.
Are we sufficiently geared up and focused on that patient perspective? We certainly receive a lot of information from patient surveys and we use that in analysing what is put into our risk profiles. We are where we are, Chairman, and I think that we have to be constantly mindful of the need for us to, as I said earlier, work in an interdependent way with those others that have responsibilities as well as ourselves.
Q139 Chair: On the basis that we are where we are but the new chief executive is taking us somewhere else, hopefully.
Dame Jo Williams: Hopefully, in terms of taking the service forward, indeed, but that was not quite what I meant.
David Behan: Rather boringly, I will repeat. This has been right at the centre of the debate about why the CQC exists. The 2008 Act is unambiguous in that our role is to protect and promote-"promote" is a big word, I think, Chair-the health, safety and welfare of people who use health and social care services. It goes on to say that we will do that for the general purpose of encouraging three things: improvement, ensuring that services focus on the people who use them and then, thirdly-and I think this plays to Grahame Morris’s earlier question-that resources are used effectively and efficiently. That is unambiguously clear.
Our unique contribution to what is arguably a crowded landscape around quality is that we measure whether services meet the national standards of quality and safety, the essential standards of quality and safety. Nobody else does that. The Committee has challenged us on whether people can trust our judgments and that is exactly our role, but I think we do that for the purpose of improvement. We are not an improvement agency, but one of the big things that we have got back, not just from yourselves but also from people whom we regulate, is "Why don’t you acknowledge what ‘good’ looks like and describe what ‘good’ looks like?" There is a legitimate challenge, I think, about how we do that without becoming an improvement agency. What we are doing in the document is signalling that we have a role to identify when we see "good" work, that we talk about that good work.
One thing that the CQC needs to consider-the board, myself and the executive team-is, when does the bar in relation to quality get raised? At what time does that happen and how do we have that conversation? When do today’s "quality standards" become tomorrow’s "essential standards"? Otherwise, we are saying that this is a zerosum game and we stay where we are. I anticipate that you would, as a Committee, have something to say if that is what we set out. So very clearly in this document we are setting out that we are not going to drop standards as we move through this next phase of our development and there is an important conversation that I hope we can join in together about how we do that. But I would ask that we do not see measuring against essential standards and improvement in a binary way. These are not either/ors. They are "ands". We undertake this for the purpose of improvement, otherwise services will simply stay where they are and won’t improve. That is not the job I think I have been hired to do, nor is it the job I think you would want me to do.
Q140 Chair: On that note, thank you very much.
Dame Jo Williams: Chairman, before you close, may I express my apology for straying into sharing information in a way that I acknowledge and regret?
Chair: Thank you. I probably should have stopped you and I apologise for not doing so. Thank you very much.