Monitor and CQC: unfit for purpose?

The report yesterday from CQC about dignity and nutrition at NHS hospital trusts raises several questions. Clearly it is unacceptable that people are not fed. However, one question that has not been asked is: why did these trusts get into the this situation?

The report lists trusts that they categorise as raising "major concerns and those that raised "moderate concerns". Interestingly the media give the aggregate of these two – 20 trusts – rather than reporting that there were just two that raised "major concerns". These two worst trusts are NHS Trusts, that is, they have not yet achieved Foundation Trust status. Of the 18 that raised "moderate concerns" nine are Foundation Trusts.

When Foundation Trusts were introduced the initial criteria were financial: if a trust showed that it had the financial skills to keep in the black (indeed, to make a surplus every year) then it was awarded FT status. When the Mid Staffs scandal blew up, the Foundation Trust regulator, Monitor, initially suspended all applications and then changed the authorisation criteria so that a trust has to show that it fulfils clinical as well as financial criteria. After authorisation a FT must continually prove that it meets the authorisation criteria (listed here, pdf) or else it will be in breach of its authorisation. Monitor has a range of powers varying from requesting that changes are made, to interventions like replacing board members, to the ultimate sanction of de-authorising a trust. (Of course, after the Health Bill is passed de-authorisation will not be an option since there is nothing a trust can be de-authorised to.)

Monitor states that FTs boards must continue to show that their trust complies with their authorisation criteria including:

• delivering healthcare services to specified standards under agreed contracts with their commissioners;
• maintaining registration with the Care Quality Commission and addressing conditions associated with registration;
• complying with healthcare targets and indicators
• cooperating with the Care Quality Commission and a range of NHS and non-NHS bodies which may have a remit in relation to the provision of healthcare services

This says that to remain as an FT a trust must show that it provides high quality healthcare. CQC inspects all FTs and reports their findings to Monitor who then issues notifications of breaches. Monitor says that:

"In cases where the Care Quality Commission indicates that it has material concerns regarding an NHS foundation trust’s registration with Care Quality Commission standards, Monitor will work with the Care Quality Commission to establish the most appropriate course of action to return the trust to compliance with those standards in a suitable timeframe."

So it is quite clear that between them CQC and Monitor have a responsibility to ensure that FTs have high standards of clinical care. If a trust's standards fall this should be picked up by CQC, who will then inform Monitor. Monitor then determines the intervention that is needed. 

Monitor lists nine FTs where an intervention was necessary, most of these interventions were due to poor financial governance and only one was listed in the CQC nutrition and dignity report. Monitor also lists 12 hospitals in breach of their authorisation, none of which are in the CQC report. CQC lists on its website the trusts that it has concerns about. This gives just three acute hospital FTs and none of which were mentioned in their report on elderly care. 

Why didn't CQC notice before that there were nutrition and dignity issues at the 20 trusts? Monitor exists to ensure that FTs are high quality. CQC has a responsibility to report on poor care. CQC and Monitor exist solely to ensure that Foundation Trusts are high quality, and any perennial failure in quality of FTs indicates that these two regulators are not fulfilling their responsibilities. There are serious questions that needs to be answered about whether these two regulators are actually fit for purpose. Finally, when the Secretary of State removes his own responsibility for the NHS bear in mind that we will be left to the mercy of these two organisations, there will be no one to take leadership over any failings in quality.

Update: Community Care have an article today about the reaction from Action on Elder on the CQC report. AEA say:

"These inspections suggest CQC has little or no sense or urgency in terms of its regulatory activity, often leaving very vulnerable people in neglectful or abusive settings while waiting for 'action plans' to be delivered by a care provider. In our view this is a major failing in its 'duty of care'."

Remember that CQC has not yet taken over the responsibility for inspecting primary care: GPs, opticians, dentists etc. If CQC are failing now, what will it be like when their workload increases due to these extra duties?