David Oliver: Why shouldn’t hospitals challenge inspections?BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5320 (Published 06 October 2015) Cite this as: BMJ 2015;351:h5320
- David Oliver, consultant in geriatrics and acute general medicine, Berkshire
England’s health regulator, the Care Quality Commission (CQC), recently judged Addenbrooke’s Hospital in Cambridge as “inadequate” and instigated special measures.1 The hospital’s reputation guaranteed headlines,2 as did the resigning chief executive’s self defence.3 Commentators fanned the flames, questioning the value of over-zealous regulation.4
The CQC then published a blog, Shooting the Messenger, which said that inspected hospitals shouldn’t waste time contesting findings but rather should apologise and deliver the changes needed.5
I can’t dispute the specifics of the Addenbrooke’s judgment. But I will defend hospitals’ right to challenge or explain. Inspections have statutory force. They can trigger resignations, worsen staff morale and recruitment, and damage public confidence. Does this help patients?
There’s no inconsistency between a hospital taking immediate action on serious care failings and yet speaking out on an inspection’s quality and fairness or explaining mitigating factors (not “excuses”) in its wider ecosystem.
Under newish leadership the CQC has transformed and expanded its approach to inspections. But its journey to infallibility has been tortuous. In leaked minutes its inspectors described an intolerable workload, poor support, and inconsistency.6 The CQC has advertised for specialist advisers, acknowledging its lack of clinicians for expert peer inspection of services. To frontline staff, credibility and track record count.7 This includes the track record of inspectors in their own organisations and careers.
In the CQC’s own quarterly performance report it rated itself as “requires improvement” across most domains.8 It also highlighted internal disciplinary actions for plagiarism, poor behaviour by inspectors, and breaches of protocol. Similar behaviours were reported in the Health Service Journal.9 An independent review of the hospital inspection process commissioned by the CQC described a steadily improving but still inconsistent process with ratings too dependent on professional judgment.10
The CQC has used its own growing workload, reorganisation, funding, and staffing to explain its variable performance and delays to hospital reports.11 12 But it doesn’t extend such mitigation to the hospitals it inspects.
Addenbrooke’s is but one example of an English hospital struggling to recruit and retain nurses and to staff wards safely, partly because of local living costs and a failure to train enough UK nurses or to make permanent posts attractive. Like most English hospitals, it faces growing urgent demand, funding pressures, and “exit block,” with a lack of capacity and reduced funding in local community and social care. Hospitals have some responsibility in tackling these system issues. But they’re not islands. I’d say they have a positive duty to air them for the good of the whole NHS.
Shooting the messenger would be hypocritical, so I don’t expect the CQC to reply to this. Better for it to tackle its problems compliantly rather than waste time justifying them.
Cite this as: BMJ 2015;351:h5320
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.
thebmj.com Feature: What went wrong at Addenbrooke’s? (BMJ 2015;351:h5278, doi:10.1136/bmj.h5278)