What will the Care Quality Commission Performance and Capability Review mean for mental health services?

The Care Quality Commission has been in trouble for a while. Externally it has been under fire from the media for failing in big ways and in smaller ways. Internally it has struggled to deal with the demands of delivering a new streamlined regulatory model to ensure compliance across all ‘care’ settings in England, especially as it is fashioned from the remnants of three older regulatory bodies: the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission, bodies which themselves had diverse institutional histories and cultures.

So the publication today of the DH Performance and Capability Review is of great interest to anyone interested in standards in care for people with mental health needs in England. The report published is basic but a few conclusions are transparent:

• The CQC has to improve significantly on several fronts. It needs to develop a clearer strategic vision and communicate this more effectively to the regulated sectors and to the wider public.

• We need to work out what effective regulation of care looks like. The CQC has focused narrowly on using inspection to ensure compliance, and unlike its predecessors it has not defined its role as driving up the quality of care through engagement within the regulated sectors(para 2.16). This may or may not be the right approach but it has yet to be evaluated (para 2.19).

• But perhaps most importantly we are stuck with the CQC. Whilst many stakeholders have little affection for it no one wants to go through the pain of restructuring again (para. 10).

Within mental health there have long been murmurings about the short-sightedness of dismantling the Mental Health Act Commission. The MHAC may not have always have been well-loved but it had the virtue of not being despised by health and social care professionals or the public. The report says little specifically about the role of the CQC in inspecting settings where people are detained under the Mental Health Act beyond observing that the integration of the former MHAC responsibilities into the wider organisational structure of the CQC has not been effective (para 3.36).

So what are the implications of the performance and capability review for the inspection of mental health services?

Well obviously we are not going to get a specialist inspector with a specific responsibility for mental health services reinstated. I do not think anyone anticipated this, but the case that was made for not losing the MHAC under the amendments to the Mental Health Act 1983 seems to me to be as strong as ever. Places where people can be legally detained if they are unwell enough and are potentially unwilling to adhere to treatment have a very different atmosphere to other social care settings. Nurses, doctors and auxiliary staff in psychiatric wards all know that they have practical and legal powers to detain patients who try to leave. Of course abuses of power may occur in any care setting, but they are more likely to arise in settings where people feel that their use of authority is both natural and inevitable and as a result stop critically examining their conduct.

We should listen carefully to all further communications concerning the evaluation of the CQC’s ‘regulatory model’. Since the review itself states that the effectiveness of this model has not been established it is premature to draw conclusions here. But in light of the above of particular interest will be whether the CQC is able to continue to promote a generic model of inspection across care settings whilst maintaining a sensitivity to the needs of specific groups of service users. The Review identifies adults deprived of their liberty or lacking mental capacity as two such groups (para 3.45).

There are some very welcome references in the Review to the fact that the CQC needs to be especially sensitive to the views of service users. It identifies the need to integrate user perspectives into the development of the regulatory model (para 3.43) and the need to ensure inspectors have access to user expertise where required although they stop short of recommending that (some) inspectors should have personal experience as users (para 4.6). In mental health the CQC already employs a service user panel who not only consult on strategy but also participate in inspections in conjunction with commissioners. This may be an area where mental health practice can inform practice in other areas.

It is a shame that the Review makes no reference to the CQC’s critical role in protecting human rights. The CQC is listed by the UK as one of the 18 member organisations that make up the national preventative mechanism we have established to meet our obligations under the Optional Protocal to the United Nations Convention Against Torture (OPCAT). No reference is made to the OPCAT in the CQC’s Position Statement and Action Plan for Mental Health. Whilst it may be the case that CQC inspection and ongoing monitoring will deliver adequate safeguards to meet our obligations under OPCAT it is a shame that this link is not made explicit. It is further a shame that the normative goal of achieving human rights protection is not explicitly identified by the Review as one of the goals of an effective regulatory model.

Taken together the findings of the Review itself lead to a big hmmm from me. The task the CQC was given was hard and it has struggled to find its feet. Criticising the individuals involved seems pointless, especially in light of the universal reluctance to dismantle it and start over. A much more important question which this review does not provide an answer to is what does the public expect the CQC to deliver? The review conceptualises the tension between regulation to secure compliance and regulation to secure improved standards in care as a technical issue. It is, instead, a tension based upon a clash of values which has not been openly acknowledged let alone debated.

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3 thoughts on “What will the Care Quality Commission Performance and Capability Review mean for mental health services?

  1. First things first – all this is in the public domain already.

    I was a service user governor at Cambridgeshire and Peterborough NHS Foundation Trust (CPFT). I reported my own trust to the Care Quality Commission because I witnessed poor quality care when I was an inpatient myself in a CPFT ward. I saw CPFT staff treat detained service users in an unacceptable manner. I also believed that CPFT staff had detained me unlawfully. I was denied my right to go before a mental health tribunal so I ran away. I did an interview for BBC Look East. My interview was included in a wider news report on the Care Quality Commission’s own report. Here’s a link to the BBC report:

    http://bbc.in/BBCLookEast

    Shortly after this report CPFT made a further attempt to detain me. I subsequently obtained my health records and the psychiatrist concerned made false statements on my detention form.

    I have complained to CPFT, the Care Quality Commission and the NHS Ombudsman. I reckon you need inside knowledge to know who to turn to. I found it hard to make sense of the CQC web site and I was an NHS governor so I do not know how an ordinary member of the public is likely to learn that they can go to the CQC.

    I know I was not the only complainant. The Care Quality Commission has subjected CPFT to a lot of scrutiny over the past few years. There is a new chief exec (a planned event) and this new guy – Dr Attila Vegh – has made lots of staff changes.

    Both Dr Vegh and me appeared recently on a BBC Radio Cambridgeshire breakfast show – from rather different perspectives. This BBC show included a whole series of reports on CPFT’s difficulties with the CQC. The number of absconders and complainants has shot up in recent years.

    This time round there were no threats to detain me for speaking to the media but CPFT has yet to apologise for its transgressions last year. I do not feel I can trust NHS staff any longer because they have refused to discuss these detentions with me. CPFT staff seem to detain people in arbitrary manner without giving any explanations.

    My initial contact at the Care Quality Commission was good. The CQC did respond at an institutional level but the CQC response to me as an individual has been disappointing. I stuck my neck out and I faced a lot of threats from CPFT staff. I did it to help vulnerable people. I was an elected service user governor. I saw wrong doing so I acted and I did so in the public interest but I do not see why I should have to tolerate three detentions and one attempted detentions just for making complaints about poor quality nursing care.

    I no longer use secondary mental health services. I feel severely misunderstood. There does not seem a sensible way to give effective help to service users who have been traumatised by inappropriate use of the Mental Health Act. The regulatory system has not worked for me. I have done my best for other people but this particular whistleblower is pretty badly damaged.

    Having gone through all this I have decided that I will never again work within the NHS. I have learned the hard way that it is not safe to work with staff who have the power to detain you. The NHS and the CQC need people with experience of mental illness and detention but how can we safely work with mental health staff?

  2. Thanks for this. You cannot work safely with staff who retain an involvement in your clinical care. I do not think this is ever appropriate. An ongoing role as a pro-active monitor of standards is not feasible if at any time staff may challenge your findings on the basis of their knowledge of your past or current mental health. I’ve witnessed the ‘well he/she would say that wouldn’t they’ attitude time and again and it sucks . Which is why integrating service user’s into arms length regulatory bodies like the CQC can make a difference because they can ensure that the service users they recruit are not required to inspect services they are currently using or may make use of in the future.

    There is an insoluble tension about whistleblowing though and I am sorry you have experienced that first hand. All social care settings have largely invisible aspects and if abuse occurs it may only be exposed if service users themselves bear the risk of ill-treatment for speaking out. I do not think we can practically eliminate this, though as a society we should do more to recognise the achievements of people who challenge poor care and treatment. Sorry, I wish I had something more constructive to say about that.

    On the communication point, I agree the CQC website is hard to navigate and not at all informative for service users (or anyone else really). I think this relates to the big problem the Review identifies though, which is that the CQC does not have a clear vision of its role. It also had practical problems dealing with the sheer amount of contact it had had from the public especially after the exposure of the abuse occurring at Winterbourne View.

  3. 16 April 2012

    I made the following request for information to the Care Quality Commission via the charity website whatdotheyknow, and have received a response from the CQC saying that someone is dealing with it:

    “According to the news articles in recent weeks,
    Ms Bower resigned as CEO of the Care Quality Commission.

    At about the same time a report was published about the Care Quality Commission.

    http://mediacentre.dh.gov.uk/2012/02/23/

    I would like to know precisely what the connection of these two events is please.

    Why did Ms Bower resign? What documentation shows the reasons behind her decision to resign? Are they publicly available?”

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