Time for user-led inspections?

Obviously the quality of NHS care is in the spotlight now that the Francis report into appalling failures at Mid Staffs Hospital has finally been published. But social care is also going through some quality changes. The Care Provider Alliance (which I’m chairing for the year) came together with The Nuffield Trust last week, which has been asked by the government to explore the idea of developing a new approach to quality ratings within social care. We used to have them of course: the inspector, before it became the Care Quality Commission (CQC) and its role diminished to inspection of safety and compliance with essential standards, used to rate services on quality. In Shared Lives, we were very keen on this, because were top of the class with 35% excellent, 95% good or excellent. In truth, star ratings were a blunt instrument, but much mourned when they were abolished by the Dept Health.

Things have changed since then. We have moved on from believing that a visiting inspector can comprehensively judge the quality of a service, towards believing that the key issue is the outcomes being achieved for each individual using a service and that best people to judge the achievement of those outcomes are the individual themselves and their families or advocates. After all, many people are now individually choosing their service using a personal budget and in many cases taking personal responsibility for buying that care via a Direct Payment, so ensuring they are involved in monitoring its quality is the next logical step (see below for more on this).

There was a fairly intense discussion: the CPA brings together the representatives from the vast majority of the independent care provider sector, including care homes, home care and community services, of all sizes. However, I felt there was a fairly broad consensus from CPA members on some key points:

  • There is a need for quality ratings, which are fair, accurate and proportionate
  • There is a need for a strategic overview and leadership from DH to ensure that the Quality Ratings review, NICE Quality Standards, CQC’s activities, PQP & NHS Choices, Healthwatch, the TLAP programme and its quality strand are brought into alignment as part of a strategic vision.  There is currently confusion.
  • The starting point must be the experience of outcomes of people using social care – the kinds of outcomes aimed for will often be the same across different settings, even if the approach to achieving them will differ.
  • We do not believe we can have a single health and social care rating system without adding to confusion and measuring the wrong things for social care in the wrong way.
  • The new system must do enough to reassure commissioners on quality to reduce and ideally remove duplication of quasi-inspection by commissioners, but we do not believe that councils and commissioners are the right people to inspect the quality of the care they commission – this must be an independent national body.
  • Data collection alone will not give an accurate picture of a social care provider’s quality and outcomes and this is an important difference to rating quality in the health care sector, where more data is collected and outcomes can be easier to capture. The social care sector does  thoguh need to improve its data collection, particularly through developing a shared approach to outcome measuring and collection of outcomes data.
  • Inspectors should have specialist skills relevant to the area of work they are inspecting.
  • Any quality rating system, to achieve buy-in and genuine improvement, must be co-designed with the full range of large and small providers of all kinds.
  • Ideally ratings should be ongoing and certainly not less frequently renewed than annually.

 Here’s a further idea which we didn’t discuss in detail, so it’s one on which my CPA colleagues may or may not agree: there is a user-led alternative which could replace and enhance a great deal of inspection activity. We know that frequent inspections reduce risks but even highly frequent unannounced visits from inspectors cannot eliminate risk or give a clear sense of the experience of people living in or using that service. In reality, CQC are not resourced to carry out frequent, in-depth inspections and in any case, an inspector’s perspective will not necessarily reflect the range of perceptions of people using services and their families in any service. It is those people and their families who spend the most time using or living in a service. Many older people in particular who use care homes and home care services say that they are not as occupied as they would like to be and would like to find more ways to contribute actively to the life of where they live and their community. Many younger adults who use social care struggle to find employment.

So why not train and support people who use services and their families to carry out inspections? Some people may be able to take on paid work and be quite active. Others may wish or be able to be involved only on a more occasional, voluntary basis, perhaps as one of number of named people willing to collect and share feedback from others involved in the service they use.

The regulator has explored peer-led inspections and expert-by-experience approaches already and it has said it will be making more use of them in NHS inspections in the wake of the Francis report, but perhaps those approaches could form a much more major part of its recruitment strategy for the future. Implementing this idea fairly and sustainably would be an interesting challenge, but if nothing else, I bet those people using a service who were also inspectors would rarely receive poor care ….

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