The Care Quality Commission (CQC) was formed in 2009 to monitor the service provided by the National Health Service. As a regulatory body, it has frequently drawn criticism for negating provider performance. Now, in the midst of COVID-19, an anonymous NHS worker gives an insider account of how we are all paying the price.
It is heartening to see the NHS being lauded from every corner of British society during the current pandemic. However, this public support can only go so far, and will not help us save patients. If people are serious about their support for our healthcare system, then they would do well to understand the crippling impositions that have been foisted upon the NHS by the CQC in the last ten years. This structure has put the trust I work for in a vulnerable position, directly placing patients and staff at risk, and therefore reducing the quality of care it will be able to provide in this crisis. Consequently, more people will die.
The aim of the CQC is to encourage competition between NHS trusts, so that the quality of their service improves and provides patients (or as my trust calls them, ‘customers’), with a greater choice as to where they receive care. As with every type of inspection, it can be gamed, and the criteria of assessment presents a false reflection of the true quality of NHS trusts. The trust I work in has performed extremely highly in its last two CQC inspections. In theory, we should be among the best placed trusts to face the current pandemic. In practice, like every other trust, we are struggling, and it will be patients and staff who suffer the most.
The CQC assess a trust on five broad-ranging criteria. These are: safety, effectiveness, extent to which they are caring, responsiveness to patient needs and leadership. My trust ensured that we passed our CQC by creating a team specifically for the purpose of managing the inspection, whose principle task was to ensure that our paperwork was perfect. So, when we received our grading, it was this team (not the rest of the staff), that was explicitly singled out for praise. Our CQC team were so brilliant that they created a false view of our trust, one that completely obscured the reality of our inadequacies. COVID has now exacerbated our shortcomings that the CQC failed to detect.
For instance, the CQC failed to spot that across the trust we are short-staffed. During our inspection, we made sure that we were operating under full capacity. This was a monumental achievement but was taken as license for future carte blanche. At the time of writing – during a pandemic – we are still trying to fill gaps. Crucially, we often do not have enough radiographers to operate all the necessary equipment. Here is an idea of scale: in the last three days our beleaguered radiographers have had to x-ray over 100 potential COVID patients. We are also suffering a dearth of housekeeping staff. This limits the efficiency and frequency that the hospitals can be cleaned – a vital procedure even outside of current circumstances. The consistent understaffing has forced us to recruit agency staff, many of whom are poorly trained. We are even having to call back staff who were initially allowed to leave their jobs due to ill health. They are at high-risk, and very much aware of the list of NHS staff who have succumbed to COVID. But they have nevertheless returned.
Just two weeks after our CQC inspection result, at one of the hospitals in the trust, we did not have enough stretchers to transport patients to our radiology department. They kept breaking, but because we had just passed our inspection with flying colours, we never replaced them. Again, this directly negates the quality of the care we are currently able to provide our patients. We have had to wait for the right equipment to arrive, by which point we had a significant backlog of scans. At another hospital in the trust, we have a lift that has been broken for two years, all since our last inspection. This has recently become particularly problematic, as the part of the hospital that is lift-accessed has been designated the COVID-positive section. We are now without a lift that could be turned into a COVID-only lift. This means, of course, that other lifts will be contaminated.
This is ridiculous, but not as farcical as the decontamination tents that were procured a few years ago, with great fanfare and at huge expense, all for our CQC inspection. The intention was to show that we are prepared for every eventuality. The aim was to demonstrate that we had stocked all necessary equipment for any large-scale medical emergency. The reality is somewhat different. The tents purchased were designed to be erected on grass. But as with most hospitals in the UK, the hospitals in our trust are built on concrete. So, the expensive decontamination tents are useless, as they cannot even be erected. It was, unfortunately, too expensive to drill the peg emplacements into concrete.
More relevant to the clinical side of the pandemic is our shortage of basic medical supplies, like swabbing equipment. One shift, I had to hunt round other hospital departments, because we did not stock enough in A/E, meaning some patients had to wait longer to be tested. Like many trusts, we have had to have protective glasses donated from local schools because our Personal Protective Equipment (PPE) stockpile was too small. As staff we are grateful for the donation; but it is hardly reassuring that we are that depleted. Furthermore, we have had to take shortcuts in our handling of deceased COVID patients. Initially, bodies were to be encased in a sealed body-bag to prevent the virus inside the body spreading. One week into the pandemic, our staff were told that these patients would now be wrapped in a sheet (as is done with uninfected patients), because we do not have enough body-bags. This all stems back to our success at our inspection. Had we not gamed our CQC so well, these issues would have been addressed more quickly.
All of these problems could be fixed by better managerial oversight. However, this leads to the fundamental problem with the method of assessment used by the CQC. For them, a functioning trust is not one that ensures it has the right equipment for staff and patient alike, but one that is financially ‘sensible’, and most importantly has a senior management team who can charm the inspectors. As a trust, we have saved £1.5 million – largely by not investing properly in equipment, infrastructure and staff pay – and we have now been granted an additional £10 million from the Provider Sustainability Fund. Now we have got a lot of money to spend on all the broken stuff we didn’t fix in order to get a lot of money. Except we can’t fix that stuff straight away, because we’re now in the middle of a global pandemic, all while being under-staffed and under-resourced.
Our position of ostensibly brilliant but significantly flawed highlights how, in order to survive, NHS trusts have had to make incredibly difficult decisions and run down the service complying with an arbitrary set of guidelines from a bureaucratic body. Rather than correcting these errors, the system encourages and facilitates them. Two of my colleagues previously worked for the CQC. They eventually resigned, disillusioned with the echo chamber-like nature of the discourse; incensed by the self-congratulatory smugness with which the CQC operated a crippling bureaucracy with little understanding of the clinical realities faced by NHS trusts across the country. Considering this, I do not blame our management for the problems in our trust. I think they genuinely try their best. I blame the system that places them in an impossible position.
If our senior management do not abide by this flawed system of assessment, and try to finesse the processes to which they are subjugated, then patients will suffer, as the trust would receive less funding, be less appealing to potential workers and be placed under suffocating scrutiny. This is what is so twisted about the whole situation. Although gaming the inspection system has resulted in our trust not addressing fundamental shortages in staff and equipment, it is still preferable to the alternative of having the CQC breathing down our necks, and at worse, placing us under special measures (as has befallen a neighbouring trust).
COVID has held up a mirror to the NHS, to its shortcomings and limitations. When we do come through this pandemic; the system needs to change, otherwise more and more of the NHS will have to mask its deficiencies instead of fixing them. There is after all a limit to the extent to which we can all play up, play up, and play the game.
Illustration by Alex Christian.