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The new face of regulation: what will the CQC mean for nursing

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The new super-regulator, the Care Quality Commission, took up its powers at the start of last month, marking the beginning of a raft of changes in healthcare regulation. Alastair McLellan talks to its chief executive, Cynthia Bower, about what the commission has in store for nurses

Nursing’s ability to deliver ‘basic standards of care’ is the greatest area of concern for the health service’s new regulator, the Care Quality Commission, when it comes to assessing the profession’s contribution to patient care.

Speaking to Nursing Times, less than a month after the regulator’s official launch, CQC chief executive Cynthia Bower said: ‘The things we’ve got to focus on most now are the basic standards of care. We’ve got to constantly challenge ourselves on dignity, privacy and how people’s rights are maintained when they are in vulnerable situations.

‘We are going to be focusing on those fundamental things about the healthcare experience. The factors that influence the quality of the patient experience are all going to be in the CQC registration standards [see box].’

She added that the new regulator would want to know if a healthcare organisation was ‘putting an emphasis on those basics’ and whether ‘everybody from the top to bottom’ of that organisation understood the importance of that mission.

Ms Bower believes that much of what needs to be better delivered is already well defined by nursing’s ‘essence of care’ approach and she praises the profession for ‘leading the way’ on tackling those things which make care ‘difficult, lengthy or unpleasant for patients’.

She is also very clear about what is likely to lie behind the current shortfall in what she calls the ‘timeless’ elements of nursing care.

‘In the organisations I ran I found that staff who didn’t feel in control, who felt disempowered and disengaged, who were treated rudely and weren’t told what was going on, lost their ability to reassure the patient and help the patient feel in control,’ Ms Bower said.

She stressed, however, that this view did not ‘let people off the hook’ and that it was still up to nurses to try and understand and respond to patient needs whatever the circumstances.

Her experience is that it is environmental factors, such as clinical leadership at ward level, which has the most influence on how patient care is delivered. It is for this reason that the new regulator will take a closer look at how healthcare organisations manage their staff at all levels.

The results of the NHS staff survey will continue to be included in the regulation of NHS organisations, but Ms Bower explained: ‘It is important for us to better understand what organisations are doing to engage their own staff [and] staff engagement – if it means anything – must be ward based.’

She acknowledged that senior managers must visibly demonstrate a commitment to delivering quality care by ensuring a good working environment, but added that staff are most likely to be affected adversely and positively by ‘the 10 people they see every day.’

Ms Bower’s focus on nursing ‘basics’ chimes with the sombre mood music created by the furore surrounding Mid Staffordshire NHS Foundation Trust. Incidents such as patients being left in wet and soiled sheets or designated ‘nil by mouth’ for several days after cancelled operations, were highlighted in an investigation undertaken by the CQC’s predecessor, the Healthcare Commission.

Even more crucial for the CQC chief executive in the light of the Mid Staffordshire case is the need to have a better grasp of patient experience.

‘The main thing we have learnt is the importance of an absolute focus on the view of the patients. The definition of quality has to be the patient’s,’ she said. ‘There’s no point in everybody else saying this is a marvellous organisation if the patient voice is not being heard.

‘[At Mid-Staffordshire and other troubled NHS organisations] if you’d gone straight to the user voice it would have often given you a completely different perspective on a service that everybody thought was doing alright.’

The outrage created by the revelations at Mid Staffordshire has reignited the debate over adequate staffing levels, with nursing shortages one of the criticisms made by the Healthcare Commission’s report. Additionally, analysis carried out by Nursing Times and healthcare information specialists Dr Foster Intelligence in March showed that the trust was one of those displaying a link between a lower nurse per bed ratio and a high hospital standardised mortality ratio - that is to say a patient mortality rate that is higher than expected, based on a typical English hospital.

One senior nursing director contacted by Nursing Times for this article felt that insisting on minimum numbers of registered nurses for each trust, as is already done in the Californian health care system, was now ‘essential’ for the NHS.   

He drew a comparison between ICU and paediatric wards where minimum staffing levels were ‘more or less nationally accepted’ and nurse numbers on general medical and surgical wards, where ‘anything goes’.

One of the CQC’s registration standards will focus on workforce, but Ms Bower is initially reluctant to follow the path of mandated staffing levels.

‘My inclination is to focus on outcomes for the patient rather than saying ‘this needs X number of nurses. I’m sure NHS chief executives wouldn’t thank us for saying “in order for this to be a safe service we want X number of staff”, because they would say that was their judgement to make. They’d tell us: “You make the judgement about the quality of care, but don’t tell us what the inputs are”,’ she said.

However, she reveals that the CQC is in dialogue with the clinical Royal Colleges on what should be included in the CQC standards.

‘We’re saying to them: “If in your particular area there are things which are so critical that they should be in registration, then we will put them in”, she said.

Another area up for debate is the role of nursing in primary care. ‘We will be registering practices, not individual GPs, so the registration [process] will essentially involve the contribution of [practice] nurses,’ said Ms Bower.

‘We’d be very happy to have a specific dialogue with nurses in primary care about their vision. We’re currently looking closely at the Royal College of GPs’ practice accreditation scheme – so nurses need to be influencing that model as well.’

Whistleblowing is another hot topic in the wake of Mid Staffordshire and the NMC’s decision to strike off Margaret Haywood for her part in the covert filming of NHS patients.

Ms Bower believes that one of the questions that must be asked about the case of Mid Staffordshire is ‘where was the clinical voice saying there were problems?’

‘Particularly now, when quality is so high on the agenda, there’s going to be less and less tolerance for any of us who see poor practice and don’t do anything about it,’ she said, reiterating a point she made in Nursing Times at the beginning of April.

The CQC chief executive stresses it is also up to NHS organisations to make sure these concerns are heard. So what advice would she give to a nurse who felt the need to raise a concern?

‘It is the job of managers to make sure staff get the best environment to work in. If there’s a problem, talk to them. If that doesn’t get you anywhere, talk to their boss. If that doesn’t get you anywhere, talk to the chief executive. If you don’t get anywhere with that, talk to the board. Most importantly, don’t stop until you get action.’

She also recommends seeking supporting from representative bodies such as the nursing unions.

Ms Bower began her working life as a social worker. She joined the NHS in 1995 as director [OF?]primary care for Birmingham Health Authority. In 2000 she became chief executive of Birmingham Specialist Community Health NHS Trust and then, in 2002, chief executive of South Birmingham PCT – at the time the largest PCT in the country.

Three years later she became managing director of Birmingham and the Black Country Strategic Health Authority and in July 2006 chief executive of NHS West Midlands.

Given her career path – from frontline delivery to a series of ever more senior managerial posts – it is little surprise that professional ‘leadership’ and involvement in service design and planning is close to her heart.

Her mantra – borrowed with due acknowledgement from health minister Lord Darzi – is that clinicians and managers must share the same ‘agenda’. This so-called ‘ward to board’ approach is also dear to NHS chief executive David Nicholson according to Ms Bower, who worked with him closely in Birmingham.

Key to the development of this shared ‘agenda’ is the involvement of clinicians in decisions made about NHS services. Ms Bower recognises that, unlike doctors, many nurses do go into NHS management – but still claims to feel uneasy with the largely ‘parallel worlds’ occupied by managers and clinicians. ‘Coming from social care, I was used to a professional management system’, she said.

‘I’ve talked to many who are very nervous about staying on top of their professional responsibilities when taking on managerial roles. I would like to see the NHS construct leadership roles that allow nurses to feel they are still in touch with what is happening to patients,’ she added.

Speaking again from experience as a senior general manager, she said: ‘There is no substitute for surrounding yourself with people who understand what it is like to work in the service – who have empathy [with staff] and credibility when they go on to a ward and say: “Why are we doing it like this”.’

She cites Peter Blythin, head of nursing at NHS West Midlands, as an example. ‘If you bumped into him for the first time in Marks & Spencer you’d know he was a nurse within five minutes. He constantly refers back to nursing values, things he learnt on wards. We need to continue to validate this way of thinking, we don’t want people to feel that by talking about frontline care that they’re somehow dragging everybody back.’

The CQC chief executive is also keen to point out that her own organisation wants and requires nursing input. There are already approximately 300 nurses in the CQC’s inspection workforce. However, Ms Bower says: ‘We will bring in associates to work on particular projects. Lots of people email me and say: “I’m really interested in working with the regulator”, so if nurses are interested they should get in touch with us.

‘Above all, we want nurses to look at our standards and recognise what they see as good practice,’ she said.

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