Healthcare watchdog sharpens its teeth to improve patient care

The Care Quality Commission (CQC) is seen as a watchdog whose bark is worse than its bite. A succession of recent investigations have reported unacceptably poor patient care at three hospital trusts, but the power of the commission, since it took over health and social care regulation almost a year ago, has been limited to naming and shaming. This week, however, the CQC becomes a rather more fearsome beast, prepared not just to snarl but to sink its teeth in to the bone. The commission will move from scrutinising the NHS to protecting its patients – a long overdue move, say critics, who claim that the regulator has often backed hospital management rather than patients. Failing hospitals will first be warned about bad practices. If they persist, the commission can see the offending departments closed down, the management prosecuted, and the hospitals fined up to £50,000. If all else fails, the commission can shut an entire hospital by withdrawing its licence to operate. Tomorrow, it will issue its first list of hospitals that will have to improve or suffer the consequences. What hospitals will face is not only trial by figures – ensuring that its services are being run appropriately, safely and responsibly – but also a critique based on patients' experiences. Whether a patient has enough food and water, whether consent has been taken and, perhaps most controversially, whether "privacy, dignity and independence (have been) respected" will all be documented. "We want to put the patient at the heart of what we do," says Jo Williams, acting chair of the commission. "Doesn't matter if it's the health service, the banking system or Tesco's, there is something about the way you are treated as a patient or a client or a customer. There is nothing so disempowering as being in a hospital bed in a nightie or a pair of pyjamas, but your human rights have to be respected." This is no empty threat. Borrowing from the work already being done by its social care division, the CQC will send teams of investigators, accompanied by groups of patients, to hospitals to see whether they match "client" expectations. The inspection regime has been beefed up and has the capacity to carry out up to 2,000 unannounced visits a year – three times the current level. However, the commission, Williams stresses, is keen to dispel the idea that it will be "thumping the table and effecting a short-term response. We want to engage [hospitals] and get them to concentrate on quality care." The need for the tighter regulation is in part recognition of the £110bn poured into the health service last year, and that Whitehall edicts have largely failed to stir hospital managers. The thinking, Williams says, is that patient criticism, coupled with sanctions against hospitals, will do the job. The aim is to see the health service providing more, better and prompter treatments for patients. "I think we have to recognise that the investment has been made, and that we have to shift to meet public aspirations for healthcare," Williams says. To test whether the system would work, the commission was given its new powers a year early to look at risk of healthcare-associated infections (HCAIs), which have been rising and for which no targets have been set. Many patients now worry that if they go to hospital they may come out cured of one complaint, only to be infected by the ward superbug. Of the167 trusts in its survey of hospital infections in 2009, published tomorrow, the CQC found that 42 were not meeting standards. The reasons for failure were bleak: 36 trusts were not providing areas to decontaminate instruments, in three trusts there was a failure to regularly flush unused water outlets – crucial for the control of legionellal infections – and 13 trusts were criticised for not keeping clinical areas clean. Of these failing trusts, five had to be issued with a warning notice – the first step towards the watchdog biting. Three culprits were ambulance trusts: North West, East of England and East Midlands ambulance services all came under fire. The two others were foundation trusts: Basildon and Thurrock University Hospitals, and Alder Hey Children's foundation trust in Liverpool. In all five cases, the CQC says it has "gained assurance through follow-up inspections that the trusts have met the requirements". Nigel Ellis, CQC head of national inspection, says that the unannounced inspections at more than 200 trusts in the last year were effective, adding that when the commission "found evidence of a direct risk to patients, we have intervened, using our new enforcement powers to ensure swift improvements were made". The exercise has not been an academic one. What the focus on infections highlighted was how badly ambulance trusts fared, and how cleanliness had not been taken as seriously as it should. For the first time, the CQC inspected every ambulance trust in England. Of those 11 trusts, four didn't comply with the government regulation, and a further six had areas in need of improvement. Ellis says: "Good infection control takes constant vigilance. Meeting that every day, for every patient, is an ongoing challenge for the NHS."