The Care Quality Commission exists to inspect quality in our health and care services – but when chief executive David Behan joined it in 2012, its own services were in turmoil. He tells Matt Ross what he’s doing to turn it around.
“If somebody had said to me at age 21: ‘You’ll work in the civil service in a national job,’ I wouldn’t have believed them,” says David Behan. “It wasn’t something that, at the beginning of my career, I thought I’d do – or even had a sense of ambition to do.” Instead, this tall, gentle individual became a social worker; a profession that he pursued for nearly 25 years. He only moved onto the national stage a decade ago, starting in inspection work before joining the Department of Health and, now, the Care Quality Commission – yet “when I got this job, people said: ‘They’ve appointed a civil servant’,” he recalls. “I’d worked for 32 years by that time, and only six of them had been in the civil service. Somehow it begins to define you – and it was defining me in a way that didn’t begin to compute.”
Indeed, Behan is far from your average civil servant: he may share with most a sense of social purpose, but his background is unusual amongst the Whitehall top brass. “My mum passed her 11-plus, but they couldn’t afford the school uniform, so – like many people in Blackburn at that time – she went to work in a textile mill as a spinner”, he recalls, his Lancashire accent still strong. “My father was an electrician, also working in textiles.” During his sixth form, Behan did voluntary work with homeless people: “I learned about the essential dignity of each individual, and it led me to a strong belief in social justice,” he says – and that in turn prompted him to cross the Pennines to Bradford University, where he read Social Studies. “I wanted to contribute to making the society I lived in a more just place,” he says. “My upbringing, my identity, has shaped what I’m doing today.”
What he’s doing today is leading the Care Quality Commission: an organisation with both a crucial role in our health and care services, and an ugly recent history of dysfunctional inspections, management bust-ups, staff bullying and, allegedly, cover-ups. Created in 2009 by the merger of three health and social care regulators, the CQC soon ran into trouble: it failed to highlight disastrous care in Winterbourne View care home and hospitals in Essex and Morecambe Bay, only to have its inadequacies made painfully clear by whistleblowers, media exposés and leaks.
Behan’s predecessor as chief executive, Cynthia Bower, had seen the CQC heavily criticised in the mid-Staffordshire public inquiry, and by the health select committee and the NAO; she finally quit as the Department of Health published a capability review that called for action on 23 fronts. Behan arrived in July 2012, but things hadn't yet calmed down: two months later the CQC's chair, who'd also come under fire over the organisation's management, announced her own resignation. Jo Williams departed following a clash with fellow board member Kay Sheldon, who’d highlighted a bullying culture and raised concerns that the board was a “predominantly passive” group in which “debate and challenge are seen as disloyal or unreasonable.” When the health secretary pointedly turned down Williams’ request to sack Sheldon, she became the second CQC chair to quit in three years. It is fair to say that Behan was not joining a happy organisation.
The Davids face Goliath
In January 2013, the former businessman and Tory MP David Prior became the new chair, and the two Davids set about tackling the organisation’s many problems. “There were a number of issues,” says Behan. “CQC had been created quickly; it took on new responsibilities; and there was a reduction in the resource available to undertake the job.” The quality of its inspections, he believes, was fatally undermined by the decision – made to cut costs – to move to a “generic” inspection model, under which visits weren’t made by specialists in the field. “That model wasn’t appropriate to do what we were being asked to in terms of inspection services,” he says. “If you’re looking at, for example, the quality of maternity care or paediatric cardiac surgery, then I would want to know that [the inspectors] have clinical experience and a medical background in those specialisms.”
Many of these “issues”, Behan says, can be traced back to the fact that “there was a lack of clarity about the purpose of CQC. That was pretty contested territory: different people had different views about why CQC existed.” To get everyone pointing in the same direction, he and Prior spent a year defining the organisation’s purpose, then used that as the basis for a restructure. They eventually produced a business plan that identifies and addresses the dangers facing CQC, including “the material risk of too-high expectations on our current capacity and capability to deliver”, and the “inherent risk in making changes to our organisational structure, our leadership and management teams and our wider team of staff while delivering a transformative programme of change.”
So Behan has taken a very close look at the CQC’s problems: does he think its repeated failure to sound the alarm over poor care standards was rooted in a desire not to upset care providers or ministers, or were its inspections simply ineffective? “Our view was that the methodologies weren’t robust enough to get to the bottom of what the quality of care was,” he replies. “Thing were missed, and they weren’t missed because staff weren’t conscientious and focused on the job they had to do; they were missed because the model and the methods being used were not appropriate.”
Inspecting inspections
This is an indictment of the CQC’s earlier leaders: the system they put in place couldn’t identify poor care – and the result was a failure to challenge care standards likely to have caused unnecessary deaths. But it is at least a problem that its current leaders are able to address: the CQC is now moving to a system under which specialist functions are examined by experts in the field, and abandoning its old ‘pass or fail’ approach in favour of a methodology that provides “richness in its judgements about quality and safety.” The public, says Behan, don’t want the CQC to say simply “whether the care is okay or not okay – but when we see good or outstanding care, to describe it. We think assessing and judging and rating care will drive improvements.” Like education inspector Ofsted, the CQC will be offering more detailed verdicts on the providers that it examines.
To further improve the reach and depth of its inspections, the CQC is involving more voices in its ratings decisions – for example, by inviting members of the public to join its inspections, and analysing patient feedback submitted via NHS Choices – and changing its approach to whistleblowers. “Whistleblowing signifies a failure of the organisation to listen to the concerns of its staff,” says Behan: he’s reviewing the CQC’s handling of whistleblowers, tweaking inspections so that they examine care providers’ own policies, and employing James Titcombe – the father of a baby who died in Morecambe Bay – as the CQC’s “national safety adviser”.
Equally importantly, the commission is launching “thematic inspections” to examine the “case pathway” of particular kinds of patient. These thematic programmes, says Behan, might look at how people with dementia are handled by all the relevant services in a geographical area – acute healthcare, primary care and adult social care, for example – or how people move across “transition points”, such as when a disabled child becomes an adult. “When people tell you about their experiences, their degree of satisfaction with individual clinicians or carers is often very high,” he comments. “Where the lack of satisfaction comes in is at that transition point. That’s where the fractures and fragmentation come in.”
A bully for you?
Many of the CQC’s inspectors, Behan notes, “didn’t have confidence in the generic inspection model”; their morale fell further still as the same cost pressures that had led to the model’s introduction ratcheted up their workloads, putting many under extreme pressure. When Behan arrived, he discovered that “we had a problem with bullying: a number of people emailed me and spoke to me confidentially about it.” Concerned, he commissioned an external report: “I’ve gone into lots of new organisations, and this was the first time I’d experienced people coming to me so consistently in relation to [bullying],” he says.
The report found that many employees had “a genuine concern” that excessive workloads were creating “real risk to the organisation and to patients”, with some complaining that they were being bullied by line managers because they wanted to make “more thorough inspections than their line manager felt was necessary.” Rather bravely, Behan released the report: “It was quite a difficult report to publish,” he comments. “But if we’re asking other organisations to be open in the way they relate to us, it’s absolutely essential that we can demonstrate that we’re being open, too.” He’s now watching the staff survey results and feedback channels carefully, and feels that “we’re making progress. The issue is whether we’re making progress quickly enough.”
Behan has clearly done a lot of work to tackle bullying in his organisation – but his inspectors are still under time pressure: the organisation’s website highlights its targets for the number of inspections completed, and the chief is clear that “we’re not credible if we can’t discharge our statutory obligations.” The challenge now, he adds, is to “make sure that not only can we complete what we’ve said we’ll complete, but that we can do that to a standard such that there’s no debate about whether we’re compromising the quality of our inspections in order to deliver the quantity.” As soon as the organisation has developed metrics to measure the quality of its own inspection work, he says, it will replace its quantitative targets with a more intelligent measure.
Follow the money
At the root of many of these problems lies money – or, rather, the lack of it. The CQC’s budget is just 0.2% of NHS spending, and it also oversees social care: is that enough cash to do the job? This is an awkward one for Behan, and prompts a long response. At the core of his answer, though, lies a single sentence: “I think it is the case that there is insufficient resource available for us to do the job, and we’re doing something about that now.” That ‘something’ involves the Department of Health handing over an additional £20m for 2013-14 – representing about 10% of the CQC’s budget – to “support the development and delivery of the new approach, the new methodology,” Behan explains. “And we will get more again next year.”
“There’s been a political debate about regulation,” he argues, referring to the government’s repeated attacks on ‘red tape’, but “the members of the public, particularly in health and care, have a much greater appetite for regulation. They expect regulation to be there, because they see it as essentially protective of their interests, and they want us to be successful.” The CQC is being asked to raise more of its budget from fees levied on health and care providers, which will throw up fresh challenges; but in the short term, at least, Behan has secured enough extra cash in the form of ‘grant in aid’ to pursue his plan for more specialised, wide-ranging and cross-cutting inspections.
Meanwhile, things have calmed down at the top of the organisation: the board is once again fully staffed, and its members include clinical professionals – a psychiatrist, a doctor, and the chief inspector of hospitals – alongside non-clinicians such as a retail consultant, a former Labour special adviser, and journalist Camilla Cavendish. Kay Sheldon, the board member who spoke out about poor management at CQC, retains her seat: “Her period of office will be extended, which is a good thing,” says Behan carefully.
The next two years, he adds, will be “pretty critical, as we change quite dramatically the way we inspect hospitals; we really begin to develop new ways of inspecting general practice; and we improve and further develop the way we inspect adult social care. What we’re doing is quite a radical overhaul of the regulatory system for health and social care.”
Lot by lot, then little by little
Following those big structural changes, Behan intends to focus on continuous, incremental improvement. “If you look at successful organisations, they’re constantly curious about what they need to do to improve,” he says: he follows cycling, and is “absolutely fascinated” by the way that teams GB and Sky have built “multidisciplinary teams that constantly look for that 1% improvement, that 0.1% improvement – because that can be the difference between success and failure.”
As he embeds and improves his new systems Behan will, of course, need to keep a wary eye on the powerful politics of healthcare: the very first risk listed in his business plan is the danger that “new policy and/or legislative changes could place significant new obligations on us which may compromise our ability to deliver on both our strategic priorities and core activities”, whilst the forthcoming election only increases the likelihood of new announcements or political pressures. At last year’s Tory conference, health secretary Jeremy Hunt controversially accused his Labour predecessor, Andy Burnham, of leaning on the CQC to keep quiet about poor care – and the topic of NHS standards is a political football that has been used to score goals not only against politicians, but against service providers and the commission itself.
However, Hunt’s conference speech set out policies which should give the CQC a little more freedom from political influence: the health secretary promised to give up a range of powers, including the ability to direct CQC on the content of its annual report and the opportunity to veto investigations, and to put the commission’s new chief inspector roles on a statutory footing. Behan doesn’t quite acknowledge that the commission has been subject to political pressures in the past – “Whether it’s true or not, the important thing is people’s perceptions,” he says – but he welcomes Hunt’s announcements. “The secretary of state is giving us the operational independence to judge the quality of care as we find it, without political influence, and that independence is absolutely essential,” he says. “I don’t think it’s acceptable for there to be any political influence at all over our assessments”.
So David Behan now runs an organisation that looks very different from the one he inherited. The staff are happier with the jobs they do, the board is less riven by rivalries, the budgetary pressures are easing a little, and the inspections regime has been designed primarily to test clinical quality rather than to save money. The CQC’s softly-spoken boss, though, says it’s way too early to claim victory in the struggle for high-quality appraisals of our health and social care services. “I’d like to think I’m making a difference – but 18 months into a job, this is still a work in progress,” he says. “If somebody had said to me 18 months ago that we’d make this much progress, I’d have settled for that. But these things are difficult.”
Throughout his career – as a volunteer with the homeless, a frontline social worker, a social work manager, an inspector and a departmental director-general – Behan has tackled tough jobs. When he joined the CQC, though, he entered an organisation in meltdown: many of its board members were embattled; its senior managers discredited, its line managers bullies; its staff disillusioned; its inspections inadequate.
Turning that around doesn’t require only organisational change, but also the creation of a new top team and a revived and appropriate culture. “The judgement on that will come in four, five, ten years’ time; and actually, the ultimate judgement will probably be after I’ve gone,” he concludes. Meanwhile, he’s got a lot more work to do to secure the legacy he wants – and he doesn’t pretend that it’s straightforward. “If I’m being brutally honest,” he says, “this is the hardest thing I’ve ever done.”
Note: This article has been amended since its publication in Civil Service World, correcting some inaccuracies in its coverage of the history of CQC.
See also: Behan: CQC budget was so low, it couldn’t properly inspect care
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