Cynthia Bower unveils the shadow Care Quality Commission

Cynthia Bower is the chief executive of the  Care Quality Commission . As it prepares to go live Emily Ford asks her about the benefits the new watchdog will bring

October 1 spells the beginning of the end for the regulation of adult social care as we know it. Of course, it’s not the first time. In 2000, the Care Standards Act established the National Care Standards Commission. Then, in 2004, it became the Commission for Social Care Inspection, also amalgamating the Social Services Inspectorate. Now, a new regulator, the Care Quality Commission is being launched to incorporate the work of CSCI, the Healthcare Commission and the Mental Health Act Commission.

It has been a controversial move. CSCI complains that it is losing its grip just as it has become effective. Dame Denise Platt, chair of CSCI, has remarked: “We are handing over a piece of work that’s unfinished.”

Perhaps the biggest concern is that at a critical time for adult social care, the job of the commission with a clear role to regulate the sector and champion the interests of the most vulnerable, would be lost against the backdrop of healthcare.

After the much publicised appointment of Barbara Young as chair, it was announced more quietly that Cynthia Bower would be the chief executive. Her background – 19 years in social care, then 13 years in health care – makes her a poster girl for the new commission with a duty to appoint officials with a relevant mix of experience.

Platt’s fears

Nevertheless, fears persist. Platt has said: “Any chief executive will spend their time worrying about the health service because that’s what politicians worry about.” So is social care going to become eclipsed by healthcare?

“Absolutely not,” says Bower. Her vision, is of health and social care being mentioned in the same breath, their regulation governed by the same principles, with officials working side by side and learning from each other’s approaches.

A single regulator reflects the service user’s experience, she says. “A high quality experience isn’t just an experience of health care or social care, it’s how services work together. Where things go wrong is at the interface the point at which you pass between them. An older person coming out of hospital won’t think ‘the NHS was fantastic but social care let me down’, they think ‘was this a quality experience?’. If it’s not all working together then it won’t have been.”

Social care will not lose its importance in the commission, she insists, because our ageing population means it will rapidly ascend the national agenda. “If the 20th century challenges for the health services were infectious diseases, now the challenges are how older people and those with long-term conditions are supported across a range of social care services.

“That’s the way the regulator has to look at it. What we expect the NHS to provide for us is very clear, the challenge is achieving it. In social care it’s much more fluid.”

Bower heaps praise on the CSCI’s service user-oriented perspective and “challenging and interesting” work. “One of the things I admire enormously about social care is the way it’s positioned itself. You’ll be looking for us to move into that space – being an organisation that talks about social care in a very overt way.”

First priority

At the same time, she is clearly preoccupied with the first job of the shadow commission, which runs until 1 April: to devise a system to register providers on healthcare-associated infections. In the short term at least, its priority is healthcare.

The approaches of the Healthcare Commission and CSCI have been necessarily very different: a big brain approach versus fingertip inspections. Bower says the difference can be overstated, but she intends to retain the two approaches, “although the commissions would have had to refine them anyway”.

The plan is to keep what works well but within a recognisably different brand. “The critical thing is ‘what product is going to be a CQC product’?” she says.

“I would expect in two years’ time to be able to walk round [a hospital or care home] and recognise a common approach. We want to bring our own way of doing things and the advantage of being able to look across the services.”


So, how is it going to work? A chief priority is recruiting people who are “sympathetic” to the new vision. One concern raised by CSCI is that the commission would be operating on a significantly reduced budget with increased responsibilities and a slashed headcount. Does she feel as though she is being asked to do more with less? “Of all my anxieties, money is the least,” she says. “My understanding is that we will inherit staffing changes that were happening anyway.”

While the vision is there, beyond the buzzwords “safety” and “quality”, much of the substance is yet to be worked out. For the first year, things will carry on much as before within a newly worked out regional system – currently, the Healthcare Commission and Mental Health Act Commission work to four regions, while CSCI has seven.

Most structural changes will happen at the most senior level. “On the frontline people will be doing the jobs that they have done. Integrating their work more and with a wider range of services is a longer term job. Frankly, if [they] haven’t got ideas on how to do that then I’d be very surprised.”

But there is consternation that something will have to go. Rob Greig, chief executive of the National Development Team, says: “One idea is that they will be reducing inspections. That would be a major problem. You cannot rely on self regulation.”

Themed reviews

The highly regarded themed reviews of CSCI are to be downgraded from a duty to a power. “The overall burden of regulation – how much it costs to operate – will be reduced,” says Bower. “I’m sure that’s not the driving factor but it’s something we are being asked to look at and quite rightly.”

She rejects Greig’s suggestion that the CQC juggernaut could become insular. “Local area agreements, local service priorities and comprehensive area assessments are already encouraging primary care trusts – and adult services – to work together in a way that I’ve never seen before.”

Over the next year the commission will consult on compliance criteria and a registration system for health and social care. Bower plans to make registration easier – requiring a provider of care homes to register just once, for example – and in 2010 the CQC will launch with its own system.

But some remain unconvinced. Greig says: “The notion that you can have one approach for a large hospital and small supported housing risks being flawed.”

Single system benefits

David Johnstone, chair of the standards and performance network at the Association of Directors of Adult Social Services, can see the benefits of a single system “for people with long-term complex conditions,” but is concerned about whether day and domiciliary care will be regulated to the same standard.

The CQC offers an opportunity for a better performance framework, he says. “In relation to social care the 198 national indicators are very poor. We have to see whether lighter touch, locally determined regulation actually happens.”

As the date of the merger grows closer, the mood is one of cautious optimism. “It’s a sensible move,” Johnstone says. “With the emphasis on delivering care earlier and dealing with long-term conditions in the community it’s becoming more difficult to see the divide between health and social care.”

The chief optimist is Bower herself.

“I want to run an organisation that is technically brilliant,” she says. “A place where everybody wants to work.”

Published in Community Care 2 October 2008 under headline ‘Ever the optimist’

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