The ‘inadequate’ rating of Addenbrooke’s Hospital by the Care Quality Commission appears not only unfair, but arguably wrong. The regulator has set about destroying the credibility of senior management, Paul Ridout writes

On 22 September the Care Quality Commission finally published its report upon the inspection of Addenbrooke’s in late April and early May, that delay being in itself cause for comment.

The gap of five months means it is impossible to treat this report as an accurate measure of the current position.

Reputational damage

Given the reputational damage, this does not give the public a contemporary view.

That said, we congratulate the CQC on a thorough and detailed review of a large hospital complete with an informative and helpful review as an objective assessment of a wide variety of issues, good and bad. It is to be applauded that the regulator has developed a practice of external reflection which can drive improvement. 

‘Aspiration is muddled with stigmatisation in a way that is unhelpful’

That followed by strict performance management with SMART objectives backed by sanctions both personal and corporate that would undoubtedly lead to improvement in quality services.

However, the CQC’s obsession with a flawed methodology copied from OFSTED (the most glaring omission being the lack of a “compliant” rating) combined with a determination to produce whole hospital ratings, delivers a conclusion that is both irrational and perverse.

Those reading should remember that the rating “requires improvement” is improvement to achieve “good”, but that is absolutely not apparent to the non-specialist reader. This is based on the laudable premise that only “good” is good enough, when in many cases “compliant” would be satisfactory to many. 

Aspiration is muddled with stigmatisation in a way that is unhelpful and the Addenbrooke’s report demonstrates this in spades.

To any objective reader of this report, Addenbrooke’s is not “inadequate”:

  • Eight activities were inspected.
  • One was rated good (children).
  • Five were rated “requires improvement” i.e. certainly compliant and probably almost “good”.
  • Of those five reviewing the 35 specific areas inspected 10 were rated “good” and three “outstanding”, 15 “requires improvement” and six “inadequate”, with one not rated.
  • Gynaecology and diagnostic imaging were reported to be “good” but reported “inadequate” simply because they were linked with maternity and outpatients which were the only “inadequate” services.
  • Maternity is not even within Addenbrooke’s but at a sister hospital - the Rosie.
  • On the target areas the hospitals
  • Were rated “outstanding” for caring and 13 areas of “outstanding” practice were specifically identified, including the birthing unit and the neo-natal intensive care unit at the so-called “inadequate” maternity service.
  • Rated “good” for effective in four out of seven services with no “inadequates” and the so-called “inadequate” outpatients not rated.
  • Rated “good” for safe in three out of eight services with only two “inadequate”.
  • Rated “good” or “outstanding” for caring in all areas including maternity and outpatients.
  • Rated “good” for responsive in one area with six “requiring improvement” and two “inadequate” (one of those not being maternity).
  • Rated “good” for well led in two areas with four “requiring improvement” and two “inadequate” (maternity and outpatients).

Flawed methodology

This is an irrational obsession with following a flawed methodology with tools to mark down, stigmatise and squeeze an overall rating out of a process which, by its complexity, is bound to fail and thereby seriously to mislead.

In a précis this short, it would be wrong to take on the detail but, overall, it does seem to base its judgments on:

  • insufficient numbers of staff (although staff are generally praised);
  • the struggle to manage a new computer system (not unknown);
  • a thorough disrespect for senior management (somehow however, tiers of management are praised); and
  • criticism of a lack of resource without mentioning the budget shortfall with which senior management have had to wrestle.

In some services managers are criticised for being unsafe through insufficient staff and, then, unresponsive when services are temporarily closed on safety grounds. Some explanation is required as to the mismatch between an outstanding birthing unit and a birthing unit said to be unsafe through poor ventilation.

No injury or near miss is reported. If the position is really so bad one wonders why the health and safety executive or, CQC on a previous visit, had not intervened.

Having achieved a finding which appears unfair if not, arguably, wrong, the CQC has set about destroying the credibility of senior management - no doubt demoralising staff and causing deep concern and distress to patients and families by the “inadequate” judgement.

‘The overall rating, by its complexity, is bound to fail and seriously mislead’

For the public this is demonstrated by the requirement, on threat of criminal prosecution for non-compliance, to place conspicuous notices at all entrances and reception areas and publicity - for example, their website -informing those who enter that they are stepping into an inadequate service.

First class, well developed procedures - which support and performance manage leaders throughout the service have been used to traduce the reputation of a flagship hospital - demoralise its hardworking staff and engineer fear and panic in the public who must be seriously misled by the public presentation.

Trusts should consider carefully resisting unfair and incorrect criticism in the interests of patients and staff, and the Department of Health should seriously consider whether this approach, as exemplified at Addenbrooke’s, is in any way likely to foster the improvement said to be necessary or, rather, to increase pressures even to maintain the status quo.

Paul Ridout is partner of Ridouts LLP

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