The Urology Trade Association welcomes the opportunity to respond to the Care Quality Commission consultation A new start: consultation on changes to the way CQC regulates, inspects and monitors care.
The Urology Trade Association (UTA) is the leading urology industry membership organisation in the UK, representing 95% of urology product manufacturers and suppliers to the urology appliance market. An estimated six million people in the UK are affected by continence problems and many rely on urology appliances on a daily basis. High quality urology appliances allow users to manage their conditions, maintaining their quality of life and independence, and avoiding repeated medical consultations.
The UTA focuses on primary and community care and thus this response will particularly focus on questions in sections two and four.
- What do you think about the overall changes we are making to how we regulate? What do you like about them? Do you have any concerns?
The UTA welcomes the changes being made to the way the CQC regulates, in particular the division between fundamentals of care, expected standards, and high-quality care.
Continence problems are an element in many long-term conditions, and with the growing number of people with long-term conditions it is becoming increasingly essential that the proper treatment of patients with continence needs, in all settings, is managed properly with the patient at the centre of everything the health service does.
The particular challenges faced by users with continence problems (and potential continence problems) are firstly that those problems are recognised and discussed openly between the patient and clinician, with the clinician taking proactive steps to assess the patients’ wellbeing. Patients also need to be able to access specialist advice to help them manage their condition, and need to be able to access specialist products which meet their needs.
Urinary tract infections (UTIs), an example of a healthcare-associated infection (HCAI), continue to pose a significant challenge to the health service, and more significantly to the individual with the infection and their carer(s).
The UTA’s view is that generalist staff often do not have a strong enough understanding of the importance of proper continence care, and that one of the priorities of the CQC in regulating healthcare providers must be to ensure that providers are challenged to minimise harm from UTIs as well as ensure that patients are comfortable with the way in which their intimate continence needs are being met. We encourage the CQC to ensure that its expert inspectorate fully understands the importance of good continence care and is able to robustly challenge arrangements which lead to poor continence care outcomes – as well as praise and highlight those which excel.
We agree with the CQC’s statement that the main responsibility for delivering quality care lies with care professionals, clinical staff, providers and those who arrange and fund local services. It is important that all such participants understand the impact of their decisions on patients, and that the CQC does not fail to properly scrutinise the decisions and arrangements put in place by commissioners, who are not in direct contact with patients, which can lead to poor outcomes for patients.
- Do you agree with our definitions of the five questions we will ask about quality and safety (is the service safe, effective, caring, responsive and well-led)?
The UTA agrees with the definitions of these five questions.
In relation to the definition of “safe”, we would ask that harm from urinary tract infections is considered as part of efforts to keep patients safe from physical harm.
We note that the definition of “effective” refers to relevant NICE quality standards and effective new techniques. We are keen to ensure that clinicians are able to use the most effective recent innovations in continence care, which can make a real difference to patient outcomes, and that there are processes in place to ensure that patients are able to access innovative products.
In relation to the definition of “caring“ the UTA would welcome an emphasis on understanding the continence needs of an individual as part of this – a need which is not always properly addressed. It needs to be accepted that, when it comes to continence, there is not a “one size fits all” approach to ensuring patient comfort and dignity.
We note the definition of “responsive”, and believe that as part of this, consideration should be given to the nature of individual conditions – for example a patient with continence needs may be less willing to travel as understandably they do not wish to have an accident. The CQC must challenge administrative or organisational arrangements which are made for the organisation’s convenience, rather than the convenience of the patient.
Further to the definition of “well-led”, we would suggest that an essential element of being well-led relates to the culture and decisions taken when an organisation is under significant financial pressure. High-quality services should take strategic decisions in the interests of the patients they serve and the long-term financial health of the organisations, rather than making short-term decisions which simply cut costs. The UTA views this as a particularly significant challenge in the current financial climate even with the presence of the ring-fence on NHS funding.
The UTA continues to be concerned that clinical commissioning groups are under significant amounts of pressure to save money, which could lead to them making choices which disadvantage patients by restricting the choices available to them, such as the urology products patients can access. This is often done through local initiatives such as formularies which retain the illusion of patient choice while restricting it in practice. As users of continence devices may be elderly and unused to challenging the decisions made by health service professionals, this may lead to patients using products which are not suitable for their individual needs, leaving them at risk of developing urinary tract infections – which is both distressing for the user, and costly for the health service.
In our experience, there is often a false choice made between saving money and improving patient choice. If the CQC is to be effective, it will need to demonstrate that it understands this false choice and is able to challenge commissioner-led decisions which are carried out with little scrutiny and often without impact assessments.
Fundamentals of care
- Do you think any of the areas in the draft fundamentals of care above should not be included?
The UTA agrees with the inclusion of the areas included – given our focus on urology and continence care, we are particularly keen to see the inclusion of the areas in relation to harm; assistance in using the toilet; listening to complaints about care; and not being coerced.
- Do you think there are additional areas that should be fundamentals of care?
Effective continence care and access to support and advice should be considered fundamental to good quality care, given the impact which it has on a patient’s wellbeing and dignity.
- Are the fundamentals of care expressed in a way that makes it clear whether they have been broken?
We look forward to further discussion on what the “fundamentals of care” consists of – and we hope that continence care will form part of these fundamentals.
The suggestions for the fundamentals of care are expressed clearly and simply in the document, but we believe that it would be useful for more detailed advice to be given which covers more specific situations, such as how to minimise the risk of catheter related UTIs.
- Do the draft fundamentals of care feel relevant to all groups of people and settings?
The UTA feels these draft fundamentals are relevant to all groups of people and settings, including primary and community care settings. However, it should be remembered that there is a difference between having a catheter inserted in the hospital and using one regularly within a community setting, and that there may be different challenges in ensuring dignity and preventing harm.
Duty of candour
- Do you agree that a duty of candour should be introduced as a registration requirement, requiring providers to ensure their staff and clinicians are open with people and their families where there are failings in care?
The UTA does agree with this. In particular, we feel that this must not simply deal with an individual or team’s failings but also systemic failings – for example if some trusts have higher than average rates of urinary tract infections, there is a need to examine why this is and look at how, for example, procurement decisions can impact the quality of care later down the line.
- Do you agree that we should aim to draft a duty of candour sufficiently clearly that prosecution can be brought against a health or care provider that breaches this duty.
- Do you have any other comments about the introduction of a statutory duty of candour on providers of services via CQC registration requirements?