The Care Quality Commission (CQC) has been going through a wide range of consultations and announcements over the last 18 months, as it adjusts to a changing landscape of provision and accountability.
A new assessment framework for NHS trusts is already underway, with adult social care and primary care providers expected to implement theirs from November 2017, and independent providers following this.
Overall, the CQC plans to retain its five Key Questions (see below), but is revising and fine-tuning the Key Lines of Enquiry and Prompts. Alongside this, the Commission is changing the frequency of some inspection regimes, and has singled out some areas for stand-alone inspection. It is also revising the number of bodies to be registered and inspected, and piloting new inspections which will operate across the sectors.
“The CQC is trying to find ways to create new legislation, which allows it to track true accountability for quality and safety within the new corporate structures and models of care,” says DAC Beachcroft partner Corinne Slingo.
“The Commission recognises the changes in delivery, but doesn’t want to lose the accountability. The different consultations are all working towards this to a greater or lesser extent. Each one has something very particular in tackling this.”
Tim Gardner, Senior Policy Fellow at the Health Foundation, recognises that health and social care services providers may struggle to make sense of the changing regulatory landscape.
“Our research suggests that the reforms in the last parliament exacerbated the lack of clarity about the roles and responsibilities of the various national bodies,” he points out.
“There are several national bodies involved in overseeing, commissioning and regulating local organisations. A coherent approach to local accountability depends on those bodies working closely together to help support and enable change. This isn’t easy, but it’s essential.”
While some inspections will become more flexible, others will become more regular, depending on previous ratings. NHS trusts will be inspected on a service-by service basis, with the frequency based on their previous rating for core services. For example, the maximum time before a revisit to a service rated as ‘inadequate’ will be a year, while one rated as ‘outstanding’ could see five years before the next inspection.
Each trust should also receive a stand-alone annual assessment for the ‘well-led’ key question, focusing on its leadership, governance and management.
This will also examine how well the trust works with its partners, and integrates services across the sector.
This is a new development for the CQC’s inspection regime, and fits in with an approach that believes that if the leadership is right, the overall quality should follow.
Trusts will know in advance when to expect an inspection, though the precise nature and focus of each inspection may vary from trust to trust. The first information requests are now being sent out, with the system expected to be fully embedded by spring 2018.
“It’s a big change, and for NHS bodies, it’s more regulatory scrutiny, and more compliance to get their heads round,” Slingo points out. “Good providers will simply add it in, but it will still mean more work preparing for an inspection. But providers who haven’t kept up with the cycle of reviewing may find it a lot harder.”
However, she warns against making like-for-like comparisons when the new regime is extended to the independent sector. There could be tensions when, say, comparing the universal approach the regulator looks for in the NHS, with organisations set up to meet a particular need.
“The evidence base – especially for the independent sector – might be slightly different,” she says. “How independent providers deliver services may not fit easily into a framework the CQC will recognise. That’s one of the biggest tensions providers will have to grapple with.
“From a CQC perspective, it’s a matter of robust risk management, but it does require greater understanding of diversity within leadership, staff and teams.”
New social care regulation
The CQC singles out adult social care services as a particular issue.
The commission recognises that the struggle to improve can be “a particular problem for some of the adult social care services that we have repeatedly rated as requires improvement”.
To tackle this, it proposes changes to how information is collected and providers are inspected.
While NHS trusts will move away from comprehensive inspections, adult social care services will continue to receive them. But the timing will vary. Services rated ‘good’ will be inspected after two and a half years; ‘outstanding’ services after three; while those rated ‘requires improvement’ will be inspected annually, and ‘inadequate’ after six months. Slingo comments: “The difference is a slight divergence in frequency and content between NHS and social care providers.
“Social care bodies will be scrutinized for everything, but ‘well led’ is built in. While for NHS trusts, inspections will be less comprehensive, there’s a stand-alone inspection for ‘well led’. It’s changing for both sectors, and changing in slightly different ways.”
Senior scrutiny for independent providers
As part of its review of adult social care services, the CQC is also proposing a change in the line of accountability for provider groups. The change will require parent companies and group organisations considered to have a direct influence over quality and safety to be registered. This will include matters such as staffing, and to some extent, finances.
In theory, this should resolve the issues that arise when a provider must fall into line with a decision made by its parent organisation. In practice, however, Slingo highlights some potential caveats:
“Organisations vary hugely in the level of autonomy they give to their subsidiaries, but this is not always reflected in the organisational structure.”
In addition, there are legal implications. Registering an additional legal entity makes it possible to act against both the parent company and the immediate provider.
This could potentially push back against the “robust” structures of clinical governance that have been sought over the years, according to Slingo.
“The best practice currently in place is a really strong clinical governance structure, which enables everyone to learn from shared information. That suggests that it’s better to have a much closer relationship between the provider and its parent company. If the proposals go ahead, the CQC will need to take a slightly more analytical look at true control within an organisation. And as Slingo points out, the natural source for that is the clinical governance structure.
“Ironically, this will mean organisations that have worked hard to establish a robust clinical governance structure being identified as having a close relationship. And this will necessitate registration for the parent governing body.”
Whole-system reviews for health and social care
Slingo also points out that as health and social care systems work increasingly as integrated entities, separate inspection regimes may not always be appropriate.
“In some areas, there isn’t one single provider. So we’ll need alternative ways of monitoring and regulating service provision.”
To this end, from November the CQC will undertake a programme of local system reviews of health and social care in 20 local authority areas. These will also look at how commissioning is managed across the two areas – especially the way older people move from hospital to home or another care setting. It will also consider governance for managing resources. Gardner believes that it’s the right approach to look at “quality of care in a place”.
“The NHS Five Year Forward View majors on coordinating care better across traditional organisational boundaries, and the regulatory regime needs to change to reflect that. Much of this is unknown territory, but it’s where the future of accountability lies.
“Ideally, the reviews would look at patient flow generally across local health systems, but the CQC has been asked to focus on how older people move between health and social care. No one wants to stay in hospital longer than necessary, but getting the right support outside of hospital is just as important as reducing delays.”
Margaret Willcox, President of the Association of Directors of Adult Social Services (ADASS), takes this point further.
“These reviews will miss the point if they do not look at the whole system. That means primary, mental health and community NHS services which, alongside social care, keep people well in the community; and the interface between health and social care at the point of discharge from hospital.”
The five key questions for providers to answer
The CQC has five questions it asks of all care services:
- Are they safe? Patients are protected from abuse and avoidable harm.
- Are they effective? The care, treatment and support provided achieve good outcomes, help to maintain quality of life, and are based on the best available evidence.
- Are they caring? Staff involve patients and treat them with compassion, kindness, dignity and respect.
- Are they responsive to people's needs? Services are organised to meet patients’ needs.
- Are they well-led? The leadership, management and governance of the organisation ensure that it provides high-quality care based on individuals’ needs; encourages learning and innovation; and promotes an open and fair culture.