This month (September 2017) marks the commencement of the ‘use of resources’ (‘UoR’) assessment which is to be undertaken jointly by the Care Quality Commission (‘CQC’) and NHS Improvement. The finalised Use of Resources: assessment framework, published in August 2017, states the two organisations ‘believe there is significant potential for more productive use of resources across the NHS, which would improve quality of care for patients’.
Initially, the UoR assessments will be carried out solely within NHS acute non-specialist trusts with plans to roll out the process to specialist acute, ambulance, mental health and community services from April 2019. The UoR assessment is intended to assess efficiency and effectiveness in the way that providers use the resources available to them to provide high quality, efficient and sustainable care for patients. The UoR assessment will cover, not only finances, but also effective use of available workforce, estates, facilities, data and procurement.
NHS Improvement will be responsible for undertaking the UoR assessment. This will involve an analysis of the trust’s performance against defined initial metrics, such as the number of emergency readmissions and staff retention rates. Local intelligence gathered through day-to-day interactions between NHS Improvement and the trust will also be considered along with any other relevant evidence. Following this initial analysis, NHS Improvement will conduct a one-day site visit to undertake a qualitative assessment, during which NHS Improvement will meet with key members of the trust’s leadership team. A report of the collated evidence will then be prepared and submitted to the CQC along with a proposed UoR rating of outstanding, good, requires improvement or inadequate.
Once NHS Improvement has drafted the report and put forward a proposed rating, the responsibility for determining the final UoR rating of a trust lies with the CQC. The CQC will consider the report and proposed UoR rating and, if in agreement, will publish the final report and rating alongside its own trust-level inspection report and the current overall quality rating. This process is, however, subject to change as there are plans to combine the UoR rating with the overall quality rating from early 2018 following further consultation as to how a combined rating could be developed and applied. One area that is yet to be further defined is the process to be followed if the CQC does not agree with NHS Improvement’s proposed UoR rating. The joint consultation document published in December 2016 stated that a process for discussion between the two organisations will be set out to deal with this event but the finalised Use of Resources: assessment framework does not provide any further detail on the point.
There are some clear benefits of the UoR assessment being undertaken by NHS Improvement. The organisation is well placed in terms of expertise and the overlap in its existing remit could, somewhat ironically, help to avoid duplication of work. One of the concerns expressed during the consultation period, however, is the scope for subjectivity in making judgements, particularly in the taking account of information gathered during day-to-day interactions. NHS Improvement is, ultimately, an arm of the government operating during a time that the NHS is under extreme stress. Whilst the CQC is the organisation responsible for determining the final UoR rating, it will do so based on the assessment conducted by NHS Improvement’s assessment. The process arguably gives rise to a risk that a CQC approved UoR rating is vulnerable to influence at some point in the assessment by external pressures. The question is how this might impact upon the private sector providers, who at present time fall outside the assessment regime. Might this lead to a disparity in the assessment process or have the potential to undermine the independence of the CQC?