Last reviewed 18 April 2023
In this feature article Thoreya Swage, Healthcare Consultant, explores the Care Quality Commission’s approach to assessing the quality of care delivered by Integrated Care Systems in England, as outlined in its publication, Interim Guidance on Our Approach to Local Authority Assessments.
The Health and Care Act 2022 granted new regulatory powers for the Care Quality Commission (CQC) to assess Integrated Care Systems (ICSs) in England commencing from April 2023. The CQC has published interim guidance in March 2023 on its approach while it waits for approval from the Secretary of State for Health and Social Care.
What currently happens?
Currently the CQC undertakes assessments of individual NHS organisations across all sectors, including primary care, and rates them according to five key questions covering safety, effectiveness, leadership (well-led), responsiveness and caring domains. The resultant ratings are “outstanding”, “good”, “requires improvement” and “inadequate”. These individual assessments, however, do not indicate the overall performance of an ICS.
The approach to change
The CQC, recognising that patients experience care across a pathway which is delivered by more than one organisation and the formal establishment of Integrated Care Systems, is proposing a single assessment framework to reflect this picture. This has been developed in conjunction with a number of stakeholders including ICS personnel, patients and their carers, local authorities, NHS England, the Department of Health and Social Care and other key bodies representing providers, eg the NHS Confederation and strategic partners.
A phased approach has been taken by the CQC with “test and learn activity” in ICSs and local authorities in two different parts of the country to determine what works well and not so well and to develop a sense of what feels good.
What is being proposed?
The assessment and rating approach will be structured around the context, aims and roles of an Integrated Care System using six evidence categories to ensure that the judgements are structured and consistent.
The assessment takes into account the core purpose of ICSs as well as the requirements of the legislation, focussing on three themes which are as follows.
Quality and safety.
Seventeen quality statements supporting these themes as identified by the Health and Care Act 2022 will be used in the process.
Themes and quality statements
Quality and Safety — theme 1
Supporting quality statements.
Enabling people to live more healthily.
A culture that learns.
Staffing that is safe and effective.
Equity in experience and outcomes.
Integration — theme 2
Supporting quality statements.
Systems, pathways and transitions that are safe.
Provision, integration and continuity of care.
Staff, teams and services working together.
Leadership — theme 3
Supporting quality statements.
Direction and culture that is shared.
Leaders who are capable, compassionate and inclusive.
Freedom to speak up.
Governance, management and sustainability.
Communities and partnerships.
Learning, improvement and innovation.
Sustainability in the environment and in development.
Equality, diversity and inclusion in the workforce.
The six evidence categories include the following.
People’s experience — this is set out in the CQC’s strategy which states a commitment to use people’s experience in their regulation of care. The evidence will be gathered from not only patients themselves but also carers, families and advocates of people who use services, including interviews and feedback.
Feedback from staff and leaders — this includes interviews, concerns, surveys and self- assessments.
Feedback from partner organisations — for example, from commissioners, providers, professionals, Royal Colleges and other key bodies as well as other bodies such as housing, licensing or environment services.
Observation — for example tracking of cases, observation of meetings and health and social care forums ranging from Integrated Board meetings, place-led meetings and health and wellbeing boards.
Processes — specifically examining the effectiveness of these steps or activities that support people’s needs and are safe. This includes measures such as waiting times, plus audits, policies and strategies.
Outcomes — This looks at the impacts of processes on people and populations and how care has affected people’s physical, mental and functional status.
The evidence gathered for an ICS assessment may form part of the evidence used in assessments for individual providers, eg around partnership working, although ratings for individual providers will not directly determine the final ICS assessment.
Implementation of the ICS assessments
As this is a new function, the CQC will begin the process of implementation by undertaking a baseline of initial assessments of all the ICSs. During the first six months of this period the CQC will develop a method for reporting the themes after gathering evidence and understanding the relative performance across ICSs.
The second six months will involve formal assessment in which the CQC reports on the evidence for the baseline assessments of all the ICSs and awards ratings. This will be done within the next two years.
The ratings scoring will follow that of the current four-point rating scale, ie “outstanding”, “good”, “requires improvement” and “inadequate”.
Before publication of the assessment on the CQC website there will be an opportunity for organisations within the ICS to carry out factual accuracy checks and the draft report will be shared with the Integrated Care Board and Integrated Care Partnership.
The CQC will use a risk-based approach to determine the focus and frequency of assessments.
The next steps
As required by the Health and Care Act 2022 this guidance is subject to the approval of the Secretary of State for Health and Social Care. In the interim, the CQC will be developing the process and guidance further in collaboration with partners and other key stakeholders.
One of the major concerns around the approach to ratings is that these may be determined before the CQC and ICSs have an opportunity to develop a clear understanding of what “good” looks like in this new way of working across different providers.
Although some of the evidence will be derived from information from constituent providers within an ICS to form the final ratings, there is little indication from the guidance about how other factors will be assessed, such as how well the system works, the strength of relationships across the different partners, mutual accountability and improvement processes such as peer review. These activities are a greater indication of what “good” looks like.
There are also concerns that a simple four-point rating system does not give a clear picture of how a complex system like an ICS operates or functions and may give a false sense of security.
The CQC will need to recruit staff with the knowledge and skills to assess the complex systems that form ICSs.
In addition, there needs to be greater clarity on data gathering and information particularly a reduction on duplicate requests for evidence. During the pandemic when this activity was slowed down, healthcare leaders found that they had more time and energy to focus on innovation and transformation. The development of a single digital platform as mentioned in the guidance would facilitate this although the timescale is not clear.
Finally the recommendations of the Hewitt review of ICSs (commissioned by Jeremy Hunt when he was chair of the Commons health and social care committee in 2022) and published in April 2023 should be taken into account when the final guidance is produced.
Allowing time for this process to mature would facilitate a constructive approach to improvement.
Interim Guidance on Our Approach to Assessing Integrated Care Systems March 2023, Care Quality Commission
Our Approach to Assessing Local Authorities, Care Quality Commission