Last reviewed 24 January 2017
The Care Quality Commission (CQC) has launched a new consultation on proposed changes to the regulation of health and care services in England, Martin Hodgson explains.
The changes are set out in a new document, Our Next Phase of Regulation: A More Targeted, Responsive and Collaborative Approach, published in December 2016. The document seeks to implement the proposals for a more targeted, responsive and collaborative approach made in the latest CQC strategy for 2016–2021, also published last year.
Relevant to all types of providers, the consultation seeks views on:
the principles that the CQC will use to regulate new models of care and complex providers
changes to the CQC assessment frameworks across all sectors
changes to how the CQC will register services for people with learning disabilities
changes to the way that inspectors will regulate NHS trusts and foundation trusts.
Comments on the draft changes should be made to CQC by 14 February. CQC states that there will be a second consultation in the spring of 2017 prior to final changes being made.
Alongside the current consultation, CQC is also consulting jointly with NHS Improvement on its approach to leadership and use of resources in NHS trusts.
Regulating new models of care and complex providers
Our Next Phase of Regulation starts from the premise that the world of health and social care is changing and that regulation must also change so that it continues to ensure the provision of safe, effective, compassionate, high-quality care. The changes originally planned in the 2016–2021 strategy, and reflected in the consultation paper, have been further informed by the 2016 State of Care report. This report, according to CQC, showed that much good care is being delivered and many services have improved. However, the CQC states that it also painted a “varied picture” of quality, with some evidence of deterioration and some providers struggling to improve its rating beyond the “requires improvement” level.
Looking to the future, the CQC states that they need to decide how to respond to these providers, especially those who have improved their performance after a “requires improvement” rating but have not yet done enough for a “good” rating. The consultation document states that the CQC will include further details on this in its spring consultation which will also include an additional focus on how inspectors will regulate adult social care and primary medical services in future.
Regarding larger and more complex organisations, the CQC states that they have noted the importance of good leadership and states that they will be working with stakeholders to develop proposals for consultation in Spring 2017 about how they can change the way they register providers at the level of what they call the organisation’s “guiding mind”.
The CQC also states that they need to be more flexible in future to better support those health and social care providers employing new or innovative approaches. The draft document encourages any provider who is thinking through a change to let inspectors know early in the process so that appropriate support can be offered where it is needed.
The assessment framework
Our Next Phase of Regulation introduces some proposed changes to the current assessment framework which consists of the five key-question test, and key lines of enquiry (KLOEs) and ratings characteristics to guide inspectors’ ratings judgments.
To reflect the way services are changing, the CQC proposes to move away from the 11 separate assessment frameworks currently published in guidance handbooks for each sector. In future, the CQC proposes having just two handbooks — one for healthcare, and one for adult social care.
The two new draft handbooks are published with the consultation document. These are the following.
Annex A1: Key Lines of Enquiry, Prompts and Ratings Characteristics — Healthcare Services.
Annex A2: Key Lines of Enquiry, Prompts and Ratings Characteristics — Adult Social Care Services.
The CQC believes that this change will reduce complexity and confusion, especially for providers that deliver more than one type of service, for example, a trust that delivers acute or mental health care and community health services and also runs several care homes. The changes are also intended to reflect new or emerging themes in health and social care, such as the increasing integration of care and the use of technology to enhance care delivery, and to simplify the process by more closely aligning the questions asked of different sectors and the characteristics that reflect a rating.
The same five key-question test remains: Is the service safe, effective, caring, responsive and well-led? However, there are slight changes.
The CQC is not proposing to make any changes to the focus of the safe key question, which looks at whether people are protected from abuse and avoidable harm. The proposals strengthen the effectiveness and caring questions, including more of an emphasis on a caring culture. The responsive question has been refocused and the well-led question has been given more emphasis to provide a demonstrable link between leadership, culture and the delivery of safe, high-quality care. To support this change the well-led framework for healthcare providers includes changes to the structure of KLOEs, increasing the number from five to eight. New prompts to guide inspectors have also been added.
The characteristics that inform adult social care ratings have been revised to clarify how they relate to each of the KLOEs and associated prompts. CQC stresses that this is intended to bring greater clarity to expectations of what good-quality care looks like and does not mean that the “bar” has been shifted for each rating.
Timetable for introduction
Our Next Phase of Regulation states that the revised assessment frameworks will be introduced over a phased period as follows.
NHS and independent acute hospitals from April 2017.
Community and residential adult social care services from July 2017.
NHS GP practices and GP out-of-hours services from October 2017.
Registering services for people with learning disabilities
As part of the consultation, the CQC is seeking views on draft updated guidance for providers registering to care for people with learning disabilities.
The proposals are contained in Annex B: Registering the Right Support CQC’s Policy on Registration and Variations to Registration for Providers Supporting People with Learning Disabilities, also published on the CQC website.
The revised draft guidance follows on from the Registering the Right Support proposals published in February 2016. The guidance clarifies the expectation on providers to ensure their care homes or supported living services are focused on person-centred care and developed in line with national policy developed since the Winterbourne View public enquiry.
A number of modifications are proposed to the regulation of NHS Trusts, including acute, mental health, community and ambulance trusts. A more responsive, collaborative, targeted approach is set out, with more importance given to effective leadership. Far fewer comprehensive inspections are proposed, with greater use made of improved monitoring and inspection activity focused where risk is greatest. Comprehensive inspections will continue for newly registered providers or where inspectors have significant concerns.
In this context, the CQC proposes replacing its “intelligent monitoring” system with a new “insight” model designed to identify potential changes to quality since the previous inspection and based on strengthened relationships between inspectors and trusts.
Lastly, a number of changes to the approach used to rate trusts are set out.