Last reviewed 20 June 2016
The Care Quality Commission’s (CQC’s) new strategy has been published six months after a disheartening judgment from the House of Commons Public Accounts Committee (PAC) that it was failing to prove effective as a health and care services regulator. Christine Grey examines the publication.
The question is whether the latest plan will enable the CQC to become more efficient and effective in improving care standards for people who use services in England, while responding to the increasing pressures providers are under and their evolving models of care.
Shaping the Future: Strategy for 2016 to 2021 continues in the direction of its previous strategy of 2013 to 2016, which had an ambitious timetable for the reform of registration and inspection, while acknowledging that there are still improvements to be made to the way it operates and that these will need to be delivered with fewer resources.
Describing itself as “an ambitious vision for a more targeted, responsive and collaborative approach”, the strategy responds to the transformation that health and social care is undergoing, primarily driven by increasing and more complex care needs of the population and the financial demands and restraints on all public services.
The main focus in the new strategy is on how the CQC will improve its use of data and information from the public, providers and other regulators so that it can better target its resources to where risk to the quality of care provided is greatest or to where quality is likely to have changed. CQC Chief Executive David Behan explained: “Inspection will always be crucial to our understanding of quality, but we’ll increasingly be getting more and better information from the public and providers and using it alongside inspections.”
He said that even social media will be used to capture the views of service users and that, after the comprehensive reviews are all completed, better information would result in more use of focused, unannounced inspections that target the areas where the CQC’s improved insight flags up greatest risk. A particular focus will be on improving the data available from the social care sector, which is more limited than in other healthcare settings.
Improving intelligence will go hand in hand with developing a shared data set for primary care services, to be developed with NHS England and the General Medical Council, so that providers will only need to submit the same information once. The CQC said it would also move towards analysing general practice data across local areas, such as clinical commissioning groups, to try to see patterns that may not show up at the individual practice level.
As the CQC plans to develop and implement a single, shared view of quality, providers will be increasingly encouraged to monitor themselves against this new framework and report back to the CQC. The regulator will be inviting providers and national and local organisations to help form the definition of quality and how it will be measured.
With improved intelligence, the CQC will be working towards inspecting services rated “Good” or “Outstanding” less frequently. The strategy says it will move to “a maximum interval between inspections of five years” for best performing for primary medical services, although David Behan told the House of Commons accountability hearing in 2014 that no provider would go as long as five years without inspection, adding that the CQC “got a very clear message from (the) consultation that five years is out”.
Some providers see the new direction as a welcome reduction in bureaucracy but others have questioned whether this approach is simply a way of reducing expensive inspection time and pushing more processes such as self-monitoring and reporting back onto the provider. A number of respondents also expressed concerns during the consultation that a rapid deterioration in a service could be missed and that the risk assessments may not be robust enough for targeting inspections in this way.
Aware of concerns, in his first interview after being appointed CQC Chairman, Peter Wyman told The Telegraph that the strategy would not “rip up” the current approach to inspection but would “refine” its methods. Despite the CQC’s budget being cut by £32 million over the next four years, he stressed: “I wouldn’t want this to be perceived as a change in order to save money.”
Judging whether an organisation is “well-led” has become a focus for the CQC, and in the past inspections did not come close to being able to assess this. The chief inspectors’ roles were then created with the responsibility of making the assessment not only of board level governance but also of whether a culture of openness and challenge exists among front-line staff. The regulator is now piloting a GP Practice Leadership Assessment Tool to see if it could be useful in enabling organisations and the CQC to assess their leadership and culture, and an independent National Freedom to Speak Up Guardian will be recruited next year to support culture change across the NHS.
The CQC aims to start implementing aspects of its new approach from April 2017 after it has completed its current programme of comprehensive inspections, which has been running behind target. This leads to the question about whether the CQC is improving its own efficiency and effectiveness — another of the targets in the strategy.
The move from generic inspection to expert inspection has meant that the CQC still needs to worry about whether it is doing enough to attract the extra specialist inspectors it requires to fulfil its strategic aims. The PAC warned on 11 December 2015 that six years after the CQC was established: “Because of staff shortages it is not meeting the trajectory it set itself for completing inspections of hospitals, adult social care and primary care.”
The CQC has admitted that it is struggling to recruit the skills and capability needed to regulate effectively, although it was working to reduce the risk by amending internal training and development.
The committee also raised concerns about the consistency and accuracy of draft inspection reports, the time taken to finalise a report after an inspection and the CQC’s ability to respond quickly and effectively to information received from service users and staff.
The use of new technology, better data and online processes outlined in the strategy should allow inspection reports to become shorter and quicker to produce and publish. This streamlining could help the CQC to be more responsive and to reduce the workload of the inspectorate. The House of Commons Select Committee also warned in 2014 that workforce planning associated with the new regulatory model must avoid the mistakes of the past and allow inspectors to be able to complete their work thoroughly without being required to manage unreasonable workloads.
And a light still needs to be shone on the CQC’s own culture. On accepting his position as CQC Chairman on December 2015, Peter Wyman said that improving CQC staff morale would be a key priority because it was “very low”. The CQC’s business plan outlines next year’s work to encourage improvements in its own culture, including delivering an internal management and leadership development programme, an engagement strategy to support people to lead change and improving staff opportunities to speak out. The staff survey will be started in September to measure culture and performance, and the CQC will plan activities to address workplace bullying and harassment.
The problems in recruitment extend to the experts by experience — people who have experience of services and are involved in inspections. Many left their jobs after the recruitment and management for the North, South and London regions was outsourced to the profit-making organisation Remploy, when they had to reapply for their jobs for half of their previous pay. Before the contracts transferred in February, the CQC had to step in and ensure that the agency would pay every expert £15 per hour in the first six months of work.
The CQC’s goal over the next two years is to involve experts in up to 80% of inspections in some areas, particularly in areas like dementia care. In the meantime, the inspection programme for care homes has been delayed by these recruitment problems, the whole system has been put at risk, and without user involvement in inspections “the CQC runs the risk of being a blunt and bureaucratic instrument”, according to Brunel University, London, Emeritus Professor of Social Policy Peter Beresford.
In terms of the regulator’s independence, it is hoped that future arrangements to ensure that the cost of regulation is met by the registrant community will strengthen independence from government, although this may involve another unpopular rise in registrants’ fees.
Together with so many challenges and warnings that it has not responded quickly enough to change in the health and care sectors, it is a wonder the CQC has survived long enough to be drawing up a new business plan for the next five years. It remains to be seen whether the dent in trust over its own ability to grow and invest in its workforce, in order to keep up with its inspection regime, will be repaired sufficiently to enable it to be the reformed regulator it is striving to be in the future.
The CQC’s strategy documents are available at the CQC’s website.