Last reviewed 16 February 2016

The Care Quality Commission (CQC) has published its new draft strategy and business plan for the next five years. Martin Hodgson, healthcare consultant, takes a look at what the strategy may mean for primary care.

The changing face of regulation

The new strategy for 2016-2021, Shaping the Future, builds on an earlier discussion paper published last year, Building on Strong Foundations.

The previous CQC strategy, Raising Standards, Putting People First, introduced a series of significant changes to the way that services such as hospitals, adult social care services and primary care are inspected and regulated. It was introduced at a time when the CQC was struggling for credibility in the face of scandals such as the Winterborne View abuse, and the care failings at the Mid-Staffordshire NHS Foundation Trust that provoked numerous headlines.

The Francis Inquiry into the failings at the Mid-Staffordshires trust demanded tougher regulation and, in response, the 2013-2016 CQC strategy included a range of regulatory reforms, as follows.

  • Developing a new updated set of regulations, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and identifying a set of “Fundamental Standards” as a baseline below which care must not fall.

  • Establishing new chief inspectors, including a chief inspector for primary care, and new, professional teams of inspectors responsible not only for visiting general practices and other health and social care services, but also for establishing new systems of “intelligent monitoring” by which information was collected about services from a variety of sources.

  • Introducing a new five “key-question” test used by inspection teams, asking if services were safe, effective, caring, responsive and well-led.

  • Introducing a quality grading system based on “key lines of enquiry” by which each service is given a quality rating and has its rating published on the CQC website.

Taken together, the measures represented a radical change from what went before. They have seen the CQC recover both its confidence and, apart from some criticism — particularly from GPs and those representing primary care — its public credibility as an effective regulator of health and care standards.

However, the strategy has now run its course, and last year the CQC announced in its Building on Strong Foundations document that it has no intention to stand still. Instead, it plans to move forward with further improvements to the systems it has established as part of the new strategy.

The proposed new strategy

The new draft strategy, published for consultation, does not represent a significant change from the current direction of travel. Indeed, many aspects are a logical extension of the current strategy, seeking to make systems more efficient and effective rather than changing them directly. However, the CQC does recognise that its core inspection model still needs refining and must improve to make regulation more effective and relevant.

As well as building on its existing approach, and making continuous improvements to its core operating model, the draft strategy is structured into six main themes.

  1. Improving the use of data and information.

  2. Implementing a single shared view of quality.

  3. Targeting and tailoring inspection activity.

  4. Developing a more flexible approach to registration.

  5. Assessing how well hospitals use resources.

  6. Developing methods to assess quality for populations and across local areas.

The themes interrelate with each other and are designed to address what the CQC recognises as key drivers and pressures in health and social care over the next five years.

For instance, the strategy quotes the NHS England’s Five Year Forward View, which describes three key challenges facing the heath and care system.

  1. A health and wellbeing gap.

  2. A care and quality gap.

  3. A funding and efficiency gap.

The strategy acknowledges that financial pressures will be significant over the next five years. Despite the Government’s Spending Review in November 2015 providing increased funding for the NHS up to 2019-2020, the strategy states that greater efficiency savings than ever before will be required.

Improving the efficiency of inspection activity

The CQC states that the first year of the new plan (2016-2017) will focus on completing work from the previous strategy — that of ensuring that comprehensive inspections for all registered services are finished and quality ratings published. Once this has been achieved, the CQC states that it intend to continue its move to what it describes as a more “risk based” regulatory regime.

This will mean that services rated as “Good” or “Outstanding” will be inspected less frequently while services rated as “Inadequate” will be inspected more frequently.

The CQC proposes that it will also make inspection activities more efficient, including improving the use of data and information. The CQC refers to the inspection process as becoming more “intelligence driven” with new and “innovative techniques” developed for collecting and analysing data which will identify poor care.

One such method of intelligence gathering will be accomplished through an expanded Experts by Experience programme.

This programme involves service users, carers and other people who have direct experience of services being involved in inspections, interviewing other service users and contributing to inspection judgments.

Another method will be gathering staff feedback and opinion through the work of the National Freedom to Speak Up Guardian, a new role occupied by Dame Eileen Sills which will help to create a culture of openness in the NHS and ensure that the concerns of staff are valued, encouraged, listened to and acted on.

The CQC refers to its new model for the obtaining and analysing information as “CQC Insight”, which will be used by the inspectors to prioritise their resources and focus on identified risks.

More responsive and tailored inspections

For general practice, the CQC proposes that it will continue to develop the way it inspects so as to take account of changes to the way the sector is organised and delivered. The strategy cites new models of care or federated practices as examples and states that the CQC will work with the profession and partners such as NHS England and the General Medical Council to improve the way they work together, reducing the burden on practices and using a single view of quality. This approach, the CQC says, will enable them to continue to rate general practice as well as focusing on the role that practices play in the wider health and social care system.

A single shared view of quality

The CQC proposes that the efficiency of inspection will also be increased — and costs reduced — by more co-ordination of reviews across agencies. The CQC will develop a “single shared view of quality” across health and care services, and work with other agencies and professional bodies to reduce the burden on providers by ensuring all regulatory bodies work together and follow the CQC framework on quality. This will include other oversight bodies adopting the five key-question test, along with the key lines of enquiry that underpin it, and improving this model.

The CQC states:

“We would ultimately like to see all national and local oversight bodies (such as NHS Improvement, NHS England, commissioning groups, local authorities and professional regulators), as well as providers themselves, use this framework to understand and report on provider quality.”

It also states that feedback from providers suggest that they have “welcomed the transparency that CQC’s inspections and reports have brought to understanding the quality of care” and they predict that the benefits would be even greater if everyone in the system looked at quality in the same way.

A focus on areas and populations

The CQC is currently piloting comprehensive assessments of quality of care in whole areas, rather than just looking at individual providers and organisations. The draft strategy suggests that the results of these pilots will be used to inform methods for inspectors to assess the quality of care received by people in local areas or by specific population groups.

Responding to the consultation

GPs and general practice staff who wish to contribute to the consultation should do so by the 14 March 2016. Responses will be used to develop CQC’s final strategy, which is intended to be published and implemented from May 2016.