Will providers see a revolution in the way they are regulated or a steady evolution?
Introduction
The way CQC monitors health and social care services is going to change, although quite what it will look like remains to be seen given the 5-year strategy published on 27 May 2021 is light on detail. It can best be described as a set of principles that plot a strategic direction rather than amounting to a plan. The changes will be introduced by CQC over time, some large, some small, having engaged with providers and other stakeholders at co-production events. CQC says it is not a static strategy; it will be reviewed regularly and modified where needed.
At the time of writing this article on 4 July 2021, CQC has started the process of reviewing its performance assessment framework, as well as committing to introduce a revised monitoring approach in adult social care from 13 July 2021. These activities are touched on below but first, the article summarises the broad strategic direction CQC is embarking on.
CQC’s strategy from 2021
CQC has been forced to work differently because of the pandemic with more work being done remotely by inspectors, using different tools, methods and techniques. That will continue under the new strategy, with a move away from a set schedule of physical inspections. Regulation will be more targeted and flexible, aimed at giving a more up-to-date picture of how regulated services are doing. The move to a more real time form of regulation is an ambitious one that has never been delivered on before by CQC or its predecessors. It will be backed up by enhanced digital tools to capture and share information in a more efficient and effective manner. As CQC says in its strategy:
“We’ll use innovative analysis, artificial intelligence and data science techniques proactively to support robust and proportionate decision-making, based on the best information available.”
Physical inspections will continue to happen as required but CQC says that “By looking at data continuously, we’ll have more time to spend during our visits to services to observe care.” Additionally, “we will be spending more time speaking with staff when we visit a service.”
Significantly, CQC adds, “We’ll build stronger ongoing relationships with services by having more regular contact with them” and “our regulation will become more constructive and supportive – using what we know to help services to tackle problems early.”
Key themes
There are four key themes in the strategy:
“Regulation that’s driven by people’s needs and experiences, focusing on what’s important to people and communities when they access, use and move between services”.
“Smarter, more dynamic and flexible regulation that provides up-to-date and high-quality information and ratings, easier ways of working with us and a more proportionate response.”
“Regulating for stronger safety cultures across health and care, prioritising learning and improvement and collaborating to value everyone’s perspectives.”
“Enabling health and care services and local systems to access support to help improve the quality of care where it is most needed.”
CQC stresses two core ambitions running through each theme:
Assessing local systems
“Providing independent assurance to the public of the quality of care in their area.”
Central to delivering on this ambition will be new statutory roles for CQC in performance assessing (1) local authorities in relation to their adult social services functions and (2) NHS Integrated Care Systems in terms of quality and leadership.
Reducing Inequalities
“Pushing for equality of access, experiences and outcomes from health and social care services.”
Revised monitoring framework
From 13 July 2021, CQC intends to introduce monthly remote reviews of adult care services “to help support our ability to monitor risk.” If the information in CQC’s possession about a service does not point to a need to reassess a rating or the quality of care, CQC will publish a short statement on the provider profile page of its website informing the public that “ a review has taken place and that we had no concerns based on the information we held at that time. We will also communicate this with the provider by email prior to the public statement being published.”
If a reassessment is needed, CQC may ask for additional information. Where it believes “people may be at increased risk of poor quality care, we may undertake an immediate on-site inspection and this may happen at any time. In these cases, we may update the rating for a service.” For the time being it appears that changes to ratings will continue to be linked to on-site inspections, pending CQC deciding on the circumstances where it may be possible to change ratings without visiting a service.
Assessment Framework
CQC wishes to update and revise its assessment framework which has been in place for the last 5-6 years. It will not be changing the 5 key questions – Safe, Effective, Caring, Responsive and Well-led – but it does want to create a single framework across health and social care to define what is meant by quality, safe care.
Currently, there are some 335 key lines of enquiry and prompts and 70 pages of ratings characteristics across the two assessment frameworks for health and social care. CQC wants to rationalise all of this into a single framework which will set out a clearer and shorter definition of Good using key quality statements. Examples of quality statements are “managing risks”, “infection prevention and control” and “medicines management” under the Safe key question.
It seems there will be less of a focus on defining Requires Improvement and Inadequate. CQC also wants to make the minimum standards clearer so that everyone knows what is expected in order to comply with legal obligations.
To support the rating of the quality statements, CQC says it wants to be clear about the evidence needed, otherwise known as “routes to evidence.” CQC has identified 6 types of evidence:
- People’s experiences of care
- Feedback from staff and leaders
- Observations of care and the care environment
- Feedback from partners such as commissioners and other regulators
- Processes which will include records and policies and procedures
- Outcomes of care
CQC acknowledges that there are varied types of providers and varied circumstances. Therefore, there will be specific sets of evidence which will be required from the different types of provider and systems which will be continuously kept up-to-date linked to best practice.
Conclusion
CQC emphasises that it does not want to disrupt the sector, rather it wants to introduce changes in a careful and transparent manner. It will be evolution rather than revolution. Helpfully, there is no longer any reference to setting the bar higher in terms of standards. As the sector starts to emerge from the pandemic it needs a regulatory strategy that will help rebuild services, not weaken them. There is also a realisation on CQC’s part that its role is to support improvement rather than direct it. However, quite where that support will come from and who will fund it remains to be seen.
There is much to welcome in the strategy, notably a move to a more real-time form of regulation which is more proportionate and focuses on outcomes of care. There is also the prospect of CQC regulating local authority commissioning and safeguarding which for so long have been the missing pieces of the puzzle as far as quality and safety are concerned. It is about time that local authorities were held accountable for the way in which they deliver their social services functions.
With no clear plan or timetable in place, providers will have to keep abreast of the changes as they are introduced and then, no doubt, revised through experience. As the sector well knows, nothing ever stays the same in the world of regulation for long.
About the Author
Partner & Health and Social Care Solicitor
D.D: 01483 366069
Tel: 01483 451900
Email: neil@gordonsols.co.uk