The Care Quality Commission and improvement: a system-wide issue

Ruth Robertson writing at The King’s Fund – Many policy issues seem simple from afar but they nearly always become more intricate on closer inspection, one current example being Brexit. Understanding the impact of the regulatory approach of the Care Quality Commission (CQC) is no different. On the surface, we seem to have a simple bilateral interaction: CQC tells a provider where it needs to improve; the provider then does or does not make the improvement. When we look closer, however, this view starts to fragment.




Regulation is a multifaceted intervention. It happens over long periods of time and, for best effect, requires a whole system focused on improvement. Our recent research about CQC’s regulatory process developed a framework of eight impact mechanisms as a tool to help policy-makers and practitioners understand and navigate this complexity. Once we understand how regulation affects provider performance, it becomes easier to work out the best way to maximise its impact.

Caring

Getting this right is a system-wide challenge, which is why, following the publication of our recent report, The King’s Fund and Alliance Manchester Business School gathered with representatives from CQC, leaders from health and care providers, commissioners, national bodies and patient representatives to unpick the issue. At this roundtable discussion, we discussed three system challenges that emerged from our research as key areas for action to maximise CQC’s impact.

First, how can regulators and providers develop the effective relationships that our research shows are critical to the functioning and impact of regulation? The CQC is rolling out a new programme of training for its inspectors to help with this. While investment in the development of regulatory staff is critical, relationships are a shared responsibility. For regulation to work, providers need to respond openly and constructively to inspection and use ongoing regulatory relationships to drive improvement in their organisations.

Second, how can CQC ensure it has the right insights about providers and systems to prioritise inspection activity and assess performance? Our research shows that routine performance indicators are not very useful for this type of prioritisation because they don’t correlate with inspection outcomes. CQC is working to widen its pool of hard and soft intelligence by, for example, working with charity call centres and scraping social media posts for patient comments. CQC is developing a new monitoring approach but no one should underestimate the difficulty of getting this right.

Third, how do we ensure providers and local systems have the right skills and support to respond to CQC inspections? Our research found that ‘improvement capability’ (skills within providers and external support from improvement agencies) is critical in determining impact. There is a great deal more of this capability in the hospital sector than in general practice and – most notably – adult social care. The lack of improvement capability in general practice and adult social care may explain why some providers in those sectors are stuck at the bottom of the performance tables.

One idea from our roundtable discussion is that, although many social care organisations are private providers operating in a competitive market, this does not have to hamper collaborative improvement efforts. There are examples from other sectors (a roundtable participant mentioned the US blood-donation market as one) in which providers have worked together to improve quality through benchmarking. This has been achieved despite the providers being competitors, although this type of work usual requires external facilitation. While improvement support is not CQC’s business, its absence in some sectors is reducing the effectiveness of CQC’s approach.

I left the roundtable discussion with a looming sense of the scale of this task and the many tensions within it. To get the most out of regulation, CQC needs to spend more time on local relationship-building but initial estimates show that its new risk-based approach to inspection is leading CQC to inspect more, not less – a challenge for local CQC staff with a limited number of hours in their day. To gain an accurate view of performance in local areas, CQC needs to cast the net wide and combine qualitative and quantitative information. But with such a diverse and broad dataset, how can it identify the signal in the storm? To adapt to changes in health and care, CQC needs to inspect systems and not just individual providers. However, doing both simultaneously creates a capacity challenge – for both the regulator and those it regulates.

The challenge for CQC as it seeks to navigate these tensions will be working out what to stop doing, to create space for a new focus on relationships and systems. And how can it harness others to ensure that providers are supported to respond to CQC interventions. Creating a regulatory system that drives improvement in health and care is complex, and CQC cannot crack this nut on its own.

Source: The King’s Fund



‘Moving at the speed of trust’ – the journey to integrated care systems

Anna Charles writing at the King’s Fund: In May of this year, NHS England announced four new integrated care systems (ICSs) to join the ten existing systems. But ‘announced’ is not really the right word; as we have found in our work with the systems, creating an ICS is most definitely a journey and not an event. 

We’ve been tracking these journeys over the past year, conducting interviews with more than 70 NHS and local government leaders and other stakeholders in eight of the first ICSs. Our new report, published today, sets out the findings from this work and identifies emerging lessons for local systems and national policy-makers.

Integrated Care

ICSs (and the new care models that came before them) have been introduced in a very different way to the NHS reforms of the past. Instead of central bodies passing legislation that enforces a uniform organisational model across the country, ICSs are being designed and implemented by local areas, within a broadly permissive national programme that emphasises peer learning and support. In the words of one local leader:
 
The honest discussions about the wicked issues and how they can best be navigated has felt, to me, like a breath of fresh air…You can’t just impose a blueprint from Skipton House or Whitehall. This has to be more iterative and co-produced.

There are some drawbacks to this approach in terms of the clarity and consistency of the changes taking place, but our work suggests that an ICS can only be developed in each place, by each place; they must evolve and be owned locally if they are to succeed.

Why is this? After all, we found strong similarities in the governance arrangements that the different systems are developing and in the service changes that they are putting in place. ICSs have much in common, and there is much they can learn from each other. But the strongest message that came through loud and clear from our interviews was that this had to be founded on collaborative relationships and trust between partner organisations and their leaders:

It’s relationships, relationships, relationships…all the governance structures and technical things in the world are great, but if people don’t have an aspirational intent to work together, it doesn’t really matter what you write down.

The systems have used a variety of strategies to address this, including bringing leaders and staff from different organisations together to spend time face to face, working through collective challenges, and creating a shared purpose. Building relationships cannot be rushed or centrally imposed; it takes time and commitment and can only be done locally.

We can’t do any of this quickly. This is very big change for a lot of people across the system. I think that to do it any quicker we would have just fallen over.

Individuals spoke candidly about how developing an understanding of other organisations’ priorities and challenges had altered their own perspectives and behaviours. They described greater openness and transparency across different organisations and new ways of collectively managing finances and performance as a result:

I’ve learnt more about how local authorities work in the past 18 months than I’ve done in the past 42 years…it’s been spending time with one another and understanding one another’s problems and issues.

It is still early days for ICSs. Local leaders need to continue the work they have begun by giving priority to strengthening relationships and trust, redoubling their efforts to involve key partners, and focusing on delivering further changes in service models to improve heath and care for their populations. They also need to take active steps to listen to and work with members of their local communities on an ongoing basis, ensuring they design services that meet their needs and reflect their priorities.

National leaders must hold their nerve in allowing ICSs to be built from the bottom up, while also offering guidance and support and doing their upmost to remove the barriers that ICSs encounter.

To end on the words of one ICS leader:

The ICSs will move at the speed of trust…this is really about relationships and trust between the partners.