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



The NHS Five Year Forward View – Summary

The NHS Five Year Forward View was published on 23 October 2014 and sets out a new shared vision for the future of the NHS based around the new models of care. It has been developed by the partner organisations that deliver and oversee health and care services including Care Quality Commission, Public Health England and NHS Improvement (previously Monitor and National Trust Development Authority).

Summary

  1. The NHS has dramatically improved over the past fifteen years. Cancer and cardiac outcomes are better; waits are shorter; patient satisfaction much higher. Progress has continued even during global recession and austerity thanks to protected funding and the commitment of NHS staff. But quality of care can be variable, preventable illness is widespread, health inequalities deep-rooted. Our patients’ needs are changing, new treatment options are emerging, and we face particular challenges in areas such as mental health, cancer and support for frail older patients. Service pressures are building.
  2. Fortunately there is now quite broad consensus on what a better future should be. This ‘Forward View’ sets out a clear direction for the NHS – showing why change is needed and what it will look like. Some of what is needed can be brought about by the NHS itself. Other actions require new  partnerships with local communities, local authorities and employers. Some critical decisions – for example on investment, on various public health measures, and on local service changes – will need explicit support from the next government.
  3. The first argument we make in this Forward View is that the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgradein prevention and public health. Twelve years ago Derek Wanless’ health review warned that unless the country took prevention seriously we would be faced with a sharply rising burden of avoidable illness. That warning has not been heeded – and the NHS is on the hook for the consequences.
  4. The NHS will therefore now back hard-hitting national action on obesity, smoking, alcohol and other major health risks. We will help develop and support new workplace incentives to promote employee health and cut sickness-related unemployment. And we will advocate for stronger public health-related powers for local government and elected mayors.
  5. Second, when people do need health services, patients will gain far greater control of their own care – including the option of shared budgets combining health and social care. The 1.4 million full time unpaid carers in England will get new support, and the NHS will become a better partner with voluntary organisations and local communities.
  6. Third, the NHS will take decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care. The future will see far more care delivered locally but with some services in specialist centres, organised to support people with multiple health conditions, not just single diseases.
  7. England is too diverse for a ‘one size fits all’ care model to apply everywhere. But nor is the answer simply to let ‘a thousand flowers bloom’. Different local health communities will instead be supported by the NHS’ national leadership to choose from amongst a small number of radical new care delivery options, and then given the resources and support to implement them where that makes sense.
  8. One new option will permit groups of GPs to combine with nurses, other community health services, hospital specialists and perhaps mental health and social care to create integrated out-of-hospital care – the Multispecialty Community Provider. Early versions of these models are emerging in different parts of the country, but they generally do not yet employ hospital consultants, have admitting rights to hospital beds, run community hospitals or take delegated control of the NHS budget.
  9. A further new option will be the integrated hospital and primary care provider – Primary and Acute Care Systems – combining for the first time general practice and hospital services, similar to the Accountable Care Organisations now developing in other countries too.
  10. Across the NHS, urgent and emergency care services will be redesigned to integrate between A&E departments, GP out-of-hours services, urgent care centres, NHS 111, and ambulance services. Smaller hospitals will have new options to help them remain viable, including forming partnerships with other hospitals further afield, and partnering with specialist hospitals to provide more local services. Midwives will have new options to take charge of the maternity services they offer. The NHS will provide more support for frail older people living in care homes.
  11. The foundation of NHS care will remain list-based primary care. Given the pressures they are under, we need a ‘new deal’ for GPs. Over the next five years the NHS will invest more in primary care, while stabilising core funding for general practice nationally over the next two years. GP-led Clinical Commissioning Groups will have the option of more control over the wider NHS budget, enabling a shift in investment from acute to primary and community services. The number of GPs in training needs to be increased as fast as possible, with new options to encourage retention.
  12. In order to support these changes, the national leadership of the NHS will need to act coherently together, and provide meaningful local flexibility in the way payment rules, regulatory requirements and other mechanisms are applied. We will back diverse solutions and local leadership, in place of the distraction of further national structural reorganisation. We will invest in new options for our workforce, and raise our game on health technology – radically improving patients’ experience of interacting with the NHS. We will improve the NHS’ ability to undertake research and apply innovation – including by developing new ‘test bed’ sites for worldwide innovators, and new ‘green field’ sites where completely new NHS services will be designed from scratch.
  13. In order to provide the comprehensive and high quality care the people of England clearly want, Monitor, NHS England and independent analysts have previously calculated that a combination of growing demand if met by no further annual efficiencies and flat real terms funding would produce a mismatch between resources and patient needs of nearly £30 billion a year by 2020/21. So to sustain a comprehensive high-quality NHS, action will be needed on all three fronts – demand, efficiency and funding. Less impact on any one of them will require compensating action on the other two.
  14. The NHS’ long run performance has been efficiency of 0.8% annually, but nearer to 1.5%-2% in recent years. For the NHS repeatedly to achieve an extra 2% net efficiency/demand saving across its whole funding base each year for the rest of the decade would represent a strong performance – compared with the NHS’ own past, compared with the wider UK economy, and with other countries’ health systems. We believe it is possible – perhaps rising to as high as 3% by the end of the period – provided we take action on prevention, invest in new care models, sustain social care services, and over time see a bigger share of the efficiency coming from wider system improvements.
  15. On funding scenarios, flat real terms NHS spending overall would represent a continuation of current budget protection. Flat real terms NHS spending per person would take account of population growth. Flat NHS spending as a share of GDP would differ from the long term trend in which health spending in industrialised countries tends to rise as a share of national income.
  16. Depending on the combined efficiency and funding option pursued, the effect is to close the £30 billion gap by one third, one half, or all the way. Delivering on the transformational changes set out in this Forward View and the resulting annual efficiencies could – if matched by staged funding increases as the economy allows – close the £30 billion gap by 2020/21. Decisions on these options will be for the next Parliament and government, and will need to be updated and adjusted over the course of the five year period. However nothing in the analysis above suggests that continuing with a comprehensive taxfunded NHS is intrinsically un-doable. Instead it suggests that there are viable options for sustaining and improving the NHS over the next five years, provided that the NHS does its part, allied with the support of government, and of our other partners, both national and local.

“It suggests there are winners and losers using NHS services. We can only hope the new models of care makes more winners”