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



What does the future hold for integrated care systems?

Chris Ham writing for The King’s Fund: NHS England’s belated decision to change the name of accountable care systems to integrated care systems has the virtue of describing more accurately the work being done in the 10 areas of England operating in this way. Despite this, there is understandable confusion in many quarters about NHS England’s plans, and uncertainty about what they mean for the NHS in the medium term.

Integrated care systems, as they were re-branded in updated planning guidance published recently by NHS England, bring together NHS commissioners, providers and local authorities to plan how to improve health and care for the populations they serve. For the organisations involved in these systems, lines of accountability remain unchanged. NHS organisations continue to look upwards to NHS England and NHS Improvement and local authorities look outwards to their communities. Many systems are also working to establish a form of mutual accountability in which the organisations involved hold each other to account for the delivery of their plans.

Mutual accountability hinges on the existence of a high degree of trust and respect between organisations and their leaders. It also requires the establishment of governance arrangements that support collaboration while respecting the statutory responsibilities of these organisations. Integrated care systems have no basis in law and they depend on the willingness of the organisations involved to think and act as part of a wider system even when it may not be in their interests to do so.

Integrated Care

These systems also require NHS England and NHS Improvement to work together to oversee how areas working in this way are performing. This is beginning to happen in some areas through joint working by teams drawn from national bodies and the development of single regulatory oversight. NHS England’s expectation is that integrated care systems will become self-governing as they mature and that regulatory intervention will then be the exception rather than the rule, but this is some way off in most areas.

The updated planning guidance makes clear that integrated systems will become increasingly important in planning services and managing resources in future.

The updated planning guidance makes clear that integrated systems will become increasingly important in planning services and managing resources in future. The 10 areas already operating in this way will prepare a single system operating plan and take responsibility for a system control in 2018/19. The guidance also states that other systems will join the programme where they can demonstrate strong leadership, a track record of delivery, strong financial management, a coherent and defined population, and compelling plans to integrate care. The message could not be clearer: system working is here to stay.

Integrated care systems, like the sustainability and transformation partnerships from which they have evolved, are conscious workarounds which seek to make sense of the complex and fragmented organisational arrangements resulting from the Health and Social Care Act 2012. Changes to the law to regularise what is happening, included in the Conservative Party’s 2017 election manifesto, are off the agenda for the time being. This is because the government lacks a working majority and also because Brexit is dominating the parliamentary timetable.

The difficulty this creates is that workarounds are inherently unstable, even in the most favourable circumstances, and can only be sustained for so long. Informal mechanisms such as memoranda of understanding and partnership boards to underpin decisions about the use of NHS resources have a part to play but may break down when difficult decisions arise. There are worries too that decisions will be taken behind closed doors in forums that have no statutory basis and are not open to public scrutiny.

There are worries that decisions will be taken behind closed doors in forums that have no statutory basis and are not open to public scrutiny.

Changing the name of accountable care systems to integrated care systems will not distract attention from concerns by campaigners about a proposed national contract for accountable care organisations which they fear will result in ‘backdoor privatisation’. The contract is intended to be used by NHS commissioners who wish to undertake a competitive procurement process to integrate the delivery of care for their populations. NHS England has responded to the concerns raised by delaying the contract’s introduction and agreeing to consult on how it expects it to be used.

The puzzle is why the proposed contract is needed when many areas of England have already made moves to integrate care making use of existing legislative flexibilities. These areas are working with NHS providers to align hospital, community and mental health services, with GPs and adult social care services also involved in some places. They are doing so in a variety of ways, including through the use of alliance contracts and lead providers who subcontract with other providers to join up care in public sector partnerships..

Where this is happening, the emphasis on collaboration between commissioners and providers appears to run counter to the intention that the proposed contract should be used in a competitive procurement process. Clinical commissioning groups are also often uncertain on when they are required to go out to tender for the services they commission and are alert to the possibility of legal challenges from private companies who may feel excluded from decisions to keep contracts within the NHS family. The NHS market may be dying but is not yet dead, underlining the tension at the heart of recent developments.

For the foreseeable future, the NHS and its partners will have to live with this tension and the ambiguity it creates. They will also hope that the political will can be found before too long to align the law with the priority now being given to integrated care and partnership working. Is it too much to expect a cross party consensus to emerge that will make this possible?

Source: The King’s Fund