We are currently developing the Care Quality Commission (CQC) strategy for the next five years. This is the third in a series of documents in which we have asked for your help to develop our approach to quality regulation of health and social care services. It builds on the conversation we began in March 2015 with our first Shaping the future document, and continued with Building on strong foundations in October when we asked for your feedback to inform this consultation. This document reflects your views and reactions and sets out for final consultation our proposals for how CQC will operate over the five years from May 2016.We begin by setting out our vision for regulating health and adult social care quality. We set out the difference that we believe quality regulation can make to people who use services and organisations that deliver care. We then explain how we will achieve this vision and the areas we intend to focus on. We finish by setting out how we intend to deliver this over five years and with fewer resources. We have also published our Draft equality and human rights impact analysis which will be finalised in line with the strategy.We would like to hear your views on our proposals so that we can shape the final strategy. This is really important as it makes surewe consider what matters most to you as we develop and finalise our plans.
This response was submitted online
Care Quality Commission’s Strategy 2016 to 2021: Shaping the future
1a Do you agree with the vision we have set out for regulation of the quality of health and adult social care services in 2021? (see pages 6-11)
Agree
1b What do you agree with, or not agree with, about the vision?
We agree with the principles of the vision. Whether it is fully achievable is more debatable. When there is such wide variation of current ratings, getting useful responses from providers will be a significant challenge. Robust, good data about hospital services (both good and bad) should be available to both staff and patients and in the public domain.
There is also a dilemma at the heart of the CQC inspection process and its relationship to NHS Improvement. The CQC operates at a level of scrutiny that drives cost to providers to satisfy a quality mandate. Monitor and NHS England have financial regulation and management which may be at odds with this. One example of this can be seen in hospital nursing numbers – CQC mandates safe nursing staffing to best guidance whereas Monitor dictates cost reduction – the biggest cost is in staff. More clarity in this area is required.
The vision may be difficult to implement with so many different commissioners and providers involved. For example an acute provider might have relations with three local authorities and many tens of private care home providers, the relationships between whom influence the flow of patients through the hospital that the local CCG commission. Whose role is it to ensure that the co-ordination works?
2a Do you agree with our proposal to make greater use of data and information to better guide us in how we identify risk, and how we register and inspect services? (see pages 14-16)
Strongly agree
2b What do you agree with, or not agree with, about greater use of data and information?
Firstly, there should be a very user friendly way for the public to give feedback about services, including consultants' services, while avoiding the widespread use of anecdotal evidence that is not sufficiently triangulated.
It is important that the right quantitative and qualitative data is used with robust statistics. For example, a Trust may have a higher standardised mortality rate but which is within statistical limits – this must be appreciated and correctly interpreted. Recognised and validated specialty care standards data could perhaps be used - encouraging teams to continually assess their performance in line with their peers.
If data is to be used to guide inspection then more reliable and consistent data is required. Consistent agreements will be required between providers in how data is recorded. If this is achieved it may allow for greater transparency, however this may be challenging given different IT systems.
3a Do you agree with our proposal for implementing a single shared view of quality? (see page 17-19)
Agree
3b What do you agree with, or not agree with, about a single shared view of quality?
A shared view of quality should allow much better comparisons for the public and would be a powerful tool to use across a range of providers and regulators. However we are concerned that simple terms may obscure complex systems and processes.
It may not be possible to use this framework on training bodies (eg Health Education England). The five key questions are hugely important and are used by training organisations, but they do not map fully to the existing GMC training frameworks, so there may need to be some derogation.
4a Do you agree with our proposal for targeting and tailoring our inspection activity, including reducing the frequency of some inspections so we target our resources on the greatest risk? (see pages 19-21)
Agree
4b What do you agree with, or not agree with, about targeting and tailoring our inspection activity?
We are unsure whether there will be any significant improvements in data and information to allow for a switch to tailored visits. Consolidating the current regime such that all institutions have been visited twice will allow more understanding of what data and information will dictate in future which areas require specific assessment under a more focussed regime.
Generally we welcome targeting areas of inspection using experts by experience. The pressure on Trusts and nursing homes generated by current inspections may mean that a change to multiple shorter unplanned/unscheduled visits to get the true picture is more desirable.
However, these targeted visits may need to be in addition to other more systemic checks to ensure that "good" or "outstanding" care isn't deteriorating. Expert targeted inspection may therefore be an additional rather than alternative method of inspection - and not cost saving.
5a Do you agree with our proposal for a more flexible approach to registration? (see pages 22-23)
Agree
5b What do you agree with, or not agree with, about a more flexible approach to registration?
This seems a sensible approach.
6a Do you agree with our proposal for assessing quality for populations and across local areas? (see pages 25-27)
Agree
6b What do you agree with, or not agree with, about assessing quality for populations and across local areas?
This will likely be challenging and costly but crucial as new models of care and co-working are developed. The challenge will be in the allocation of responsibility across providers for improvement. This goes to the heart of what provider systems will look like in the future eg hub and spoke models, specialist syndicates operating across boundaries, federated GPs. This will be a slow, evolving process.
7 What impact do you think our proposals will have on equality and human rights?
One potential issue could be if overall areas of poor care were discovered in areas where there are a large population of people with a protected characteristic.
8 Are there any other points that you want to make about any of the proposals in this document?
There are no specific questions on theme 5 (assessing how well hospitals use resources). Any work on this theme will require buy in from providers at an early stage. This has the potential to muddy the waters between quality of care and fiscal responsibility. There are also other parties looking into efficiency.
It is important that management structures and inspection teams are appropriately representative of society. The CQC inspection group should include respected clinicians (both consultants and Nurses) with a record of excellent patient care and clinical service- they are the ones who will understand and judge the service well.
There is also no specific question about the performance of CQC – the strategy should contain information on how Government and the public can judge whether the CQC is achieving its purpose effectively.
With regard to the logistics of a visit, I.e. the way data is presented by the site /service, the report after a visit, including the style, speed and accuracy of the report. The ``paperwork`` could all be completed on line, with specific uploads as evidence, standards for each area, with criteria to be met. This could speed up a very slow reporting system. A good example of this is the Joint Advisory Group on GI Endoscopy visit website.