CQC, the state of care and system-level regulation

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Last week the Care Quality Commission (CQC) published its annual report to parliament The state of health care and adult social care in England, based on inspections of more than 30,000 services and providers, as well as other sources.

Much has changed since I worked on the first State of Health Care report, published in 2004 by the Healthcare Commission (the predecessor to CQC). Since then, the regulator’s focus has developed from health care to also cover social care, and – more recently – from individual providers to start looking at systems of care. The regulator has also become more confident and vocal, using its annual report to deliver strong messages to government and others about priorities for change. 

The strong messages in this year’s report are ones that CQC is uniquely placed to deliver, being the only national organisation in the triumvirate that oversee local systems that covers both health and social care (NHS Improvement and NHS England focus solely on health). The first message is for government: social care needs a long-term funding solution and improvements in NHS care will not be achievable without this. The second is mainly for local health and care systems: there is an ‘integration lottery’ contributing to wide variations in care, and better collaborative working is needed to address this.   

A few weeks ago, The King’s Fund and Alliance Manchester Business School published the first major evaluation of the CQC’s new approach to inspecting and rating health and social care providers. Our research outlined eight ways in which regulators can have an impact on providers (see slides below). The State of Care report is an example of CQC flexing its ‘systemic impact’ muscle, using its wealth of data and intelligence to diagnose system-wide issues and push for change. 

The CQC’s recommendations are in part based on a series of local system reviews that have been conducted over the past year, looking at how care for older people is provided in 20 local authority areas. This is a new approach for the CQC; focusing on the interfaces between different services, rather than individual organisations, and looking across a local health and care system to identify areas where improvements can be made. At the moment, CQC does not have legal powers to regulate across systems and can only conduct these reviews when requested to do so by the Secretaries of State for Health and Local Government, a gap in the legislation highlighted recently by the Health and Social Care Select Committee, as well as the outgoing Chief Executive, David Behan

While the CQC will always have a role assessing individual organisations, the system-level approach is a welcome first step towards a new type of regulation that better reflects the interconnected nature of the challenges health and care organisations face and the drive towards collaborative working through integrated care systems and partnerships.

It allows the CQC to look at health and care with a patient’s eye view. That might sound like a strange thing to say about something that focuses on a ‘system’ (a concept quite far away from individual patients). But so many of the difficulties that patients experience are at the joins between organisations, as they move from one service to another. After my dad recently spent ten days in a major teaching hospital before being discharged to a care home and then back home, I didn’t recognise anything about his experience in the CQC report for the hospital where he had been treated. I then read the local system review for the city where he lives and found myself nodding in recognition and agreement with much of it. 

The CQC can only have an impact at the level of local systems if their recommendations have teeth and provoke change. While there are a suite of sanctions and support processes that kick in when individual providers are rated poorly by the CQC (particularly in the acute sector), there is no equivalent set of mechanisms to drive improvement at a system level. Time and again we also hear that hospitals and other providers are being held to account for their performance against national priorities like the A&E standard, and that in responding they sometimes have to take actions that run counter to collaboration. NHS Improvement, NHS England and CQC are already working to align their processes but more work needs to be done to create a unified message on system priorities that cascades through the work of the national bodies and is reflected in the approach of their local offices. Within its own operation, CQC will also have to work out how it can account for system-level factors within its inspections of individual providers (for example, can it mark down a provider for an issue that a system-wide view shows is arguably out of their control?). 

CQC also needs to think about how it can have more of an impact at a system level. Our research highlights eight ways regulation can have an impact on performance (see the slides above). These include encouraging peer learning (lateral impact) and setting expectations that systems can respond to before the inspectors arrive (anticipatory impact). Over the next few months, CQC will conduct six more local system reviews, three of which will be return visits to places inspected previously. These return reviews will be key to understanding whether and how local areas are responding to the regulator’s diagnosis and how an effective approach to ‘system level regulation’ can be developed in the future.

As CQC develops its new approach to regulating systems they must ensure it creates a mix of regulatory tools that work together to efficiently and effectively assure people’s overall experience of care, rather than simply adding a layer of regulation to a health and care system that is already one of the most heavily regulated in the world. 

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