Part 4 of the consultation – 'The next phase of regulation – NHS trusts' – includes proposals for more streamlined regulation, but also some significant proposed enhancements to the system, with more regular, and in-depth assessments of whether trusts are 'Well-led', together with new ratings on their use of resources. Although this Part of the consultation is directed at NHS providers, it may still be informative for the independent sector as signalling CQC's intended direction of travel, including a greater focus on 'well-led' and the role of the 'guiding mind' of organisations suggesting increased board and senior management level scrutiny. Independent sector providers should also be aware that CQC have highlighted the need to ensure its methodology around ratings is sufficiently flexible, signalling a possible wish to introduce provider level ratings for independent sector providers in the future.
Having completed its comprehensive inspections for all NHS trusts in England, CQC now has a better "baseline of quality" than ever before. Going forward, CQC does not propose to repeat the cycle of comprehensive inspections - instead, comprehensive inspections will only be carried out for newly registered trusts or where CQC has significant concerns.
In the main, however, CQC's proposed approach is that its interactions with most trusts will be conducted on a more frequent basis with smaller-scale more focused inspections. A significant part of the new approach is set out in a separate joint consultation with NHS Improvement on "Use of resources and well-led assessments" - https://improvement.nhs.uk/uploads/documents/Consultation_on_use_of_resources_and_well-led_assessments.pdf . As such, these consultations also signal ever-closing working between the CQC and NHS Improvement.
Ongoing Monitoring – risk assessment
CQC proposes to revise its methodology for on-going monitoring of trusts to identify potential areas of risk requiring further scrutiny. Broadly, the monitoring of trusts will be based upon the following:-
- Findings from the trust's previous comprehensive inspection;
- CQC Insight - this is CQC's new updated intelligence system (replacing 'Intelligent Monitoring') which will collate a wide range of qualitative and quantitative data on trusts to inform risk assessments. Unlike the Intelligent Monitoring system, CQC states that CQC Insight draws upon a wider range of data sources and will include data not only at trust level, but also at location, core service and key question level. The data in CQC Insight will also be updated more frequently than under the old Intelligent Monitoring system.
- Qualitative Data/ Focus Groups - As well as information from other stakeholders, CQC will also host focus groups with staff on an on-going basis throughout the year, rather than only running these at the time of an inspection.
- A new annual Provider Information Request ("PIR") - trusts will be required to submit this once a year. However, it will be more streamlined than the old PIR and will not request data that is available from other sources, such as HES data or national audits. Trusts will, however, be required to provide additional information about their leadership, governance and organisational culture, to facilitate CQC's more in-depth assessment of 'Well-led'(see below).
All of this will go to create an 'Insight Dashboard' for the trust which will inform CQC's decisions about when, and what to inspect. It is proposed that trusts will be able to access their own Insight Dashboard and these will also be shared with key stakeholders including NHS Improvement and NHS England.
It is proposed that each trust will have an inspection "approximately annually". There will be two aspects to the inspections:-
- Core service inspections
- Well led inspections
Core service inspections
Rather than inspecting all core services (as was the case with comprehensive inspections), CQC will only inspect a sample of core services in each year. Significantly, these core service inspections will be unannounced.
The decision on the sample of core services inspected in any year will be risk-based "to focus on protecting people from poor care where there are greatest concerns, and to assess where improvements have been made". This is subject to maximum intervals for re-inspecting core services depending on their rating when last inspected by the CQC as follows:-
|Core Service Rating||Maximum Period for Re-inspection|
|Required improvement||2 years|
Accordingly, the number of core services which a trust will have inspected will vary year on year.
CQC are consulting jointing with NHS Improvement on developing a single 'Well-led Framework', combining CQC's previous KLOEs for Well-led, with the Monitor Well-led Framework. This means that CQC will now assess 'Well-led' against eight KLOEs (as opposed to the previous five). However, providers may find it helpful that CQC and NHS Improvement are now proposing to use the same framework for their assessments of 'Well-led'. CQC's consultation states that the new 'Well-led framework':-
- has been aligned to the principles articulated in "Developing People – Improving Care: A national framework for action on improvement and leadership development in NHS-funded services" - https://improvement.nhs.uk/uploads/documents/Developing_People-Improving_Care-010216.pdf
- Includes a clear emphasis on ensuring the sustainability of services "reflecting the approach set out by the National Quality Board in its Shared Commitment to Quality" - https://www.england.nhs.uk/wp-content/uploads/2016/12/nqb-shared-commitment-frmwrk.pdf
There is also proposed to be a shift in the way in which 'Well-led' is inspected by CQC. Whereas, to date, CQC's assessment of trust-wide leadership was used to corroborate, and where necessary, modify a rating for 'well-led' based on an aggregation of location-level ratings, in future the assessment of "trust-wide leadership, governance, management and culture will be the starting point for the trust-level rating of well-led". CQC state that, as with its existing approach, this assessment "will draw on a range of evidence applicable at the overall trust board level, including interviews of board members and senior staff, focus groups, analysis of data, review of strategic and trust-level policy documents, and information from external partners".
CQC also propose to reflect a trust's participation in accreditation schemes as part of its assessment of 'Well-led'. The benefit of these schemes for trusts is two-fold, as not only will CQC reflect a trust's participation in accreditation schemes in its assessment of 'well-led', but, in due course, where the accreditation scheme itself is considered to meet certain standards, CQC may rely upon accreditation to potentially replace the need for a CQC inspection of the accredited service.
Use of Resources Assessment
As well as undergoing an annual 'well-led' inspection, NHS trusts will also be subject to an annual "Use of Resources Assessment". Initially, the Use of Resources assessments will be introduced for acute non-specialist trusts but, as metrics are developed, this will be extended to specialist acute, ambulance, mental health and community services trusts.
The joint consultation confirms the proposal for these assessments to be undertaken by NHS Improvement under an assessment framework which has four domains:-
- Finance: How effectively is the trust managing its financial resources?
- Clinical Services: How well is the trust maximising patient benefit, given its resources?
- People: How effectively is the trust using its workforce to maximise patient benefit?
- Operational: How well is the trust maximising its operational productivity?
The joint consultation states that, in assessing a trust's use of resources, NHS Improvement will draw on a range of financial and productivity metrics including:
- The current finance and use of resource metrics in the Single Oversight Framework (e.g. capital service capacity; liquidity; I & E margin; distance from financial plan; and agency spend);
- Wider productivity metrics largely drawn from the Model Hospital data covering issues including clinical services, workforce, finance, estates and facilities, and procurement.
The proposal is that NHS Improvement will undertake the assessment and submit this to CQC, along with its suggested rating for use of resources on a four point scale from Outstanding to Inadequate. The final decision on the rating for use of resources will be made by CQC which will then publish this in its inspection report along side the Trust's quality rating. As with all CQC's ratings, providers will have an opportunity to challenge the rating, and underlying findings, in relation to Use of Resources at the draft report stage.
CQC indicate they will move to shorter, more succinct reports that will be more accessible with all the factual evidence set out in an evidence appendix.
As stated, it is proposed that the report will include a rating for Use of Resources, alongside the Trust-level quality rating. However, signalling a further shift in this direction, the joint consultation states (at para 30) that as the assessment methodology is finalised, consideration will be given to how the Use of Resources rating can be combined with the overall Trust-level quality rating.
The consultations signify significant change for the regulation of NHS trusts with far greater emphasis on assessments of leadership and Use of Resources. We would therefore encourage NHS providers to review the consultations thoroughly, consider what they will mean for them and respond to have their say upon the future regulatory landscape. The deadline for responses to the consultation is 14 February 2017.
|Continue reading the CQC Consultation briefing|
|Part 1: "Regulating New Models of Care and Complex Providers"|
|Part 2: The New Assessment Framework|
|Part 3: "Registering Services for People with Learning Disabilities"|
|Part 4: Next Phase of Regulation – NHS trusts|