Earlier this year, the Care Quality Commission (CQC) launched a public consultation with the aim of reviewing its current inspection methods (CQC, 2021a). The decision to hold a public consultation was taken because of the serious impact the COVID-19 pandemic was having on the functioning of the NHS as a whole. This led to the regulator having to consider amending its inspection strategies to alleviate unnecessary pressures on the NHS.
This decision was a recognition that the CQC needed to balance its statutory responsibilities with the need to allow hospitals and other providers to concentrate on delivering care during the pandemic while simultaneously coping with the stresses of increased patient flow (Glasper, 2021). The public consultation ran until 23 March 2021 and reflected the CQC's quest to continue to develop a more targeted, responsive and collaborative approach to regulation in a changing landscape of health and social care (CQC, 2021a).
In late May 2021, the CQC launched an ambitious new inspection strategy, which aims to reflect the changes to the NHS in the wake of the ongoing pandemic and which should lead to smarter regulation (CQC, 2021b).
Background
The CQC was created in 2009 following the merger of three regulatory organisations: the Commission for Healthcare Audit and Inspection, the Commission for Social Care Inspection and the Mental Health Act Commission. The primary function of the CQC is to regulate and inspect health and social care services in England to ensure that they provide safe, effective, and compassionate, high-quality care. The original inspection model had to fundamentally change in the aftermath of two specific scandals that occurred, one at the Mid Staffordshire NHS Foundation Trust and the other at Winterbourne View private hospital in south Gloucestershire, the latter providing care for people with learning disabilities and challenging behaviour. Both institutions were subject to public inquiries that revealed unacceptable patient abuse (Department of Health, 2012; Francis, 2013).
The CQC responded to the findings of these two public inquiries, which exposed weaknesses in its inspection processes, by introducing a much more stringent inspection methodology (Glasper, 2021). This more robust CQC inspection model was not, however, universally admired. One author (Castro, 2018) suggested that the CQC inspections had not actually been associated with improvements in the quality of care provided in acute NHS hospitals. Furthermore, in December 2020, Donna Ockenden published an independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust, which revealed an urgent need to improve the safety of its clinical provision (Ockenden, 2020).
Similarly, Allen et al (2019) suggested that, following CQC inspections of 118 NHS emergency departments, there was no change in performance as a result.
By the spring of 2020, as the COVID-19 pandemic threatened to overwhelm the NHS, the CQC acknowledged that changes to the way it conducted its regulatory activities within NHS trusts would have to be introduced. This was a pragmatic decision because the CQC relies heavily on frontline senior clinical staff to act as specialist advisers during inspections. When the pandemic began to accelerate and as pressures on the frontline staff delivering care became exacerbated, it became obvious that it would not be possible or appropriate to take frontline care staff away from clinical duties to participate in inspections. As a consequence, and as the pandemic entered its second year, the CQC overhauled its inspection processes.
Since the CQC was established more than a decade ago, the parameters of health and social care have changed significantly. The new CQC strategy reflects these changes and the regulatory processes being introduced later in 2021 are designed to better meet the needs of service users and to encourage innovations and improvements to care delivery. They also aim to support those who work in and lead services to deliver the best possible care.
As part of its new inspection strategy, the CQC is investigating how to better solicit the views of a wider range of people, including those who work in health and social care, and to enhance the way in which this information is recorded, analysed and used. In this way, it is envisaged that data from staff will make it easier to quickly identify changes in the quality of care, whether good or less than optimum.
During previous inspection processes, CQC staff and their specialist advisers always sought the views of the people who work within health and social care organisations, ranging from cleaners through to medical consultants. However, in the past, the temporary nature of the inspection teams has been criticised, because this may have hindered the conduct of some inspection activities (Boyd et al, 2018).
This new inspection regime aims to also make it easier for service users and their family members to provide constructive feedback to the CQC inspectors and they will be given a response to show how their feedback will be used in contributing to the regulation processes. In particular, the CQC will seek to engage with service users who may be from a disadvantaged community and those who have endured distressing or traumatic experiences while using services.
The pandemic has highlighted inequalities in health and care. As a regulator the CQC is committed to reducing inequalities, and eliminating discrimination across the NHS and social care as a whole and this new strategy has been designed to help health and social care providers to do this.
The CQC is committed to a new regime where it will be essential that people who use services, those who work in them and health and care organisations work together to design, deliver, evaluate and improve care.
The new CQC strategy
The new CQC strategy is set out under four themes (CQC, 2021b).
People and communities
The CQC's regulation must be driven by people's needs and experiences, focusing on what is important to them as they access, use and move between services. Working in partnership, the CQC believes that it has an opportunity to help build care around people who use services by listening and acting, by empowering the service user and by prioritising people and communities.
Smarter regulation
The CQC will take a more dynamic and flexible approach that provides up-to-date and high-quality information and ratings, easier ways of working with the CQC, and a more proportionate regulatory response, with better targeted and smarter use of data. This will help create an effective, proportionate and efficient regulator. To achieve this, the CQC will become more focused and dynamic, making it easier for people and organisations to work with it as the regulator. In this way, the CQC has aspirations for making itself more relevant and future-proofed, with a focus on what matters most.
Safety through learning
The CQC aims to have an unremitting focus on safety, requiring a culture across health and care that enables people to speak up and in this way share learning and improvement opportunities. The CQC is committed to taking clear and proactive action when safety does not improve. To do this, the CQC wants people to influence the planning and prioritisation of safety and be truly involved as equal partners in their care at all levels.
Accelerating improvement
The CQC wants to encourage health and care services to access support to help improve the quality of care where it is needed most. The CQC seeks to empower services to help themselves while retaining its strong regulatory role. The regulator will achieve this, among other strategies, by collaborating and strengthening their relationships with services, the people who use them and their partners across health and social care (CQC, 2021b).
CQC ambitions
The CQC is seeking to embed two specific ambitions for each of the four themes. The first involves assessing local systems, which should give the service users within that locality an independent assurance about the quality of care in their area. Secondly, the CQC is focused on tackling inequalities in health and care to ensure equality of access, care experiences and outcomes for all service users. As part of this aim, the CQC will endeavour to assess how well local health and care systems function in addressing local challenges to their services.
During the 12 years of its existence, the CQC has gained significant insights into what constitutes improvement in service provision. Although some of its approaches have been criticised, with some believing that it is frontline health professionals, not external regulators, who are the key to driving up quality in the NHS (Torjesen, 2012), there is no doubt that the CQC has acquired valuable knowledge and insight about improvement. The CQC wants to use this knowledge to inform its regulatory approach to promote an improvement culture across health and social care. Future inspection activity will now be based on evidence about what actually works in practice and the CQC intends to use the evidence it collects to support improvement.
Experiences over the past 5 years, including learning from the pandemic, has put the CQC in a pivotal place for its future regulatory role. The new inspection strategy combines this learning and experience with valuable contributions from the public, service providers and their partners and service users. This means that CQC regulation activity will aim to be more relevant to the way care is delivered, with more flexibility to better manage risk and uncertainty. This will help the regulator to respond in a more rapid and more proportionate way as the health and social care environment continues to evolve post-pandemic and over time.
KEY POINTS
- The primary function of the Care Quality Commission (CQC) is to regulate and inspect health and social care services in England to ensure that they provide safe, effective, compassionate and high-quality care
- Following a public consultation, the CQC launched an ambitious new inspection strategy in May 2021
- The new CQC strategy is designed to better meet the needs of service users and to encourage innovations and improvements to care delivery
- The pandemic has highlighted that there should be a renewed focus on inequalities in health and social care and the CQC is committed to reducing these inequalities
- Future CQC inspection activity will now be based on evidence about what actually works in practice and the evidence it collects will be used to support improvements