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CQC to add financial side to ‘well led’ question in 2017 – before sixth rating

The CQC will “almost certainly” introduce a sixth key question on efficiency of resources into its ratings, as per Lord Carter’s recommendations, but this will only happen when they have “something that commands confidence throughout the service, as we have done with our quality ratings”, Sir Mike Richards, chief inspector of hospitals, said.

In the meantime, the regulator will enhance its fifth key question of whether a service is well-led by introducing an element of finance to it as well as of quality. This is being developed this year with a view to rolling it out from 2017, he said during one of the sessions at this week’s Health+Care Show.

The idea of a sixth item in CQC’s traditional five-question ratings system was first floated in Lord Carter’s efficiency review, published earlier this year. He suggested the sixth domain should revolve around money and resources, both including financial accounts and reflecting areas such as procurement, estates and use of agency staff.

But Sir Mike argued finances already formed part of the CQC’s objectives going back to the Act that set the body up in 2008, adding: “One of the functions of the commission is the efficient and effective use of resources in the provision of health and social care services. It was there from the start, and it’s not something that we have, until now, particularly focused on.”

He did acknowledge, however, that the CQC is working with NHS Improvement to build on Lord Carter’s recommendations to expand its work in the finance field.

He also noted there is a clear link between a trust’s financial position and its outcome in terms of quality, adding that “these two are not independent”. Citing the regulator’s published reports, the chief inspector said there was a strong correlation wherein trusts rated as ‘inadequate’ showed the largest deficit – 12.5% of turnover, on average – whilst those rated as good or outstanding ranged from a deficit of 3.6% of their turnover to being practically in financial harmony.

Upcoming inspection changes

Speaking to an audience of providers and health leaders at one of the last sessions on Thursday, Sir Mike hailed the week as a “celebratory” moment of the regulator – which will complete its comprehensive inspection programme of all NHS trusts “of all shapes and sizes” today.

Calling it a “major milestone” for the CQC – which has been previously slammed for falling behind its self-designated inspection schedule – Sir Mike said the completed programme will “give a really good baseline of what is going on in the NHS at the moment”.

But given the regulator has recently published its five-year strategy, Sir Mike also ran through some of the changes providers could expect in the coming years: “In general terms, our very large comprehensive inspections will be the exception to the rule. That’s because we will not need to do those on a regular basis.

“For some of the most challenged providers we will, and we’ll still go back and look at those throughout. But what we will do instead is, we’ll have an annual internal provider review meeting, where we bring together what we know about the trust from the previous inspection, what our national intelligence says about changes, what we hear from the trust through information requests, what we hear from our own staff that have been working with the trust, and bring all those things together to say: what do we know about this trust? Which parts of the trust do we most need to focus on? Which two or three core services, for example, ought we to be looking at?

“And maybe in some we’ll say well, we’ll just go back to that service, which is good or outstanding, just to make sure we keep them on their toes – but we’ll also say ‘we really need to go back to that service because it was inadequate before’. So that will help us to get to this so-called regulatory plan, and that’s what we mean by this targeted and tailored approach.

“We’ll probably be going into trusts more frequently than before, but only in some parts of trusts, which will be less intensive for the trust – but also, we’ll have a greater emphasis on the unannounced inspections.”

Place-based regulation

Sir Mike also said upcoming changes could include taking forward the CQC’s ambitions of assessing cancer and mental health provision, as well as looking at health in a more place-based, rounded way.

“We’re very near to the point where we will have inspected virtually the whole of health and social care,” he said. “So for a patch, whatever size patch you want to look at – it could be one of these STP footprints, it could be a CCG, whatever footprint you want – we will know how good the care homes are, how good the primary medical services, and how good the hospitals, the mental health services and the community services are.

“At the moment, we are doing those separately. I think the next stage for us is, we need to ask more questions about integration. I think that’s partly asking questions of patients in our surveys – ‘do you feel that the services you are getting are joined up?’ – a question along those lines. But we should also be asking the GPs in a patch how well-integrated they feel with the hospital.

“So, for example, if you want specialist advice, either by phone or email, how quickly would you get a response? If a patient has been in hospital and gets discharged, what’s the average time until you get to know the patient’s left hospital? If a patient dies, how quickly are you informed of that?

“I really welcome suggestions from others on other questions that will really help us to know whether hospitals, A&E, GPs and indeed care homes are working together. There are lots of ways through which we can test integration.”

Speaking earlier in the day, the CQC’s chief executive, David Behan, also made the case for the regulatory body, which he said “could be abolished tomorrow, and we’d still be reinvented the next day”.

“My job is to ensure the CQC is carrying out its responsibility in an appropriate and effective way,” he said. “The last thing we want is discontinuity and instability in regulation. If we didn’t learn that from 2000 onwards, when regulation changed, I don’t know what the message was.”

But he acknowledged that the regulator needs to “work hard” to streamline some of its systems and processes, because the costs involved are being borne by fee-paying providers.


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