The CQC has now completed its inspection of all NHS foundation trusts and trusts under its programme of comprehensive inspections, giving the regulator a baseline of the quality of care across all trusts in England for the first time, as detailed its recent State of care and State of care in NHS acute hospitals reports. In line with its five-year strategy, it has also consulted on moving towards a more targeted and responsive inspection model, which will see services rated ‘good’ or ‘outstanding’ inspected less frequently along with the introduction of a new ‘Insights’ model to support its ambition to become more intelligence-driven. The CQC’s proposals represent an important step forward towards a more streamlined approach. The regulator has also introduced fee increases in order to move to a model of full recovery of its costs through the fees it charges providers.
As in previous surveys, we asked respondents whose organisation had received a CQC inspection in the last 12 months a series of questions about their experience of the current inspection regime process, along with their views on key elements that will underpin the proposed new model. 56 out of 76 survey respondents reported having a CQC inspection within the last 12 months. The findings echo feedback from trusts in the earlier stages of the comprehensive programme and reflect the basis on which the success of the new model, due to be rolled out from April 2017, will be judged.
Benefits and challenges
We asked respondents to describe the benefits and challenges of their CQC inspection. In terms of the benefits of their organisation’s inspection, respondents felt that the process provided useful external validation of their performance and gave added impetus and focus to quality improvement initiatives already underway. It was also felt that CQC inspections provided the opportunity for high performing trusts to highlight areas of good practice.
“External, independent confirmation of the quality of care and standards we provide. Areas of outstanding practice and areas where we could move from good to outstanding identified.”
“It provided an opportunity to highlight and demonstrate excellent and good areas of practice, a chance for staff to showcase.”
“Comprehensive report independently confirming most of our views. Improvements have resulted from the required actions.”
In most cases, respondents reported that inspections validated what they already knew – consistent with findings from previous surveys, overall 26% reported that their inspection exposed areas of concern of which their board was not already aware, while the majority (74%) felt that their board was already aware of any areas of concern which their inspection highlighted (figure 13).
The main challenge highlighted by respondents related to the volume of data and evidence requests before, during and after an inspection and the size of the inspection teams along with the quality of inspection produced, the length of time it takes for producing those reports and concerns about the current process for moderating ratings.
“Resource intensive in terms of preparation, during the visit and post visit documentary evidence requirements.”
“Data requests brought the organisation to a near standstill.”
“The sheer number of inspectors seems disproportionate.”
“More targeted groups of inspectors with expert knowledge, rather than large multi disciplinary teams that can overpower the organisation.”
“Draft inspection report contained far too many factual errors. Too long between inspection and publication of the final report.”
“Delay in producing a final report dissipates engagement experienced even during an unannounced inspection.”
“Wasted effort in appeals process and moderation of ratings was opaque.”
Figure 13
Value of inspections
With its newly published strategy, the CQC is in a position to adapt its operating model to ensure it is responsive to changing context in the NHS, adds value and is sustainable. The need for the regulator to demonstrate effectiveness and value for money has been a persistent theme in our survey findings. Where providers have been faced with substantial fee increases as a result of the move by the CQC to recover its chargeable costs in full from providers, there must be a renewed focus on ensuring value for money. As in 2015, we asked respondents a general question on whether they felt the benefits their trust gained from the inspection justified the ‘cost’ in resources to the trust of preparing for, and hosting, the inspection team. 38% of respondents did not feel the benefits justified the costs involved, the same proportion felt they did and the rest were unsure (figure 14).
When commenting on the benefits versus the cost of inspections, respondents reported the positive impact that the inspection regime brought but felt that the same benefits could be achieved through a more streamlined approach. Further challenges identified by respondents were the need for the CQC to demonstrate significant progress in driving greater efficiencies in the regulatory model, the effectiveness of its activities and value for money in the context of the increase in the fees it has introduced.
Figure 14
CQC’s future approach
Underpinning the CQC’s new approach is the introduction of a new Insight Model which the regulator will use to monitor quality, target its resources and help guide its next phase of inspections. We asked respondents whether they were confident that the CQC’s new insight model would provide an accurate reflection and assessment of the risks to quality within their organisation. At the time of the survey, the CQC’s consultation on its proposals to adapt its regulatory approach, which covered the new insight model, was ongoing.
With the new model due to be rolled out imminently, it is concerning that only 28% of respondents were confident that the proposed insight model will effectively measure risk to patient safety and quality (figure 15a). While this may not reflect a criticism of the new model, comments from respondents do reflect a need for the CQC to provide further detail about what this will entail. Overall, 44% of respondents were unsure. Notably, a larger proportion of non-acute trusts reported being ‘neither confident or not confident’ (52 per cent), compared to 39 per cent among acute trusts (figure 15b). This suggests that there is further work for the CQC to engage with mental health, community and ambulance sectors to ensure that the new model is fit for purpose across all the sectors that the CQC regulates and we are committed to working with our members and the regulator to achieve this.
“Still understanding and assessing the impact of the new model and how this will operate in practice.”
“It needs to be tested outside of acute hospitals.”
Another element of the new approach will be more frequent inspections of core services within set intervals based on prior ratings. The majority of respondents agreed with the proposed intervals for services rated ‘inadequate’, ‘requires improvement’ and ‘good’ (93%, 77% and 80% respectively), however there was more ambivalence among respondents regarding the five year interval for services with an ‘outstanding’ rating.
“Within the pace of change within the NHS, 3 to 5 years is too long. Within 5 years, a trust’s performance could quite easily get worse.”
The CQC has recognised the need to design a regulatory system that is able to appropriately reflect the changes in how care is being delivered. The development of new models of care is complex and happening at pace. Our survey responses reflect the need for the CQC to support members around these new models of care and not to create unnecessary barriers to their implementation. Likewise, the responses flagged the need for regulation not to penalise organisations where they are acting in the best interests of the wider system, such as through the STP or taking over services that are struggling.