Conclusions and recommendations
1.Given the current stresses in the system, the Commission’s review of 20 local health and care systems will provide important information on how local systems are working, but these fall outside the core remit of the Commission. Under its current legal and regulatory framework, the Commission regulates individual organisations rather than health and care systems. When inspecting individual organisations, the Commission tests the extent to which they are working with other local stakeholders. Its view is that there needs to be oversight of how local systems are working, in addition to individual inspections. The Secretary of State for Health and Social Care specifically requested the Commission to undertake 20 local health and care system reviews, and it has now produced an interim report on the first six reviews. However, for the Commission to inspect and rate local systems and take enforcement action would require a change in legislation.
Recommendation: The Department should set out in its Treasury Minute response its plans for providing oversight of local health and care systems, making sure it draws on lessons from the Commission’s local system reviews.
2.The Commission’s hospital inspection reports are not published quickly enough after an inspection to allow the public to make informed and timely choices about their care. The Commission has made progress in improving the timeliness of publishing inspection reports since 2015. However, it still does not meet the targets it sets itself across any of the sectors it regulates. The biggest gap in performance is in hospitals. For example, in quarter one 2017–18, for hospitals where fewer than three services were inspected, only 25% of reports were published within 50 days compared to the target of 90%. Delays in publication mean the public do not have timely information to make informed decisions about their care. Reasons for delays include inefficient processes within the Commission and the time taken to resolve comments from providers on the factual accuracy of reports. The Commission has introduced an improvement programme and expects to publish at least 50% of hospital reports within its timeliness target by 2018–19. Immediately after an inspection the Commission writes to inform hospitals of any safety issues, and the actions it expects the hospital to take, but not all trusts make this letter public.
Recommendations:
The Commission should make sure findings from hospital inspections are available to the public as soon as possible. It should write to us in April 2019 with an update on its performance. This should include whether it has achieved the commitment it made on publishing at least 50% of hospital reports within its timeliness target by 2018–19 and how it has balanced this with maintaining the quality of reports.
The Commission should also work with NHS England and NHS Improvement to ensure that trusts routinely publish the post-inspection letter from the Commission, thus ensuring the public has access to this information.
3.The Commission’s regulation of GP practices is vital in highlighting poor care, although GPs continue to have concerns about the value provided by the Commission’s regulation. The Commission has rated nine out of ten GP practices as either good or outstanding, but its inspections have also identified some poor and unacceptable services. The Commission’s own provider surveys show that GPs view its regulation less favourably than other sectors. The Commission thinks this is partly due to GPs being regulated by an external independent regulator for the first time. However, the Commission recognises that it also needs to make changes to how it regulates GP practices including reducing the burden on practices. The Commission is working with the Royal College of GPs and British Medical Association to improve relationships and how it regulates the sector.
Recommendation: Without compromising the robustness of its regulation, the Commission should set out in its Treasury Minute response how it will ensure the regulatory burden on GPs is proportionate and that patients can be well informed about GP performance.
4.We are concerned that the Commission will not have enough inspection staff if its key planning assumptions do not hold, including that the quality of care services does not deteriorate. The Commission has completed its comprehensive inspection and rating programme, which took all providers through the new inspection regime introduced in 2014. The frequency of re-inspecting providers is now based on the current inspection rating, along with reactive inspections if it is aware of particular concerns. Vacancy rates for inspectors and analysts have fallen significantly since 2015 and the Commission now thinks it is adequately resourced. As part of its cost reduction strategy, the Commission plans to reduce staffing levels through to 2019–20. Its ability to do so, while also being able to carry out enough inspections, will depend on the accuracy of certain assumptions it has made; one of which is that the current profile of provider ratings remains unchanged. However, providers in all sectors are under stress, which is causing some services to deteriorate, and has already resulted in a greater number of inspections than planned at the start of the 2017–18 financial year.
Recommendation: When the Commission writes to the Committee in April 2019, it should include an update on whether changes in the external environment are affecting its staffing assumptions and how it is managing these changes. The update should include the impact of any changes on its planned cost reductions and on its ability to meet its inspection programme.
5.The Commission’s ambition for a more intelligence-driven regulatory approach, including reducing the frequency and depth of its inspections, is heavily dependent on improving its information systems. The Committee has highlighted in other areas of government the importance of ensuring the right infrastructure is in place before introducing wider changes. The Commission’s current information systems require significant work including: improving its registration systems; fully implementing its software for analysing text-based information; updating its systems for collecting information from providers; and continuing to develop its ability to draw together information on a provider from different sources. The Commission is testing its new systems as it progresses and has developed a wider digital strategy which sets out the priorities for moving towards an intelligence-driven regulatory approach.
Recommendation: The Commission should ensure that its digital and information collection infrastructure is in place and working as expected before fully extending the inspection periods in its frequency-based inspection regime planned for 2019–20.
6.The Commission has more work to do to ensure it has the wide range of intelligence it needs to identify early warning signs of poor care. Around 20% of the Commission’s re-inspections are in response to receiving information of concern. The Commission collects information from a wide range of sources including: the public; whistleblowers; other health bodies and local Healthwatch organisations; the health and local government Ombudsmen; and professional regulators (e.g. the General Medical Council). However, the Commission’s relationships with local Healthwatch organisations are variable; there has been a recent decline in the number of whistleblowers providing information to the Commission; and while the Commission is increasingly seeing clinical commissioning groups as a source of information, there is variation in the extent to which individual groups share information with local inspection teams.
Recommendation: The Commission should set out in its Treasury Minute response how it intends to strengthen local relationships and the information it collects including how it will: work with NHS England to ensure clinical commissioning groups are sharing intelligence on local services; reduce the variation in relationships with local Healthwatch organisations; and ensure that whistleblowers feel confident to contact the Commission with any concerns they have.
8 March 2018