Care Quality Commission: regulating health and social care Contents

2Future Challenges

13.In May 2016, the Care Quality Commission (the Commission) introduced its five-year strategy for 2016–2021. It aims to deliver “a more targeted, responsive and collaborative approach to regulation”, including more targeted use of inspections and a more intelligence-driven regulatory approach. The strategy does not fundamentally change the Commission’s purpose, role or regulatory model. As part of its five year strategy the Commission intends to change the frequency and depth of its inspections including: extending the period between inspections for ‘good’ and ‘outstanding’ providers; and undertaking shorter, more focused inspections where appropriate. The Commission’s budget is set to reduce by 13% from £249 million in 2015–16 to £217 million in 2019–20. It expects around half of its cost savings to come from reducing staff.21

Inspection staffing levels

14.In January 2017, the Commission completed its comprehensive inspection and rating programme, comprising inspections at more than 28,000 provider locations between October 2014 and January 2017. All providers registered with the Commission had therefore been through the new inspection regime introduced by the Commission in 2014.22

15.The Commission explained that the frequency with which it re-inspects services is now based on the current inspection rating, along with reactive inspections if it is aware of particular concerns. For example, for adult social care services, it will re-inspect services rated ‘inadequate’ within six months and in certain cases more quickly. It will re-inspect services rated ‘requires improvement’ within 12 months and services rated either ‘good’ or ‘outstanding’ within two years.23 By 2019–20, the Commission plans to extend the re-inspection time period for ‘good’ and ‘outstanding’ adult social care services to two and a half years and three years respectively as it improves its information systems and the information it collects from providers. Hospitals will receive an approximately annual inspection covering how well-led the hospital is and a minimum of one individual service; re-inspection of individual hospital services will also be based on their previous rating or can be reactive. The Commission set out that approximately one in five of its inspections is reactive, that is in response to it becoming aware of information of concern rather than carried out at a pre-defined interval.24

16.The Commission’s vacancy rates for inspectors and inspection managers have fallen significantly since 2015. In June 2017 vacancy rates were 6% for inspectors and 0% for inspection managers compared with 34% and 35% respectively in April 2015.25 The Commission stated that the number of inspectors has increased from 846 full-time equivalent inspectors in 2012 to 1,370 as at 1 April 2017. It has plans to recruit a further 280 inspectors by March 2019 and does not have any current restrictions on recruitment. The Commission said that it is confident it currently has broadly the right level of staffing.26

17.The Commission stated that in the longer-term, to live within its reduced budget, it does have plans to reduce staffing levels. It explained that this will be achieved through moving to the risk-based approach to regulation outlined in its strategy.27 The Commission set out how it plans future staffing levels. This is based on calculating the number of frequency-based inspections it will undertake according to the current rating profile of providers and then factoring in the number of reactive inspections it estimates it will undertake. From this total number of inspections, it calculates the number of inspectors it needs and the resulting budget.28

18.The Commission thought that its current planning assumptions were reasonable, including that the profile of provider ratings would remain the same in the future.29 However, it also highlighted that it is beginning to see a deterioration in some providers with ratings reducing from ‘good’ to ‘requires improvement’, as noted in its annual State of Care report. As a result, it was having to re-inspect a greater number of services than it had planned for at the beginning of the financial year. The Commission confirmed that if the profile of ratings did change it would need to revisit its planning assumptions and that it was monitoring this.30 The Commission expressed the view that the health and social care system does need more funding, but this funding needs to go into a reformed system.31

19.The Department of Health and Social Care (the Department) stated that the Commission had historically underspent against its budget, so funding had not been a constraint on activity. It confirmed that if funding was becoming a constraint this would prompt a discussion between the Department and the Commission to ensure that what was being asked of the Commission and its level of funding remained aligned.32

Information systems

20.The changes that the Commission is planning to make to the frequency and depth of its inspections depend on making improvements to its information systems. The Commission recognised the importance of getting the timing right between changing its inspection regime and having the information systems in place to support this.33

21.The Committee has highlighted before the impact of not getting the timing right when introducing changes, for example in its report Quality of service to personal taxpayers and replacing the Aspire contract. The report found that HM Revenue & Customs released too many staff too soon because it was over-optimistic about how quickly the demand on its call centres would fall following the digitisation of its services.34

22.The Commission set out that much of its registration system remains paper based. At present around 50% of its registration applications are completed on-line. Where applications are undertaken on-line around 70% do not need any further action before being processed compared with only around 40% of application forms sent by email.35 The Commission explained that it has put in place a registration improvement programme to digitise its processes and is also making changes to its underlying process, for example, extending the time period to undertake Disclosure and Barring Service (DBS) checks when a GP practice partnership changes.36

23.The Commission confirmed it has purchased an off-the-shelf software package in February 2016 to enable it to analyse and quantify the text based information it receives from the public through its website. The Commission explained that the software is not intuitive and it needed to train staff to use it.37 The Commission also stated that its processes for collecting information from adult social care providers will become digital in January 2018 with an ambition for GP collections to be digital by April 2018. This will allow providers to submit information in real-time rather than through an annual collection.38

24.The Commission explained it has been developing its ‘Insight’ model which supports inspectors by drawing information together on individual providers from different sources. It also highlighted that, for GP practices, this information is available on its website to allow practices to benchmark themselves against others.39

25.The Department and Commission confirmed that the Commission is testing its systems as it develops them with support from the Department’s digital assurance teams and the Cabinet Office.40 The Commission confirmed that it has established a digital strategy to support its ambition for a more intelligence-driven regulatory approach and that it had agreed this strategy with its board.41 The Commission explained that its strategy has two key elements: first, to strengthen its digital infrastructure; and second, to ensure it is collecting the right information and using it effectively. To support the implementation of the strategy, the Commission has made two key appointments: a chief digital officer (jointly with NHS Improvement) and a director of intelligence.42

Sources of information

26.The Department highlighted that regulators across all sectors need a wide range of information sources to effectively assess the risk of providers. The Commission confirmed that over the last six months it had brought forward 230 inspections as a result of information from the public raising concerns about a provider, and that approximately 20% of its inspection activity is reactive inspections when it receives information of concern.43

27.The Commission confirmed that it receives information from a wide range of sources including: the public through its ‘tell us about your care’ webpage; whistleblowers; local Healthwatch organisations; the Parliamentary and Health Service Ombudsman, and the Local Government and Social Care Ombudsman; other professional regulators such as the General Medical Council and Nursing and Midwifery Council; and clinical commissioning groups.44

28.The Commission stated that, while it has looked to formalise its relationships with local Healthwatch organisations, relationships remain variable.45 In Healthwatch England’s 2016 survey, 65% of local Healthwatch organisations said that they had a very or fairly good relationship with their local inspection team, while 55% felt that the Commission used their information to inform its work.46

29.From 2015–16 to 2016–17, the number of whistleblowers contacting the Commission had declined by 16%. The Commission claimed that the number of referrals of concern from whistleblowers was higher in 2016–17 when compared to 2012–13.47 It confirmed whistleblower information had resulted in it bringing forward inspections. However, the Commission also acknowledged that this is an area where it needs to do more work. It is reviewing its whistleblowing policy and will be carrying out quality reviews of how it deals with individual whistleblowing cases. Its ambition is to ensure whistleblowers feel confident in approaching the Commission and that the Commission uses the information they provide.48

30.The Commission confirmed that it works with clinical commissioning groups and is increasingly seeing them as a source of information, particularly with regard to GP practices.49 However, there is still variation in information-sharing between the Commission’s local inspection teams and other bodies such as Clinical Commissioning Groups.50

Local system reviews

31.The Commission explained that under its current legal framework it regulates individual organisations rather than health and social care systems and that it has no plans to change this approach. It stated that it is monitoring how new models of care develop and is preparing for potential new legal entities to be established, such as Accountable Care Organisations.51

32.The Commission confirmed that when it inspects individual organisations, particularly hospitals, it expects them to be able to demonstrate how they are collaborating with other areas of the health and social care system. It had been specifically requested by the Secretary of State for Health to undertake 20 local system reviews using powers under section 48 of the Health and Social Care Act 2008. The Department provided additional funding for these reviews.52 The Commission has now produced an interim report setting out the key findings from the first six reviews.53

33.The Commission felt that it was important that there was oversight of how local health and social care systems are working, in addition to inspecting individual organisations. However, it stated that there would need to be a change in the legislation if the Commission was to inspect and rate local health and social care systems, and use its enforcement powers. This would require agreement by the Secretaries of State for both the Ministry for Housing, Communities and Local Government and the Department of Health and Social Care.54

21 Q 35; C&AG’s Report, paras 4.2–4.3, 4.7, figure 14

22 Q 32, C&AG’s Report, para 2.14, figure 7

23 Q 57

24 Qq 80, 92–93; C&AG’s Report, para 4.7, figure 14

25 C&AG’s Report, para 3.6

26 Qq 33–34

27 Qq 35, 64

28 Qq 61–62

29 Qq 87, 89

30 Q 63

31 Q 103

32 Qq 64, 114

33 Q 76, C&AG’s Report, para 4.7, figure 14

34 Committee of Public Accounts, Quality of service to personal taxpayers and replacing the Aspire contract, Thirteenth Report of Session 2016–17, HC 78, 20 July 2016.

35 Q 48

36 Qq 47, 50

37 Qq 68, 75; C&AG’s Report, para 2.13

38 Qq 72, 76

39 Q 71

40 Qq 54, 77–79

41 Qq 65–66

42 Qq 65–69, 72; C&AG’s Report, para 4.7

43 Qq 80–82, 92–93

44 Qq 80–83,

45 Q 82

46 C&AG’s Report, para 2.11