The Care Quality Commission’s plans for a fees hike are worrying but could herald major shifts in the regulator’s relationship with trusts, argues Johnny Marshall
CQC’s new strategy covering 2016-21 offers a vital opportunity to recast quality regulation to deliver far better value, as it develops. However, their new proposals on provider fees risk undermining the prospects for meaningful engagement unless essential actions are taken.
It is very concerning that current plans would lead to a minimum 40 per cent increase for NHS trusts next year alone – and even larger increases for some types of providers such as GP practices, who are facing a nearly seven fold increase in fees to achieve cost recovery. A fee increase of this size risks jeopardising goodwill among our provider members towards the CQC and its new approach to inspections.
The approach on fees being proposed today by CQC reflects broader Government policy around cost recovery for regulators. This shift towards full cost recovery must be reflected in additional resources for NHS organisations and not taken from front-line funding, which is already being stretched like never before. Ahead of the forthcoming spending review, the NHS Confederation has asked the Treasury to protect all Department of Health spending in real terms before the additional £8bn of resources are allocated to the NHS, to account for issues like this.
Clearer picture of costs
In light of the fact that CQC will soon start assessing our members’ use of resources, it too needs to demonstrate value for money.
Our 2013 Challenging Bureaucracy report, commissioned by the secretary of state, advocated that all national bodies should reduce their bureaucratic burden by 10 per cent over each of the subsequent two years. However, since then CQC’s income for regulating providers has increased by 25 per cent as its role has become more complex. Value-based care delivery, built upon the notion that finance and quality are two sides of the same coin, has to be supported by value-based regulation.
As a first step, CQC should publish its efficiency modelling as soon as possible, to provide a clearer picture on future regulatory costs.
More broadly, value-based regulation urgently requires much greater alignment between the arm’s length bodies and the requirements they place on providers and commissioners. In the most recent survey of NHS Confederation members, 96 per cent of NHS leaders agreed that national bodies need to better align their work, priorities and purpose to support efforts to improve quality.
CQC’s proposal to inspect organisations with good or outstanding ratings less frequently is welcome. We have long supported a light-touch approach for providers with a track record of delivering high-quality care, while also recognising the need for a sliding scale of more active interventions for those that pose concerns. Boards are ultimately responsible for improving quality in their organisations and inspections can only ever hope to provide a snapshot view.
A fundamental shift in the way we regulate care, using a system or place-based approach, is also long overdue. No organisation across health and care is an island. Our members continue to express frustration that they are rated on factors that are outside their control and which are consequences of their surrounding health and care system. So it is encouraging that the CQC have acknowledged the need for their assessments to sweep across a broader canvass, for example in their quality of care in a place project, and we look forward to working with them further on this agenda. It is crucial that CCGs are fully engaged in the development of system- and place-based approaches to regulation, to help support a positive learning culture across a local health and care economy.
Our members will soon be directly contributing a very substantial proportion of CQC’s funding. So it is undeniable that they should have a much more powerful voice in shaping the regulatory model. The NHS Confederation wants to take the lead in helping to forge a new model of partnership between our members and CQC, with a focus on ensuring that regulation adds value to care delivery and provides greater support to providers in these particularly challenging times.
This arrangement could perhaps take the form of a concordat between providers and CQC. One obvious area for initial partnership working is the proposed ‘co-regulation’ approach outlined by CQC in Building on Strong Foundations. This needs further consideration to ensure that it will both streamline the regulatory process for providers and offer the necessary assurance about quality to patients and the public.
We look forward to working with the CQC and our members to help shape the future of quality regulation, but also urge both CQC and the Department of Health to pay heed to the strongly held concerns across our membership about this unprecedented fee increase. Successful strategy implementation may just depend on it!
Dr Johnny Marshall is director of policy at the NHS Confederation