HSJ’s round-up of the day’s must read stories and debate

The CQC’s four year plan

The CQC published its new strategy on Tuesday, outlining what health and social care regulation will look like over the next four years.

The key elements of the strategy, such as increased use of data to move towards a more risk based inspection regime, and longer intervals between inspections for good and outstanding GP practices – were well trailed. However, there was some important new detail. While trusts will see the intensity of CQC inspection reduce (good trusts need never receive a “comprehensive”, whole hospital inspection again) their frequency will increase.

In future, every trust will be inspected annually but the visits may only cover one core service and how well led the organisation is (the CQC’s rationale for inspecting every trust on “well led” is that it believes leadership is the most important factor in determining care quality).

Interestingly, the CQC seemed to change its mind on the importance it attached to provider self-appraisal during its strategy consultation. While trusts will have to submit an annual description of their own quality on the CQC’s five questions (the regulator hopes this will make organisations internalise quality improvement), language around provider “self-assessment” and “co-regulation,which the CQC used when it kicked off its consultation last October, are conspicuously absent from the strategy. Concerns were raised about providers “marking their own homework”, and to give the CQC credit it listened.

In an exclusive interview with HSJ, the CQC’s chair and chief executive confirmed the regulator was going to review how the fit and proper person test is working – an area where some people think the CQC has been too passive.

CEO David Behan also told us that he might have to make job cuts to cope with a budget which will decrease year on year until 2019-20.

The CQC will face two key challenges in that period: the first will be to demonstrate that its regulatory model is being changed because it is the right thing to do – for example to bring regulation into line with new care models – and not simply a response to budgetary pressure. The second will be to ensure that through targeted annual inspections and improved use of data, it can accurately assess risk and nip potential care failures in the bud.

A&E’s four hour warning

When all but a handful of trusts have missed the four hour A&E target, and the national target has been breached, you might conclude it was a macro issue.

It’s true that attendances are up, but on the type one A&E figures (the meatier indicator) the increase is milder in percentage terms.

Drill down into the figures and you can see that, similarly to last year, 20 trusts have driven more than half the national performance decline.

But this isn’t all the same trusts with the same problems. Last year providers seeing a quarter of patients were responsible for half the increase in those  waiting more than four hours. This year providers seeing a fifth of patients were responsible for half.

So a cohort of smaller trusts were responsible for disproportionately warping the national picture.

Only eight of last year’s 26 are part of this year’s 20 – so some bigger trusts have done better and some small ones disproportionately worse.

What does this mean?

Perhaps it is a macro issue, perhaps it means demands on A&E services are now so near a tipping point that smaller factors can have dramatic effects? (You can contact HSJ senior correspondent Ben Clover with your theories in confidence.)

NHS Improvement hasn’t been as quick as it might have been to support trusts on A&E (it has only just been created), but the good news is it has now invested significantly in the intensive support team for emergency care.

This is better news than word that an overhaul of the target is being considered. The four-hour wait has been around  long time, it’s not the motivator it was, and why not have patient experience and something more clinical in there as well?

England’s four hour performance is better in most other similar countries, but the fact remains that the target is a good predictor of patient care more generally.

The performance is now worse than when it was first introduced, which suggests the problem it was intended to help solve remains.