A new job for the CQC

It may be an unpopular view among NHS friends and colleagues, but if we are going to make a success of integrated care, then someone really needs to be watching what happens in the gaps between services. Having already developed an approach for reviewing how local systems work, the Care Quality Commission is arguably best placed to pick up this function.

Recovery phase

It is now seven months on from when Penny Dash’s damning review of the CQC was published. For staff working in the embattled regulator, it will have been a hard read, I know, but fair play to the CQC; they held their hands up and accepted both the findings and the recommendations in full.

Since that time, we have seen two well-regarded appointees as the new chief executive and chair. We have also had three impressive new chief inspectors announced, one of whom will be dedicated for the first time to mental health services.

The volume of inspections is up, the delay in registrations of new providers is down, and whilst I wouldn’t say the CQC has got its regulatory groove back just yet, the recovery phase is clearly well under way.

Yet there is one thing that troubles me about the government’s instruction that the CQC should “return to its core function”, which it deems as reviewing the safety and quality of individual provider organisations. For me, this overlooks all the progress that has been made, looking at integration and what happens in the gaps between formal services.

This has been made even more confusing by the Draft NHS Performance Assessment Framework, which seems to further fragment how we will collectively understand whether integrated care is being delivered and driving the sort of improvements in experiences and outcomes that we all want to see.

Mind the gaps

As someone who has spent most of my career in roles engaging with patients and care users, I have seen time and time again, it is the gaps between institutions where poor care is experienced most often and most acutely.

It’s the referral that goes missing, the medication supply that runs out, or the hospital discharge process that is poorly planned, that so frequently results in poor experiences of care and patients feeling lost and alone. And when these things go really wrong, they result in countless (largely because no one is bothering to count them) patient safety incidents, leading to unplanned and emergency trips to the hospital.

Back in 2018, the CQC was asked to do local system reviews, which for the first time put us on a path to creating a regulatory system that really is inquisitive about what happens to people beyond the bricks and mortar of health and care services. These reviews specifically looked at how people over 65 were being supported to maintain their health and wellbeing in the community, how they were being supported when they experienced a crisis, and what help they got when they left the hospital.

These reviews felt pretty groundbreaking at the time as they started to unpick the culture of organisations focusing on their own narrow performance goals, and encouraged leaders to think more about how they collectively achieve integrated person-centred care.

Improvement tools

Ultimately, these reviews paved the way for new responsibilities for the CQC under the 2022 Act, giving it a formal role in reviewing integrated care systems. But before this really got going, the government put a pause on it, a pause that has lasted nearly 18 months and currently has no end in sight.

To its credit, the CQC has continued to do what it can through its improvement function. Last year, it commissioned National Voices and the Point of Care Foundation to develop a framework which integrated care boards could use voluntarily to review how well they are involving their communities in tackling inequalities.

While the tool is not mandatory, system leaders will find it increasingly relevant following the ICB blueprint work, which has identified both community engagement and addressing inequalities as two growth areas for ICBs.

But producing self-assessment toolkits alone is not enough. ICSs are incredibly stretched right now, both in terms of their finances and their headspace. The CQC needs to maintain the momentum and continue to support the improvement journey around integrated care.

Ultimately, this needs the government to make a decision about the formal role the CQC will have in relation to ICSs, and then to provide the regulator with the necessary resources to drive up high-quality and safe integrated care.

The reviews paved the way for new responsibilities for the CQC under the 2022 Act, giving it a formal role in reviewing the ICSs

Measuring integration

As part of this, the CQC could also take over as lead for the newly developed Integration Index. Created by NHS England, this survey links up experience of care with patient level data on quality markers and use of services, to show how well services are working together for complex cohorts.

Whilst this survey has a core role at neighbourhood level, driving actionable insights for improvement, it clearly also has huge potential to be aggregated to offer insights into how whole systems are working.

In my mind, it would be a huge missed opportunity, and not to mention a massive waste of the effort to date, if the Integration Index isn’t found a new home in a post-NHSE world. The department could go even further than this and bring together the whole national patient surveys programme under the CQC, allowing better access to the questions and samples, to generate even more powerful insights into how well integrated services actually are working.

Implemented at the right scale and given the appropriate level of importance, these surveys on patient experience could create one of the major KPIs for measuring whether or not the government’s three shifts are having the impact we all want to see in making joined-up care a reality for all.