• Use of resources to become the sixth key CQC rating, with all six domains “weighted equally” and aggregated into overall trust rating
  • CQC says change may make it “slightly easier” for trusts to be rated inadequate and “slightly more challenging” to be outstanding
  • Final rating decision to “legally remain” with CQC despite NHS Improvement carrying out use of resources inspections and recommending ratings

NHS trusts’ financial efficiency will be included in their overall ratings, despite the fact it could then be “slightly easier” for providers to be rated inadequate as a result.

Under new proposals, the Care Quality Commission intends to make the use of resources rating a sixth domain alongside whether services are safe, effective, caring, responsive and well led, and then combine all six for the overall rating.

The regulator said in a consultation document this method will “ensure [its] overall ratings judgements maintain a strong focus” on quality and safety as each of the six key questions will be “weighted equally” when aggregated into a single rating.

However, the consultation said because of the changes it will be “slightly more challenging” for trusts to receive an outstanding rating and “slightly easier” for trusts to be rated inadequate. The CQC said it does not expect these changes to “have a disproportionate impact on the distribution of trust ratings across the country”.

Currently if a minimum of two out five domain ratings (40 per cent) are inadequate the overall rating will be inadequate. This rule will not change even with the additional sixth domain. This means only 33 per cent of domains will need to be rated inadequate for a provider to be inadequate overall.

Similarly, to be rated outstanding, all domain ratings must be at least good with two out of six outstanding. These rules will not change under the proposed new approach.

The CQC is changing the rules for being rated requires improvement, which appear to make it easier to be rated good. Currently if two domains (40 per cent) are rated require improvement a trust cannot be rated higher than this overall.

The CQC said: “Applying these same rules when there are six trust level ratings being aggregated… might be seen as setting the bar too high to achieve a rating of good.”

In the future, a trust will limited to an overall requires improvement rating only if three out six domains (50 per cent) are rated this way.

The document recognised that respondents to a previous consultation “highlighted concerns about combining ratings”. Some of them said aggregating the use of resources rating with the five others would mean “more trusts receiving less positive ratings due to the current financial challenges in the sector”. They also said it could “risk masking poor quality”.

The document also said:

  • The decision on the final rating will “legally remain” with CQC, though it will be NHS Improvement that carries out the use of resources inspection and makes the rating recommendation. NHSI will also deal with any challenges from trusts on the evidence this rating is based on.
  • A trust will have three top level ratings: one just for use of resources; one, as currently, which is an aggregation of the five quality domains only; and an umbrella rating of all six balanced equally. Use of resources ratings will not apply at service or location level.
  • Use of resources assessments will focus on delivery and performance at trust level over the previous 12 months and have five key lines of enquiry: clinical services; people; clinical support services; corporate services, procurement, estates and facilities; and finance.

The consultation closes in early January and the CQC will start to publish formal use of resources rating in early 2018.

It will not aggregate ratings until NHSI’s use of resources inspections of a trust are scheduled to be carried out at the same time as the CQC’s well led inspections.

No date was given for this but the document said it will happen as “soon as practicably possible”.