Following implementation of new regulatory powers in the Health and Care Act 2022 (‘the 2022 Act’) to assess integrated care systems, the CQC has recently produced interim guidance and a statement as to how it will approach such assessments.
This article looks at:
- The CQC’s new powers
- The proposed assessment framework
- Scoring and reporting
- Timeline
- The challenges
The powers
The 2022 Act introduced changes to the Health and Social Care Act 2008, requiring the CQC to conduct reviews of:
- the provision of ‘relevant health care’ (i.e. NHS care or public health) and adult social care within the area of each integrated care board (“ICB”)
- how the following bodies exercise their functions in relation to that care within the area of each ICB:
- The ICB;
- The ICB’s partner local authorities; and
- registered service providers
The new section 46B Health and Social Care Act 2008 also requires the CQC to ‘assess the functioning of the system for the provision of relevant health care, and adult social care, within the area of each integrated care board (taking into account, in particular, how those mentioned in paragraph . . (ii) work together)’ and to publish a report of its assessment.
The CQC’s interim guidance awaits Secretary of State approval, in line with the 2022 Act, and aims to help ICSs understand more about the CQC’s planned approach. As the CQC develops its model in this pilot phase, more detailed ‘end to end’ guidance will be available later in 2023.
The proposed assessment framework
The CQC plans to use a new regulatory model and single assessment framework across all of its work in all sectors of health and social care.
Within that framework, the CQC will assess how ICSs are performing through the use of a subset of 17 quality statements across 3 themes:
- Theme 1: Quality and safety (six statements on issues such as supporting people to live healthier lives, learning culture and safeguarding, equity of access)
- Theme 2: Integration (three quality statements including matters of safe systems, pathways and transitions together with issues of care provision, integration and continuity)
- Theme 3: Leadership (eight quality statements including topics such as shared direction and culture; workforce equality, diversity and inclusion).
In order to assess each quality statement, the CQC will assess six different evidence categories, each of which will be weighted equally, as follows:
- People’s experience (e.g. from those with experience in health or care service, families, carers and advocates for people who use the service).
- Feedback from staff and leaders (e.g. from direct interviews, concerns raised with the CQC, surveys and evidence from self-assessments).
- Feedback from partners (e.g. commissioners, providers, regulators, accreditation bodies, royal colleges and multi-agency bodies, housing, licensing and environment services).
- Observation (e.g. case tracking, integrated board and partnership meetings and health and wellbeing boards).
- Processes (the effectiveness of processes including metrics such as waiting times, audits, policies and strategies).
- Outcomes (impact of processes on individual people and communities including information on quality of providers in an integrated care system, clinically relevant measures, quality of life assessments and population data).
There is a clear link between ICS assessments and those of providers. The CQC interim guidance confirms ‘Ratings of individual providers will not directly determine the outcome of an integrated care system assessment, but will form part of the evidence we use for assessments.’ The converse also applies, with CQC guidance confirming ‘Our assessment and inspection teams will share information about quality and partnership working within each integrated care system. Assessments will not directly inform ratings of individual providers, but in some cases, the evidence we gather during an integrated care system assessment may form part of the evidence we will use for assessing providers.’
In a similar vein, there is a link between the CQC’s assessment of ICSs and NHS England’s assessment of ICBs: ‘We will use the results of NHS England’s oversight and assessments of integrated care boards in our assessments of the integrated care system. Findings from these assessments will inform NHS England’s oversight and support for integrated care boards.’
Scoring and reporting
In the interim guidance, the CQC advises that it intends to introduce scoring into the assessment process, consistent with the CQC’s assessment of registered providers. The evidence considered for each of the 17 quality statements assessed (which are weighted equally) will be assigned a score by CQC as follows:
- 1 = Evidence shows significant shortfalls
- 2 = Evidence shows some shortfalls
- 3 = Evidence shows a good standard
- 4 = Evidence shows an exceptional standard
Scores for quality statements will be aggregated to produce ratings and an overall score, as well as a score for each theme.
Draft assessment reports will be shared with the ICS and ICP for a factual accuracy check prior to publication on the CQC’s website.
The reports will include a summary of the key features of the ICS and focus on people’s experiences of care. Reports will include findings and scores for each theme and quality statement and clearly set out required improvements and best practice. Following the report, ICBs, local authorities and providers are expected to come together through a local system improvement summit to review findings and publish action plans which the CQC will monitor.
The CQC’s ongoing frequency of assessments will use a risk-informed approach to prioritise which ICS to assess. Presumably, given the potential for overlap, the CQC will also use intelligence from ICS assessments to inform its regulation of providers too.
Timeline
Before moving to its new model of ongoing assessments of ICSs, the CQC will carry out initial baseline assessments for each ICS. This work will be carried out in phases.
In the first phase it will focus on:
- Further developing and embedding its assessment approach
- Gathering evidence
- Developing understanding of relative performance across systems
- Building relationships in each of these areas
The guidance explains that the CQC will ‘explore opportunities for themed reporting at national level during this first six months’.
The CQC has proposed to start their consideration of ICSs with a focus on the quality statement ‘Equity in access’ – considering issues such as whether and how systems are already working together to support people to access care and treatment when needed as well as work to reduce inequalities of access. The CQC then proposes to pilot the above approach of baseline assessments of ICSs before starting formal assessments.
The second phase involves the formal baseline assessment of ICSs, with the aim to complete all initial assessments and give each ICS a rating within two years (though it is not clear when this two year period begins). The CQC will try and ensure that assessments of ICSs are timed so that they can be informed by completed assessments of all the local authorities within the area of the system. This may give some ICSs a hint about when their baseline assessment is likely to take place.
The CQC will begin by assessing the evidence it already holds, then will request further evidence and finally it will actively collect any remaining evidence that is needed. The guidance explains that in practice this means that the CQC will be gathering evidence across all ICSs throughout the baseline period.
The challenges
The new guidance is helpful to begin to understand how the CQC plans to assess the new NHS architecture. However, questions remain, such as how the management of the added regulatory burden will be managed, particularly for those providers who already span more than one ICS. Another question is how accountability and enforcement issues will be addressed by CQC within an ICS and how that task is managed within that local system. The answer to this question is especially important if individual providers are compliant from a regulatory perspective but the ICS (or a number of ICSs) as a whole needs to address system wide improvement.
For further information or support, please get in touch.
For further information, please contact:
Jenna Wong, Hill Dickinson
jenna.wong@hilldickinson.com
