In the last couple of years both NHS England (NHSE) and Care Quality Commission (CQC) have sought to adapt their regulatory approaches to keep pace with changes in policy and legislation and meet the needs of providers, patients and the public.
A little more than a year since the Health and Care Act 2022 came into force, a new survey by NHS Providers reveals how trust leaders view changes to regulation.
NHS England is undergoing a major programme of transformation, with a focus on purpose and added value, along with culture and behaviours. This is essential work as the NHS re-orientates itself around system working, and the new roles and responsibilities that brings for national and local leaders.
Meanwhile, CQC is implementing a new strategy, aimed to ensure their approach is more flexible and accounts for the complexities of system working, as well as offering the public a helpful and clear view of care quality. Trust leaders are broadly supportive of the changes being introduced by NHSE and CQC, with strong backing for the direction of travel. Most think NHSE is looking at the right things through its new oversight framework, while around eight in 10 favour CQC's move to a more risk-based approach, with reduced emphasis on inspections, in favour of ongoing assessment and more timely data. There is a clear commitment from the provider sector to regulatory frameworks that offer the public timely and helpful information on safety and quality of care.
However, over half of respondents reported an increase in the regulatory burden and ad hoc requests by both regulators last year. Many felt that regulatory demands were rising, especially during times of extreme pressure. Trust leaders were also disappointed with a continued regulatory focus on inputs and targets, rather than on outcomes and improvement. Emphasis on government priorities and financial scrutiny was sometimes felt to distract from a necessary focus on patient safety and care quality.
Trust leaders tend to view NHSE's regulatory framework as being primarily about performance management, rather than supporting them to improve, and continue to report issues with the culture and behaviours modelled by NHSE colleagues. In some cases, trusts describe ICBs adding duplication and confusion, where they are stepping into a performance management role.
The strongest criticism in this year's survey is reserved for CQC. Although some trusts do report positive experiences of inspection and of working with local CQC teams, overall there has been a notable increase in the strength of feeling from those questioning how the regulator approaches its role. A significant majority of respondents did not agree that CQC regulation encourages providers to collaborate and integrate care, or that it supports innovation and the spread of good practice. There has also been a significant drop in the percentage of those who thought CQC regulation reflects the needs of the sector since last year. Trust leaders continue to tell us about the variable quality of CQC inspections, and to raise concerns about the skills, behaviour and expertise of CQC inspection teams.
Trusts also continue to share disappointment with CQC's processes. They report discrepancies between the inspection they experienced and what was reflected in the subsequent report, and there being limited opportunities to challenge the process. Some trust leaders report getting stuck with a 'requires improvement' rating, having been deemed low-risk, and therefore low priority for reinspection.
We would like to see regulators become more open, transparent and collaborative in their relationships with providers. While it is important that they assure agreed standards of care, CQC and NHSE could do more to recognise in reports and in their narrative the context within which providers are working, both in terms of the extreme operational pressures, and the system within which a provider operates. And although providers and their staff understand they need to drive improvements locally, regulators could deliver better on their commitments to supporting improvement, innovation and the spread of good practice.
The good news is that both CQC and NHSE are making improvements. NHSE's new operating framework is still in the early stages of implementation. CQC's new single assessment framework might help address some of the concerns with its processes going forward. We also value the unique role CQC can play in collating national level information to lay bare the pressures facing care quality and the health and care sector, via its annual 'State of Care' report, for example.
Both regulators have made important steps toward improved regulation over the past year. There is, however, more that needs to change before regulation, as experienced by trusts, matches regulators' own vision and ambitions for patients, the public and those regulated.
This bog was first published in the HSJ.