In line with its five-year strategy, CQC introduced its next phase inspection model in 2017, following the completion of its programme of comprehensive inspections.
The new approach involves a more intelligence-driven and risk-based approach to inspections. CQC is moving towards a more responsive inspection model, which sees resources targeted to areas where concerns about quality of care are greatest. As part of the new approach, CQC has made changes to the provider information request (PIR) to attempt to streamline the information that trusts are required to provide in advance of inspections.
Earlier this year, CQC also consulted on changes to its fee structure in 2018-19 as part of its move to a full chargeable cost recovery model. From this year, CQC will be removing the existing banding structure and each trust will pay a different fee, charged in proportion to trusts’ turnover levels. There will be no minimum fee or maximum fee. While the majority of providers will experience a reduction in fees, around one quarter of providers will see a substantial increase. In the move to a full cost recovery model, there is a risk that CQC will become dependent on a small number of providers for a significant proportion of its income. CQC should recognise that this burden may affect the relationship those providers have with CQC and ensure they mitigate this.
As part of the new approach, CQC has made changes to the provider information request (PIR) to attempt to streamline the information that trusts are required to provide in advance of inspections.
Other changes introduced in 2017 represent an important step forward in how the CQC and NHS Improvement are aligning their approaches. CQC introduced its assessments of how well-led a provider is, based on the well-led framework which was developed in partnership with NHS Improvement. Trusts will undergo this assessment each year following a targeted inspection of at least one core service. In addition, towards the end of 2017, a small number of trusts underwent new assessments of their use of resources. These assessments are carried out by a team from NHS Improvement who provide their findings to CQC in order for CQC to write the assessment report and decide a trusts’ rating for use of resources, which is then combined with CQC’s existing five quality ratings for the trust.
As in previous surveys, we asked respondents to reflect on their most recent CQC inspection and share their views on the process and their interaction with CQC. Nearly half (49%) of the respondents had received a new PIR, indicating they had undergone a new-style inspection. Where there are differences in the responses between those trusts who reported they had received a new PIR compared to those who did not, they have been highlighted.
It is important to caveat that the findings provide a snapshot in time, with some of the changes to CQC’s inspection approach still at a relatively early stage of implementation. That said, these early findings provide a valuable insight into how the new approaches are starting to bed in.
As in previous surveys, we asked respondents to reflect on their most recent CQC inspection and share their views on the process and their interaction with CQC.
CQC’s new inspection approach
The results showed that trusts are, overall, supportive of CQC’s direction of travel and support the move to its new approach to regulation. The majority of respondents (81%) either 'fully' or 'partially agreed' that the new inspection approach would enable CQC to prioritise inspections more effectively and help them improve services and quality of care (74%). Encouragingly, among those trusts that reported they had received a new PIR, these figures were 85% and 81% respectively. In addition, 62% felt that the new approach would reflect the needs of their particular sector.
Among those trusts that reported having received a new PIR, 80% said they thought the new inspection approach would help the trust develop their own quality monitoring approaches, compared to 63% among all respondents.
"The new approach should reduce interventions and make them more risk based which will be welcome."
However, there was a general consensus that the potential positive impacts of this new approach are yet to be delivered in practice and more time is needed for the new approaches to bed-in. Trusts recognise that CQC are still in the early stages of implementation and expressed hope that it will learn and refine its approach over time. Many trusts reported that the new inspection approach still feels very resource intensive and burdensome, and 62% of respondent felt that the new approach would not reduce the administrative burden on trusts at all. Among those trusts who reported having received a new PIR, 71% gave this response.
The results showed that trusts are, overall, supportive of CQC’s direction of travel and support the move to its new approach to regulation.
Many trusts expressed concerns that the PIR and ad hoc data requests remain burdensome. Disappointingly, of those trusts that had received a new PIR, only 5% suggested it was less resource intensive than previous pre-inspection information collections, and 36% said it was more resource intensive. The responses suggest there is further work to do to reduce the burden of data collection prior to inspection. However this may be due, to some extent, to trusts having to get to grips with the new information collection process.
"The PIR was extremely onerous and the information supplied did not seem to get through to the inspection team.
"The PIR required slightly more intensive resource than previous pre-inspection information collection, but this was at least in part due to the novel nature of the process."
Some respondents commented that requests for ad hoc information from CQC have increased, particularly emphasising additional requests during and/or after inspections. Some trusts reported that they receive requests for information that is already provided through the PIR, or other means, for example, the daily sitrep data and to the National Reporting and Learning System.
"CQC are asking for weekly performance information – this is the role of NHS Improvement and commissioners…It adds additional burden to providers."
"The new regime was a partial assessment that attempted breadth but had no depth."
"New engagement process is very resource intensive, requests for ad hoc information have increased significantly."
"Engagement process with CQC has led to good partnership working but increased burden for trusts in terms of time commitments – monthly half-day meetings, fortnightly telephone discussions to go through issues log [involving] requests for follow-up information that is outside routine business."
Some respondents commented on the number of changes in CQC inspection approach in recent years and the impact this has on trusts in having to understand and adapt to new approaches. There was a view that inspection changes are made too soon before a thorough understanding of the existing approach - and what is working well or not - can be developed.
"The picture is confusing and we have been told different things by CQC at different times."
Benefits and challenges of inspections
As in previous years, we asked providers to describe the benefits of their most recent CQC inspection.
The most common source of praise among NHS trusts was that inspections offered an additional opportunity for provider boards to focus on quality and safety, identify areas for improvement and celebrate successes. Respondents reported that they found it useful to understand their progress since the last inspection.
Two thirds (66%) of respondents reported that their most recent CQC inspection had not highlighted any new areas of concern that the board weren’t already aware of, the same proportion as in last year’s survey. This suggests that trust boards have a good understanding of the challenges within their organisations. Some trusts reported that CQC inspections helped uncover pockets of good practice that had not previously been recognised, which indicates that CQC’s move to more focused inspections is having a valuable impact.
Respondents emphasised the value of an external independent inspection in providing assurance to the trust board, stakeholders and the public. It was also noted that a positive CQC inspection and rating can have a motivating impact on staff.
Respondents emphasised the value of an external independent inspection in providing assurance to the trust board, stakeholders and the public.
"It has provided an opportunity to refocus our organisation on quality and safety and not just on performance."
"Some very detailed issues were highlighted that had not been specifically visible at board level."
"Useful to give assurance to the board that our understanding of the quality of our services was generally correct."
"The inspection allowed us to demonstrate how proud we are of what we have achieved."
While 37% of respondents felt the benefits of their CQC inspection justified the cost in resources to the trust of preparing for and hosting the inspection team, 39% felt that it did not, and the rest were unsure. It is concerning that although a similar proportion to last year felt the cost was justified, the proportion has decreased from 50% since 2014. A higher proportion of non-acute providers felt the benefits of CQC inspection justified the cost (47%) compared to acute providers (35%).
The lack of change in the last year in the proportion of trusts that consider the benefits of CQC inspections justify the cost, despite the optimism about CQC’s new inspection approach, could relate to a concerns raised by respondents about the cost of CQC fees. A number of trusts questioned whether benefits of CQC regulation and inspection justified the increase in fees in 2018/19 and suggested this money could be more usefully spent on frontline activities. Other trusts commented that preparing for, and undergoing, CQC inspections diverted attention and resources away from the trusts’ main duties.
"There were many benefits from the inspection process and outcome, but this was offset by the significant work that was done in preparation and hosting the inspection."
"The trust understands the position of CQC that it needs to become self-funding, but the fees increases are difficult to swallow."
"It took a huge effort and diverted resources away from more important matters."
We also asked trusts to describe some of the challenges of inspections.
The most common area for improvement cited by trusts was the make-up of inspection teams. Respondents highlighted the importance of having experienced inspectors with the appropriate skills and knowledge, who are well-briefed on the trust and its context. Trusts emphasised the need for inspections to follow a standardised approach, rather than inspection teams forming judgements on subjective opinions or anecdotes. They also highlighted the importance of consistency, with several trusts reporting that variation persists in the quality of the inspection and inspection team.
Another common area for improvement suggested by respondents was reducing the burdensome, and sometimes duplicative, data requests.
"It is vital that assessors have appropriate skills, knowledge and credibility to undertake inspections effectively and credibly."
"Some CQC judgements are unduly influenced by the views of individual inspectors."
"The amount of time and resources consumed by the process was significant."
Respondents highlighted the importance of having experienced inspectors with the appropriate skills and knowledge, who are well-briefed on the trust and its context.
We asked trusts to describe their experiences of the factual accuracy check process. Among the 44% of respondents who had challenged their CQC inspection report during the factual accuracy check there were a wide range of experiences. While some had pointed out small inaccuracies, others had had significant disagreements. There were also mixed experiences of the response from, and interaction with, CQC during the process.
"Response from CQC inspection team was helpful and prompt."
"We previously challenged a report and were very soundly criticised for being defensive."
"Factual accuracy comments were ignored."
Trusts reported a range of views on the experience of the well-led inspection. Some felt that the process was positive and constructive, and helped to identify priorities for the board to take forward. However, concerns were raised about the experience of inspectors and whether inspections were carried out on the basis of clear assessment criteria.
Some trusts reported discrepancy in the approaches and understanding of the assessment process between CQC and NHS Improvement, suggesting that there are areas for improvement in how the regulators collaborate on these assessments.
"We found our own internal well-led inspection more valuable."
"The outcome has given us a set of clear priorities for the coming year."
"The well-led inspection felt poorly briefed, poorly resourced and poorly focused."