Putting people at the centre of system regulation: learning to lead in changing times

As we look to integrated care systems becoming established as statutory bodies from 1 July, Director of Engagement, Chris Day, sets out more detail on CQC’s role in system assessment.

Back in April this year, I wrote a blog that recognised the changes in health and social care, and how we at CQC also needed to change. In that blog, I highlighted our commitment to ensuring that genuine co-production drives how we develop our new policy, methods and ways of working, and how this was shaping our new regulatory model and single assessment framework. I also described how, in the future, we would be collecting and using data from across the system and how we’ll use people’s experiences of care to monitor and assess providers.

Why it matters

We know from our work on systems that good local systems collaboration starts with a vision that can build trust. Trust from people who use services that those providing them really understand their needs, and trust of the people delivering that there is a sustainable plan that brings together the people providing services. The plans must be a delicate balance of what needs to happen today, and what an integrated care system (ICS) is trying to achieve for its population in the long term. Regulation must be equally balanced.

The opportunity and the challenge

ICSs are intended to promote equal partnership between the NHS and those providing social care. The history of previous attempts at integration suggests there is a risk that the NHS will dominate with social care seen as a secondary partner.

The reality of course is very different. The concerns we see in health services are often linked to the lack of access of social care. Six years ago, when we began to talk about social care being at a tipping point, it wasn’t just a conversation about quality of services it was about access to those services. Often, failure here is portrayed as the fault of one sector or another. It’s about long-term thinking and planning from the centre, with local plans that understand people’s needs today and how collectively resources are moved deal with the challenges that local systems face. Arguably, the incentive for collaboration wasn’t there then. Today the case couldn’t be clearer, and we hope our system regulation will add to the clarity.

Making it work on the ground

For people working in health and social care, the task has rarely been more challenging, complex and uncertain. Trust and collaboration between health and social care organisations have never been more important.

The NHS and social care are two halves of a whole, very often providing support for the same person trying to navigate their way through a complicated system.

The challenge is to create an environment that supports people and organisations providing services across health and social care to work together. And the challenge for CQC is to effectively assess how well systems work together, as well as developing how we can share best practice across the country so that we can support and encourage improvement and innovation.

Changing behaviours

We all need to move away from understanding quality in an individual provider only. Instead, we need to have a shared understanding of what good looks like in meeting people’s health and social care needs across a whole system.

This understanding and shared vision of what a local population needs is essential to understanding how and where services need to be delivered.

This greater flexibility means we need to measure outcomes — not activity — and we need to support and trust local leaders to develop the right response for people locally. National organisations like CQC need to support collaboration, and all national and local bodies need to align ideas and resources without setting artificial limits.

Workforce

Integrated approaches to care also require a workforce that understands what people need across health and social care. Local and national workforce planning needs to create the skills and career paths that allow people to work flexibly across the system as services evolve over time to meet the population’s changing needs. We want to play a role in supporting better workforce planning, identifying outstanding practice in this area, and sharing this to support others. This is already involving new partnerships, linking not just traditional health and care organisations but also partnerships with the third sector. Above all, the workforce planning should reflect the local needs and the local population.

Our role

For CQC, we’ll be using our new responsibilities under the Health and Care Act 2022 to provide independent assurance to the public of the quality of care in their area. We’ll do this by assessing ICSs and looking at whether local authorities are delivering their duties under the Care Act 2014 — in addition to regulating the quality of care from individual providers.

Our starting position is to look at how an ICS understands the needs of its local population and how is it seeking to address them. Is there a plan that people using services and those working in them have been involved in shaping, understand and are signed up to?

If we are asking others to engage in this way its important, we do the same for our own work. In my blog in April, I also stressed the importance of co-production. That means engaging people in different ways at different times to make sure they can influence the development of our work at every stage.

Earlier this year, we held a series of workshops focused on our approach to system-level regulation. An initial session set the scene and direction of travel, followed by two more in-depth workshops aimed at ICSs and local authority assurance in turn. These helped to make sure we have the right approach and methods, and that we’re asking the right questions. This valuable work has helped to avoid duplicating oversight activity from our own inspections of providers and activity from our partners.

These sessions gave us some valuable feedback and have influenced further refinement and development of our approach. Some common themes came through these conversations:

• data
• co-production
• ratings
• measuring leadership
• proportionate regulation.

We presented the detail beneath these themes, as well as what we’re doing with what we heard, at a briefing session in May. You can watch this on our YouTube channel.

We also have an Expert Advisory Group, which performs an invaluable role in creating a forum where ideas and issues can be discussed candidly. It’s effectively a sounding board for teasing out issues and providing clarity. Through our engagement, the issue of using consistent language was raised, specifically how we use the terms ‘assessment’, ‘inspection’ and ‘assurance’. A discussion at the Expert Advisory Group helped develop clear definitions for us to work to: assessment describes the whole process of measuring the quality of care and identifying risk, inspection describes the actual physical activity, and assurance is the outcome we are all working towards.

This was just one small example of how working in co-production can draw on the experience and expertise of our partners to find solutions.

Next steps

Although the Act of parliament separates the regulation of ICSs and local authorities, we will use a single approach building on our new single assessment framework.

We’re about to start some ‘test and learn’ activity looking at how local authority assurance could work in practice, working with local authorities in Hampshire and Manchester over the coming month. Similar activity is planned to test our approach with ICSs. We’ll share some of the findings and learning from this activity in the autumn.

We’ll also be launching some activity on our online participation platform to help refine some specific areas of our approach. Look out for more on that through our bulletins and on social media.