Our ‘new strategy for the changing world of health and social care’ made ambitious commitments to change how we work. As well as our drive to promote safety and improvement, we also committed to delivering smarter regulation of health and adult social care driven by people’s needs and experiences. Our two ‘core ambitions’ that run through every aspect of our strategy involve assessing local ‘systems’ that organise care in a local area and a focus on tackling inequalities in health and care.
In this blog, our Head of equality, health inequalities and human rights, Lucy Wilkinson, discusses how we are transforming the way we regulate and the new opportunities to tackle inequalities across health and social care.
It has been said many times — the pandemic shone a light on inequalities in health and care that already existed. This has galvanised many people in health and social care to take more action to tackle inequalities. At CQC, we are committed to playing our part in this. I want to talk to you about our new regulatory approach and how it aims to make sure everyone, inclusively, has good quality care, as well as equal access, experience and outcomes from health and social care services. We are committed to being a fair regulator that delivers equality in our regulatory approach, driven by people’s needs and experiences and enabling health and care services and local systems to improve. I will talk about three topics:
- Reducing inequalities in health and care settings
- Listening to the voices of people and communities
- Holding to account and escalating concerns
So, let’s take a look at these in some more detail.
Reducing inequalities in health and care settings
One way we can tackle inequalities in health and care settings is by strengthening our focus on inequalities through our new single assessment framework. To reduce inequalities, we need to focus on the quality of care for groups of people who face barriers in getting the care they need and those most likely to have a poorer experience or outcomes. This doesn’t mean that we’re looking specifically for poor care — it means we are looking for good care for people, so we can learn from and share it.
Our new assessment framework is built on our five key questions and our well-known ratings system. It is what we will use to set out our view of quality and make judgements. In our new framework, we have specific quality statements about equity in access and equity in experience and outcomes within our responsive key question. We also have a specific quality statement about workforce equality, diversity and inclusion, within our well-led key question. These will contribute to ratings.
We will look for evidence of how providers encourage, enable and act on feedback, including from people who face communication barriers. We will check that providers actively seek out and listen to information from people who are most likely to experience inequality in their experiences or outcomes, so they can tailor people’s care, support and treatment to meet their needs.
Achieving a balance between specific quality statements on inequalities and embedding inequalities across our assessments is important. ‘People’s experience of health and care services’ is a required evidence category in the assessment framework for many of our quality statements. We are committed to seeking out and valuing the experiences of people more likely to have poor access, experience and outcomes. This means that the views and experiences of these people will contribute to our assessments across a wide range of topics, from the safety and effectiveness of care to how caring and responsive services are.
To take one important example, we know from research that people living in areas with higher levels of socio-economic deprivation have poorer health and a lower life expectancy. Our research on the impact of CQC’s regulation of GP providers who are led by doctors from an ethnic minority background found they experience increased systemic challenges. They may often work in areas of higher deprivation and this can affect a practice’s ability to achieve some national targets used in assessments of quality, and they often have challenges around recruiting staff and securing funding. Our research also showed that these GP providers can experience a lack of leadership support from external bodies.
In response to this work, we are reviewing and strengthening how we consider the context in which a GP practice works in our assessments and ratings, while at the same time ensuring we address health inequalities in the areas that these practices serve. We will also use the learning and insight in developing our approach to assessing integrated care systems (a new duty placed on CQC by the Health and Care Act 2022).
Listening to the voices of people and communities
We need to improve how we encourage and enable people to engage with us, particularly those most likely to have a poorer experience of care, or of trying to access care. This includes people who use health and care services, their families and unpaid carers, and organisations who represent them or act on their behalf. The responsibility to listen and engage is also true for those who provide and organise health and care services in a local area.
We have already engaged through our Participation Platform, sessions with the Healthwatch Network and engagement with charity and voluntary sector organisations so that we can use people’s experiences and listen to their views on our new regulatory approach. This was so important when developing our new assessment framework. We will forge stronger partnerships with organisations that represent people and other organisations to develop a shared understanding of the factors that contribute to inequalities in people’s access and experience of care, how this affects their outcomes, and the levers we can use to encourage improvement.
We know there’s more work to do, for example we will:
- work with those who provide and organise care services in a geographic area to make sure they involve people in shaping services that meet people’s needs
- encourage and enable a wider range of people to get involved in developing how we and others do our jobs
- focus more on engaging with people with protected equality characteristics, people whose voices are seldom heard and those who are most likely to have a poorer experience of care, both nationally and through our local teams
Giving assurance about quality
The Health and Care Act 2022 gives us new responsibilities to review integrated care systems. We will look at how well health and social care partners within an area are working together to
- Deliver high quality care to meet people’s needs and improve outcomes
- Reduce inequalities and
- Improve access
This is a really important addition to our powers as it gives us the opportunity to influence and improve quality for all people across whole health and care systems in England. We aim to start these reviews from April 2023.
We know that many inequalities are caused because there is variation in how easily people can access care. Inequalities also arise when there are differences between how well people have their needs met when they need to use more than one health or care service. Some people are more likely to “fall between the cracks” between services. Our powers enable us to consider inequalities in access to care and pathways of care, as well as assessing the role of systems in tackling the wider determinants of inequalities.
Our colleagues in CQC have been working hard to create a way to make that happen. We are piloting our method with two integrated care systems to test how we do this. There will be a real focus on leadership, integration, and on quality and safety, with detailed tailored quality statements sitting under these themes, including quality statements about ensuring equity. What we do has to make a difference to people.
We will be sharing more information soon about our plans for using our reviews on local areas to help reduce inequalities, through working with other bodies.
What else are we doing to tackle inequalities?
We also have a duty to publish equality objectives to meet Equality Act 2010 regulations.
Our Equality Objectives 2021–2025 are designed to help us improve the quality care for everyone, as well as improving equal access, experience and outcomes from health and social care services. They are closely aligned to our strategy and ambitions, focusing on amplifying the voices of people more likely to have poor access, experience and outcomes from care and using data to look at risk of inequalities, alongside working with others and using our independent voice to tackle inequalities.
As an independent regulator, we will take appropriate regulatory action or speak up where care isn’t good enough — for any groups of people.