The Care Quality Commission (CQC) should use a ratings system like the Ofsted system for schools, according to a Government-commissioned expert report.

The new ratings system could be applied to GP practices and social care services within two years, and later to hospital services.

Think tank the Nuffield Trust emphasised that the system should be “sector-led” and allow input from patients, making it a key facilitator of patient choice.

This would not be a revival of the previous government’s ‘star ratings’ for hospitals, which were abolished in 2004 as being narrowly target-driven.

The BMA has praised the report’s commitment to appraisal of hospital services rather than entire hospitals.

The Nuffield Trust review, commissioned by Health Secretary Jeremy Hunt, said the CQC could develop the new ratings system given “stability from disruption over a period of time”.

There is “a clear gap” in the existing NHS performance appraisal system, the report said: no process exists to give patients clear information about the quality of available care providers.

Presenting the report, Nuffield Trust Chief Executive Jennifer Dixon (pictured) said ratings systems for GP practices and social care could be introduced within two years – but for hospital services, which would require individual department and clinical service ratings, more time would be needed.

The previous ‘star rating’ system for hospitals, used to help them qualify for Foundation Trust status, did not accurately reflect care quality, Dixon said.

The report emphasised that the new “sector-led” ratings system needed to be integrated with existing appraisal systems, and that the CQC would need support from other NHS stakeholders to develop and implement it.

Sources for the ratings could include QOF indicators (for general practice), hospital records, patient and staff surveys and inspections.

The Care Quality Commission (CQC) was formed in 2009 to replace three separate inspection bodies: the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission. Since October 2010 all providers of healthcare and social care, whether in the public or private sector, have had to register with the CQC – which now regulates more than 21,000 providers.

This massive registration task was divided into phases: the Commission registered NHS secondary care providers, then re-registered adult social care and independent healthcare providers, then registered primary dental care and independent ambulance providers. Its next challenge is to register all GP practices. Most importantly, it will need to continue monitoring the quality and safety of all these providers’ services.

The CQC’s declared purpose is to eliminate poor quality care, defend patients’ rights and ensure that care is centred on people’s needs. Initially it adopted a ‘risk-based’ strategy of using evidence of potential danger to determine the frequency of inspections. In 2011/12 it shifted to annual inspection of all care providers. Next year, however, it will revert to a ‘riskbased’ approach – as well as participating in local Quality Surveillance Groups, alongside CCGs and local Healthwatch.

These changes follow a year in which the CQC has faced criticism of its leadership and its overall performance. The Mid Staffordshire Foundation Trust enquiry led to criticism (for different reasons) of its Chief Executive, Cynthia Bower, and its Chair, Dame Jo Williams. The recent scandal of sustained patient abuse at Winterbourne View Care Home led the CQC to be accused of failing to conduct regular inspections and respond to ‘whistleblowers’.

In March a Commons Public Accounts Committee concluded that the CQC had “a long way to go” before it could be considered an effective regulator. The recent resignations of Bower and Williams have reduced the shadow over the leadership. The new CQC Chief Executive, David Behan, has a background in social care rather than healthcare. But can the problems of regulating provider quality in the new health and social care system be solved by such changes, or are they systemic issues beyond the scope of the CQC?

In safe hands
The CQC’s annual report for 2010/11 noted that by April 2010 it had licensed all 378 NHS provider trusts, and had required 22 trusts to take specific actions to improve their services. By October 2010 it had re-registered 12,000 adult social care and independent health providers, and had required almost 1,000 care homes to put in place qualified managers. By July 2011 it had registered 18,000 dental care and independent ambulance providers. The inclusion of primary medical services will add 8,000 providers to the list.

Each provider is accountable for each separate ‘regulated activity’ it provides, and must show that the service meets acceptable standards of quality and safety. CQC standards cover these areas:

• Informing patients and involving them in decisions about their care.
• Personalised care, treatment and support.
• Safeguarding and safety of the care environment.
• Suitably qualified and capable management and staff .
• Risk management and incident reporting.

A further responsibility of the CQC is to respond to complaints about services – and in particular, to provide a safe and responsive port of call for ‘whistleblowers’: care provider staff who report failings in quality or safety.

Winter in social care
Financial pressure was a feature of the CQC’s role from the outset. Its initial budget was 30% less than the combined budget of the three organisations it had replaced. The Labour Government set a ‘light-touch’ agenda for inspection: unless there was evidence of risk, providers would be left uninspected for
up to two years.

The coalition Government’s review of arm’s length bodies in July 2010 reinforced the CQC’s role as regulator for health and social care. However, it was not exempt from the general requirement that the NHS ‘do more with less’. Its annual budget for 2010/11 was set at £16.4m – £10m less than it had told the DH it needed to cope with the combined task of registering and inspection.

As a result, the number of inspections carried out by the CQC fell by 70%. Concern over its performance came to a head in the Winterbourne View scandal, where action to stop the mistreatment of learning-disabled patients in a care home run by private firm Castlebeck had been unacceptably slow. The regulator had failed to act on information from a ‘whistleblower’, and only a BBC Panorama report had brought the abuses to public attention.

In the aftermath of the scandal, a Health Select Committee report accused the CQC of devoting too much of its resources to registration, a sign of “distorted priorities”. However, Kings Fund Director of Policy Anna Dixon observed: “It is no good preaching the virtues of light touch regulation, and then blaming the regulator for not taking a more interventionist approach when problems emerge.”

The later Commons Public Accounts Committee report highlighted several CQC failings: lack of inspections,
failure to fill key vacancies in its inspection team, and the decision to scrap a helpline for whistleblowers. The committee said the CQC risked becoming a mere “postbox” for complaints.

Jo Williams described the Winterbourne View case as a “watershed moment” for the CQC, triggering its abandonment of the ‘light touch’ approach. The regulator asked for – and got – a £10m increase in its budget for 2012/13 to increase its number of inspectors by 15%, enabling it to adopt a policy of inspecting each provider at least once a year.

Crisis of leadership
The issues affecting the CQC leadership reflect some of the conflicts of interest that can arise for care regulators. The Mid Staffordshire inquiry – the greatest hospital safety scandal in the NHS’s history – concerned events that took place before the formation of the CQC. However, Cynthia Bower was head of the West Midlands SHA at that time, and the inquiry was critical of her role.

The Healthcare Commission (HCC) had warned the SHA about the unusually high mortality rate at Stafford General Hospital. According to the Guardian, Bower responded by commissioning a known critic of the HCC at Birmingham University to write a report on the HCC’s methodology. When the CQC was formed, Bower disbanded the HCC’s inspection team.

The Mid Staffs inquiry led to severe damage within the CQC. Senior operations analyst Rona Bryce claimed the testimony of CQC Board members was “aspirational”. Board member Kay Sheldon contacted the enquiry to voice concerns she said she had raised internally without result. Dame Jo Williams then asked the Health Secretary to dismiss Sheldon, but he declined. Williams also commissioned a third-party investigation of Sheldon’s mental health.

The way forward
David Behan, who took over as CQC Chief Executive in July 2012, had been Director General of Social Care at the DH since 2006. His appointment suggests a shift towards greater focus on social care regulation. The DH has set three core goals for the CQC going forward: to become more strategic in its approach and define quality more clearly in terms of outcomes; to make its Board stronger and more accountable; and to make the regulatory process more systematic and proportionate to risk.

The reversion to a risk-based approach is clearly driven by the cost-cutting agenda. However, Behan promises a “more ambitious” use of performance data to highlight success as well as failure, helping to drive widespread improvements in care. He also plans a “differentiated regulation” of health, mental health and social care providers.

In addition, from April 2013 the CQC will work alongside CCGs and local Healthwatch to develop a network of local and regional Quality Surveillance Groups. According to the NHS Commissioning Board, this system will “act as a virtual team” across health and social care, and will “need to manage itself ” without governance. It will use a ‘risk summit’ model to deal with problems, but who takes primary responsibility will depend on the circumstances.

These changes show the CQC becoming more devolved, but also more able to assist the integration of health and social care. However, as providers become more diverse while funding both for inspection and for care becomes steadily tighter, the future is unlikely to be problem-free for the regulator. The CQC will need to continue walking a tightrope between a ‘light touch’ agenda and urgent reactions to healthcare disasters – its success will depend primarily on getting better at it.

CCGs are the core of the new NHS – but are they running the game?

The emerging clinical commissioning groups (CCGs) embody a core principle of the new NHS: that commissioning decisions should be made locally, by clinicians, and be focused on community-based care. According to Andrew Lansley, the defining feature of the NHS reform is a “shift of power” from national and regional organisations to local ones, of which the CCGs are the most important.

The role of CCGs in the new NHS is both structural and dynamic. They will commission healthcare at a local level, spending £60 billion of the £80 billion NHS commissioning budget, and will hold together the relationship between patients and providers. They will also work with providers and business partners to redesign local services, and those new solutions will spread through the NHS. The CCGs will thus be the drivers of healthcare innovation.

However, given that GPs are meant to lead the CCGs, the concerns raised by many GPs about the new system are significant. Will CCGs really have the opportunity to improve care, or will they simply have to drive through spending cuts? Will they really be run by clinicians or by the private sector? Is the heart of the new NHS dynamic and responsive, or divided and unstable?

Development of CCGs

In July 2010, the white paper Equity and Excellence: Liberating the NHS spoke of “putting GP commissioning on a statutory basis” through the development of ‘GP consortia’. These new organisations, to which every GP practice would belong, would run each local health economy: they would contract providers, partner with local authorities, and be accountable to patients and the public for outcomes. They would be authorised by a new national body, the NHS Commissioning Board, which would also commission GP services.

The initial reaction of the GP community was positive. Being in the driving seat of a fast-evolving NHS, able to redesign local services for their patients, appealed strongly. However, the codification of the reforms in the Health and Social Care Bill led to growing opposition among GPs. Issues raised included the power of the Board to direct GP consortia and the requirement that consortia embrace provider competition. Above all, the deepening economic crisis made GPs fear their role would be one of rationing services, not finding solutions.

The Government’s ‘listening exercise’ did not resolve the concerns about competition and rationing, but it led to a stronger assertion of the autonomy of the consortia. An important change concerned the scope of clinical representation: the new ‘clinical commissioning groups’ were defined as including specialist consultants and nurses as well as GPs. That was a step towards the ‘integrated care’ that the BMA had highlighted as a priority.

Breaking the waves

The NHS Commissioning Board Authority, set up in October 2011, has the primary responsibility of putting in place a nationwide system of CCGs to replace the PCTs by April 2013. A total of 212 CCGs have been approved to go through the authorisation process in four waves: 35 in wave 1 (commencing in June 2012), 70 in wave 2 (July), 67 in wave 3 (September) and 40 in wave 4 (October).

The authorisation process is designed, according to the Board, to ensure that CCGs have a “strong clinical and multi-professional focus”; have meaningful patient engagement; have credible plans to “deliver the QIPP challenge”; have proper governance arrangements; are set up to collaborate with other CCGs, local authorities and the Board; and have strong leadership.

It has not always been a smooth road, however. The Board, concerned at the prospect of CCGs competing for providers of commissioning support, announced it would take over the appointment of leaders to Commissioning Support Services. One CCG has already protested that its authorisation has been delayed by this.

Another issue is lack of GP leadership. Clare Gerada, chair of the Royal College of GPs, said that only “about 25 GPs” in England were actively interested in leading local commissioning. The reason, she said, was that the “transactional” aspects of commissioning as a business did not appeal to them. 

GP-led commissioning

CCGs will be responsible for commissioning community health services (including mental health care and services for children and elderly people) and hospital care (both A&E and elective care). The NHSCB will be responsible for commissioning primary care as well as pharmaceutical and dental services. Local authorities will be responsible for public health, with the NHSCB covering certain aspects.

Collaborative working between CCGs and the other statutory organisations involved in healthcare is anticipated, but the model is not one of top-down control – rather, it is one of business partnership. The NHSCB can provide assistance or support to CCG commissioning; this may take the form of extra funding or access to staff and other resources. CCGs have a duty to co-operate with local authorities in supporting aspects of public health, including child health and mental health.

CCGs are able to buy in support from external organisations, including the CSUs whose development is currently being governed by the NHSCB. For more details on the CSU landscape. CCGs can also buy in support from the private and voluntary sectors, but will retain control of commissioning decisions. These relationships will differentiate CCGs, as some are keener than others to engage in private sector partnerships.

Commissioning of hospital services is also likely to differentiate CCGs, especially as many hospital trusts are facing financial challenges as they shift to foundation trust status. CCGs will influence the development of FTs through their commissioning strategies – for example, they may promote private providers both within and beyond FT-provided services. The acute sector will have a voice in CCGs, though its representatives on a CCG board cannot come from the local area.

The GP-led nature of CCGs is variable. Fewer than 50% of current CCG board members are GPs, and there is potential for the management of local commissioning to be outsourced. CCG boards should include a non-practice nurse and a specialist consultant, but local government are excluded.

Life after April 2013

Securing GP ‘buy-in’ remains an issue for the NHS reforms, but those GPs who support the reforms have been most active in developing CCGs. The CCG boards thus represent a more pro-market segment of the GP profession. Pharma companies may find that their CCG customers and GP customers require a nuanced and varied approach.

Each CCG will have a different mix of GPs, hospital clinicians and financial or management specialists. It will also be dealing with local health issues, which are also impacting on local government and the local Healthwatch body. Every CCG will have to find its own balance between clinical outcomes and economic success.

CCGs will also face a tension between the ‘autonomy’ stressed by the NHSCB and the need for partnership with other stakeholders, within and outside the NHS. Will this tension lead to fragmentation and paralysis, or to dynamic innovation driven by the local synergy of clinical and commercial talent? Whatever the answer, the CCGs hold the key to the success or failure of the new NHS.

NICE has proposed 16 new indicators for inclusion in the 2013/14 Quality and Outcomes Framework (QOF) and rheumatoid arthritis (RA) as a new clinical area.

The recommendations include four for RA, two for men with diabetes, plus indicators for COPD rehabilitation and hypertension.

Dr Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE, said the potential indicators “can make a real difference” to improve standards of care.

QOF is a voluntary incentive scheme that rewards GPs for implementing systematic improvements in care for patients. It operates through a points system which rewards doctors for their performance against the indicators.

Indicators for RA include GP practices creating a register of patients aged over 16, and patients being assessed for cardiovascular risk and fracture risk.

In men with diabetes, indicators focus on offering advice on erectile dysfunction and on available treatment options.

The final ‘menu’ of indicators will be decided by NHS Employers and the British Medical Association later this year.

The majority of doctors want at least a month’s notice before being inspected by the Care Quality Commission (CQC), a new survey has found.

A poll by the Family Doctor Association of 100 GP practices across England revealed that 67% would require more than 30 days’ notice, 12% called for two months’ notice, 9% wanted three months’ and 12% need between three and six months.

A spokeswoman said the Association “demands” that a minimum of a month is given for routine inspections by the CQC.

The CQC has the right to visit GP practices without notice but has said the majority of practices usually get one or two days’ notice.

Practices now have to register with the Commission before April next year. The CQC will inspect practices at least once every two years.

But the Family Doctor Association explained that GP practices are unlike other facilities the CQC inspects. “The CQC forgets that general practice is not like the hospital or nursing home sectors that they regulate,” said the spokeswomen.

“What happens if they demand to inspect a single handed practice and the doctor has just left for a holiday? What effect will it have on patients who have pre-booked a doctor appointment if at very short notice the CQC demands that the registered manager, usually a GP, is available for them?”

The CQC said it was considering its notice period as part of its inspection pilot. “Most other services registered with CQC receive no notice period when we carry out an inspection,” a spokesperson said. “To ensure our inspections do not impact on patient care during inspections a variety of notice periods are being tested, from no notice up to a 10 day notice period.”

The majority of doctors want at least a month’s notice before being inspected by the Care Quality Commission (CQC), a new survey has found.

A poll by the Family Doctor Association of 100 GP practices across England revealed that 67% would require more than 30 days’ notice, 12% called for two months’ notice, 9% wanted three months’ and 12% need between three and six months.

A spokeswoman said the Association “demands” that a minimum of a month is given for routine inspections by the CQC.

The CQC has the right to visit GP practices without notice but has said the majority of practices usually get one or two days’ notice.

Practices now have to register with the Commission before April next year. The CQC will inspect practices at least once every two years.

But the Family Doctor Association explained that GP practices are unlike other facilities the CQC inspects. “The CQC forgets that general practice is not like the hospital or nursing home sectors that they regulate,” said the spokeswomen.

“What happens if they demand to inspect a single handed practice and the doctor has just left for a holiday? What effect will it have on patients who have pre-booked a doctor appointment if at very short notice the CQC demands that the registered manager, usually a GP, is available for them?”

The CQC said it was considering its notice period as part of its inspection pilot. “Most other services registered with CQC receive no notice period when we carry out an inspection,” a spokesperson said. “To ensure our inspections do not impact on patient care during inspections a variety of notice periods are being tested, from no notice up to a 10 day notice period.”

Patient feedback on GP practices, including an overall score out of 10, is now available on the NHS Choices website.

The DH claims the new online feature will empower patients both to express their views and to choose the best GP practice for their needs.

The BMA has criticised the new system for reducing multi-factorial patient experience to a single metric.

Patient feedback has been used to evaluate more than 8000 GP practices, based on several factors including ease of securing appointments, time spent waiting in reception, opening hours and communication skills of doctors and practice nurses.

The patient experience data have been gathered from responses to the annual GP Patient Survey.

Health Minister Earl Howe said: “This data will not only help patients choose the right GP surgery for them but will also give GP surgeries and the NHS new information they can use to make fresh, innovative improvements.”

A BMA spokesman commented that while enabling patients to give feedback on primary care was a good idea, the new approach failed to elicit “detailed responses” or to “take into account the differing challenges that each GP practice may face”.

Richard Vautrey, Deputy Chair of the BMA’s GP Committee, noted that the metric did not take proper account of patient priorities: “It is the quality of the consultation that is of most concern to patients.”