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The Care Quality Commission
Finnish Government Study Group –
21st May 2010
Gary Needle, Director of Methods, Care Quality
Commission
Content


This presentation will cover:

   • The role of CQC
   • The new registration and compliance system
   • The challenge facing the health and adult social care
     system




                                                             2
Our role

 The independent regulator of the quality of
 health and adult social care services in
 England.
 We also protect the interests of people
 detained under the Mental Health Act.
 We make sure that people get a good
 standard of care - whether services are
 provided by the NHS, local authorities or by
 private or voluntary organisations
 As the first regulator to work across health
 and social care we have a unique
 opportunity to look at how well health and
 social care work together to bring people
 integrated care

                                                3
Our objective


The main objective of the Commission in performing its
  functions is to protect and promote the health, safety and
  welfare of people who use health and social care services.

The Commission is to perform its functions for the general
  purpose of encouraging:

(a) the improvement of health and social care services,
(b) the provision of health and social care services in a way that
    focuses on the needs and experiences of people who use
    those services, and
(c) the efficient and effective use of resources in the provision
    of health and social care services.


                                                                     4
...on a page

Our five priorities
1. Making sure care is centred on people’s needs,      3. Acting swiftly to help eliminate poor quality care
             and which protects their rights
           2. Championing joined-up care               4. Promoting high quality care


                                  5. Regulating effectively, in partnership

What we do to achieve our priorities
    Registration and ongoing              Assessments of quality                Mental Health Act
   monitoring and enforcement                                                        visits

                       Publishing information to support people making decisions


The way we work

-Involve users to focus our assessments on what is important to them
-Are expert and independent
-Promote equality, diversity and human rights
-Engage with those providing and commissioning care to inform our work




                                                                                                               5
CQC well placed to make strong
  contribution
                  • Statutory Remit Covering ‘consumer protection’ (registration) and
                      tackling ‘information asymmetry’ (assessments of quality)
                  • Particular powers for inspection, data gathering, enforcement
Privileged Assets • ‘Whole system’ statutory remit – covering health, mental health,
                      adult social care; commissioning & provision
                  • Trust and credibility driven by independence from government and
                      commercial relationships


                  •   Intelligent data analysis and risk assessment
Specific          •   Gathering in and responding to user voice
Competencies
                  •   Local intelligence, insight & local relationship from field force
                  •   National influence, drawing on comparative view of quality &
                      safety of care


                  • User Groups & Regulated bodies
Special           • Other regulatory and oversight bodies (incl, Govt. Offices, SHAs,
Relationships         Monitor, AC, Ofsted, NPSA
                  • Secretary of State & DH
                                                                                          6
Improving the quality of care




 Enforcement                                                                Publish
  action                                              Assessment of         information
                  Registration
                                                          Quality           to reinforce
 - requires
                                                                            other levers
  providers to
  ‘improve or
  exit’




Below essential   Essential                     Above essential standards
standards         standards



                              Quality of care


                                                                                           7
How we will go about our work


                       Information
                     and Intelligence
                   about quality of care



     Judgements
                                            Analysis
      on quality
                                             of risk




                   Activities in response
                       To view of risk

                                                       8
How we will go about our work

 New information can come from a variety of sources:


 People who use
services, families                                       Providers
   and carers



Other regulatory
  bodies and                                       Staff and other
  Information                                      professionals
     Centre



  Other bodies                                              CQC
e.g. Ombudsman,                                        Assessors and
 commissioners                                           Inspectors




                                                                       9
Other players in the field


 National Quality Board      NHS Litigation Authority
                                                     PCTs
                     ADASS
    Monitor                           SHAs
                 NPSA                                   GMC

              3rd Sector                       Providers        GSCC
                                      DCLG
          Audit Commission
                                DH
                                                NHS Institute
     Quality observatories
                                                      SCIE
      NHS Information Authority           NICE
 Co-operation &                        Professional regulation
                        NHS Choices
 Competition Panel                           Professional accreditation

                                                                          10
The aim of registration



People can expect services to meet essential standards of quality,
protect their safety and respect their dignity and rights.

 Adult social care                            Single system of
                                         1    registration


                                              Single set of standards
      NHS               Registration     2

                                              Strengthened
                                         3    and extended
  Independent
   healthcare                                 enforcement powers



                                                                        11
Registration timeline
(subject to legislation)



 April                               NHS trusts
 2010


  Oct            Adult social care and independent healthcare
 2010                           providers (CSA)


 April               Primary dental care (dental practices)
 2011                and independent ambulance services


 April                        Primary medical services
 2012                      (GP practices and out of hours)

                                                                12
Benefits of registration



  Outcomes - More outcome-based registration that protects and promotes
  equality, diversity and human rights and makes providers accountable
  Information - Improved access to timely, relevant and reliable
  information enabling consistent comparisons and promotion of joined up
  care
  Enforcement - Earlier identification and swifter action to follow up
  concerns including enforcement action where necessary
  Burden - Reduced unnecessary regulatory burden and associated
  costs of demonstrating compliance
  Compliance - Increased compliance by health and adult social care
  providers
  Process - Improved transparency, speed, consistency and reliability
  of registration


                                                                           13
Guidance about compliance




                            14
Registration: the cycle



Registration application            Information
                                     Information
                                       capture
                                        capture
  Application
    made                                              Judgement
                                                        on risk
                                    Information
                                     Information
  Application          Judgement      analysis
                                       analysis
   assessed             published


  Judgement                          Regulatory       Regulatory
     made                            judgement         response


                                    Ongoing monitoring of compliance

                                                                       15
A national trend for improved
  performance


Overall performance has steadily improved right across the
  health and social care sector

However, a minority of NHS trusts, adult social care services,
  independent healthcare providers, and councils have under-
  performed




                                                             16
Real improvements
 for people using services

Hospital waiting times have been driven right down
  • 89% of hospital trusts achieved the 18-week waiting
     time target from referral to start of treatment

Rates of MRSA and Clostridium difficile have
reduced by 34% and 35% respectively

More people are living independently at home
  • 2.1% of people aged 65 and above were living
     in care homes (council-supported) in 2009,
     compared to 2.5% in 2005


                                                          17
Common concerns

  There are three areas where we have concerns
  about performance right across the health and social
  care sector:

   •   Building a safety culture

   •   Protecting people from harm

   •   Workforce training




                                                         18
Keeping people safe


Building a safety culture
 Number of incidents reported to the NPSA improved to
 1.06 million incidents last year, compared with 920,000
 incidents the year before

 In some organisations reporting levels are low
 • Reporting from PCTs with hospital beds varied over 20-fold
 We are not seeing the full picture in primary care
 • In 12 months, primary care services across the country reported
   under 3,500 incidents, compared with 693,700 from hospitals

                                                                     19
Keeping people safe

Protecting people from harm

•   9% of NHS organisations did not comply with
    the minimum standard on child safeguarding
•   Although the majority of social care providers fully
    met standards relating to safeguarding procedures,


383         (2%) failed with major
            shortfalls


                                                           20
Workforce training


Good services rely on good, well-trained people


    12 % of NHS trusts did not meet the core standard on
    mandatory training
    – the lowest compliance rate of all standards




                                                           21
Workforce training




86%         or less of adult social care services (such as
care homes and home care agencies) meet minimum
standards on training
Staff training and qualifications were a strength in only 16%
of councils




                                                                22
An increasing challenge
 for health and social care

By 2026, the Government expects there to be
 1.7 million more adults needing care and
  support
There will be greater pressure on public finances
Rightly, people are expecting more choice and control
  over their care




                                                        23
Services must
accelerate efforts to

• Work better together to join up services
• Ensure people have clear information and
  understand their options

• Support people in maintaining their independence




                                                     24
Major steps forward

More people are supported to live independently at home
In five years, the number of people with access to council-funded services
    helping them avoid emergency hospital admission has risen from

     80,000 to 148,000
In five years, the number of people with access to services helping them
    return home quickly from hospital has risen from

     112,000 to 157,000




                                                                       25
But, people face high levels
of local variation




  3-fold variation in the extent to which councils place older
  people in long-term residential care

  4-fold variation in the rate of occupied bed-days associated
  with repeated emergency admissions of older people in hospital

  Over 30-fold variation in the proportion of people whose
  discharge from hospital is delayed




                                                                   26
Our estimates suggest

If all areas in the country were able to reduce the
number of people admitted repeatedly as emergencies
and the length of their hospital stay to the low levels
seen in the best performing five areas of the country,
this would:
 Result in 8 million fewer days in hospital
 Free up 2 billion from hospital budgets




                                                          27
Sharing of information between
 organisations must improve

Only 53% of GPs reported that discharge summaries sent by acute
  trusts arrived in time to be useful
In our review of actions taken by health bodies in relation to Peter
   Connelly (Baby P), it was clear that communication between
   organisations was poor




                                                                       28
Access to healthcare: a mixed picture



The NHS has greatly improved waiting times for acute care

The percentage of people who can get an appointment with a
  GP within 48 hours varied by PCT (between 76% and 92%)

Only half of trusts provided adequate access to out-of-hours
  mental health support




                                                               29
Not all people receive useful
information on their care

• Some people do not receive enough information about their
  care, e.g. 21% of people discharged from hospital said they were
  not given sufficient information about their condition or treatment

• Information is sometimes given in a way that
  people cannot understand, e.g. 29% people with disabilities
  using social care services felt communication did not
  help them to understand things properly




                                                                        30
Choice and control has
  improved, but progress is mixed

• Nearly half of people (47%) recall being offered a
  choice of hospital at their first outpatient appointment,
  a big improvement compared with 30% in 2006
• Yet 1 in 4 people using acute mental health care
  were not as involved in their care as they wanted
• And councils are not doing enough to give
  people full control of their care with direct
  payments




                                                              31
Summary




          32
What does the analysis tell us?


•    Overall steady improvement in performance in all parts
     of the sector
•    We see some real improvements that matter to people
•    Some organisations lag behind the pack
•    Common issues where improvement is needed, including
     keeping people safe and training
•    Some people are supported in having choice, control and
     independence, but variation is high



                                                              33
Leadership challenges


•     Right across the system, an approach that focuses on
      the individual, carers, and families is needed
•     How can services best strategically commission in
      order to deliver the benefits of joined-up care?
•     Against the backdrop of future pressures, how can
      services continue to work in partnership to deliver
      person-centred care?




                                                             34
We will play our part

    A new regulatory system − centred on registration
    − keeping the spotlight on outcomes the public wants to see


We will…

•    Focus on the people who use services and their carers
•    Set clear expectations of providers through registration
•    Identify serious issues by responsive and vigilant
     assessment
•    Act swiftly, using our enforcement powers where needed
•    Drive improvements through performance assessment
     and our special reviews and studies
                                                                  35
Where to find out more

Read our full report or
   summary booklet
Visit our website:
     • Watch videos of
       people telling their
       stories
     • Browse key findings
     • Get accessible
       versions


                              36

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Care Quality Commission

  • 1. The Care Quality Commission Finnish Government Study Group – 21st May 2010 Gary Needle, Director of Methods, Care Quality Commission
  • 2. Content This presentation will cover: • The role of CQC • The new registration and compliance system • The challenge facing the health and adult social care system 2
  • 3. Our role The independent regulator of the quality of health and adult social care services in England. We also protect the interests of people detained under the Mental Health Act. We make sure that people get a good standard of care - whether services are provided by the NHS, local authorities or by private or voluntary organisations As the first regulator to work across health and social care we have a unique opportunity to look at how well health and social care work together to bring people integrated care 3
  • 4. Our objective The main objective of the Commission in performing its functions is to protect and promote the health, safety and welfare of people who use health and social care services. The Commission is to perform its functions for the general purpose of encouraging: (a) the improvement of health and social care services, (b) the provision of health and social care services in a way that focuses on the needs and experiences of people who use those services, and (c) the efficient and effective use of resources in the provision of health and social care services. 4
  • 5. ...on a page Our five priorities 1. Making sure care is centred on people’s needs, 3. Acting swiftly to help eliminate poor quality care and which protects their rights 2. Championing joined-up care 4. Promoting high quality care 5. Regulating effectively, in partnership What we do to achieve our priorities Registration and ongoing Assessments of quality Mental Health Act monitoring and enforcement visits Publishing information to support people making decisions The way we work -Involve users to focus our assessments on what is important to them -Are expert and independent -Promote equality, diversity and human rights -Engage with those providing and commissioning care to inform our work 5
  • 6. CQC well placed to make strong contribution • Statutory Remit Covering ‘consumer protection’ (registration) and tackling ‘information asymmetry’ (assessments of quality) • Particular powers for inspection, data gathering, enforcement Privileged Assets • ‘Whole system’ statutory remit – covering health, mental health, adult social care; commissioning & provision • Trust and credibility driven by independence from government and commercial relationships • Intelligent data analysis and risk assessment Specific • Gathering in and responding to user voice Competencies • Local intelligence, insight & local relationship from field force • National influence, drawing on comparative view of quality & safety of care • User Groups & Regulated bodies Special • Other regulatory and oversight bodies (incl, Govt. Offices, SHAs, Relationships Monitor, AC, Ofsted, NPSA • Secretary of State & DH 6
  • 7. Improving the quality of care Enforcement Publish action Assessment of information Registration Quality to reinforce - requires other levers providers to ‘improve or exit’ Below essential Essential Above essential standards standards standards Quality of care 7
  • 8. How we will go about our work Information and Intelligence about quality of care Judgements Analysis on quality of risk Activities in response To view of risk 8
  • 9. How we will go about our work New information can come from a variety of sources: People who use services, families Providers and carers Other regulatory bodies and Staff and other Information professionals Centre Other bodies CQC e.g. Ombudsman, Assessors and commissioners Inspectors 9
  • 10. Other players in the field National Quality Board NHS Litigation Authority PCTs ADASS Monitor SHAs NPSA GMC 3rd Sector Providers GSCC DCLG Audit Commission DH NHS Institute Quality observatories SCIE NHS Information Authority NICE Co-operation & Professional regulation NHS Choices Competition Panel Professional accreditation 10
  • 11. The aim of registration People can expect services to meet essential standards of quality, protect their safety and respect their dignity and rights. Adult social care Single system of 1 registration Single set of standards NHS Registration 2 Strengthened 3 and extended Independent healthcare enforcement powers 11
  • 12. Registration timeline (subject to legislation) April NHS trusts 2010 Oct Adult social care and independent healthcare 2010 providers (CSA) April Primary dental care (dental practices) 2011 and independent ambulance services April Primary medical services 2012 (GP practices and out of hours) 12
  • 13. Benefits of registration Outcomes - More outcome-based registration that protects and promotes equality, diversity and human rights and makes providers accountable Information - Improved access to timely, relevant and reliable information enabling consistent comparisons and promotion of joined up care Enforcement - Earlier identification and swifter action to follow up concerns including enforcement action where necessary Burden - Reduced unnecessary regulatory burden and associated costs of demonstrating compliance Compliance - Increased compliance by health and adult social care providers Process - Improved transparency, speed, consistency and reliability of registration 13
  • 15. Registration: the cycle Registration application Information Information capture capture Application made Judgement on risk Information Information Application Judgement analysis analysis assessed published Judgement Regulatory Regulatory made judgement response Ongoing monitoring of compliance 15
  • 16. A national trend for improved performance Overall performance has steadily improved right across the health and social care sector However, a minority of NHS trusts, adult social care services, independent healthcare providers, and councils have under- performed 16
  • 17. Real improvements for people using services Hospital waiting times have been driven right down • 89% of hospital trusts achieved the 18-week waiting time target from referral to start of treatment Rates of MRSA and Clostridium difficile have reduced by 34% and 35% respectively More people are living independently at home • 2.1% of people aged 65 and above were living in care homes (council-supported) in 2009, compared to 2.5% in 2005 17
  • 18. Common concerns There are three areas where we have concerns about performance right across the health and social care sector: • Building a safety culture • Protecting people from harm • Workforce training 18
  • 19. Keeping people safe Building a safety culture Number of incidents reported to the NPSA improved to 1.06 million incidents last year, compared with 920,000 incidents the year before In some organisations reporting levels are low • Reporting from PCTs with hospital beds varied over 20-fold We are not seeing the full picture in primary care • In 12 months, primary care services across the country reported under 3,500 incidents, compared with 693,700 from hospitals 19
  • 20. Keeping people safe Protecting people from harm • 9% of NHS organisations did not comply with the minimum standard on child safeguarding • Although the majority of social care providers fully met standards relating to safeguarding procedures, 383 (2%) failed with major shortfalls 20
  • 21. Workforce training Good services rely on good, well-trained people 12 % of NHS trusts did not meet the core standard on mandatory training – the lowest compliance rate of all standards 21
  • 22. Workforce training 86% or less of adult social care services (such as care homes and home care agencies) meet minimum standards on training Staff training and qualifications were a strength in only 16% of councils 22
  • 23. An increasing challenge for health and social care By 2026, the Government expects there to be 1.7 million more adults needing care and support There will be greater pressure on public finances Rightly, people are expecting more choice and control over their care 23
  • 24. Services must accelerate efforts to • Work better together to join up services • Ensure people have clear information and understand their options • Support people in maintaining their independence 24
  • 25. Major steps forward More people are supported to live independently at home In five years, the number of people with access to council-funded services helping them avoid emergency hospital admission has risen from 80,000 to 148,000 In five years, the number of people with access to services helping them return home quickly from hospital has risen from 112,000 to 157,000 25
  • 26. But, people face high levels of local variation 3-fold variation in the extent to which councils place older people in long-term residential care 4-fold variation in the rate of occupied bed-days associated with repeated emergency admissions of older people in hospital Over 30-fold variation in the proportion of people whose discharge from hospital is delayed 26
  • 27. Our estimates suggest If all areas in the country were able to reduce the number of people admitted repeatedly as emergencies and the length of their hospital stay to the low levels seen in the best performing five areas of the country, this would: Result in 8 million fewer days in hospital Free up 2 billion from hospital budgets 27
  • 28. Sharing of information between organisations must improve Only 53% of GPs reported that discharge summaries sent by acute trusts arrived in time to be useful In our review of actions taken by health bodies in relation to Peter Connelly (Baby P), it was clear that communication between organisations was poor 28
  • 29. Access to healthcare: a mixed picture The NHS has greatly improved waiting times for acute care The percentage of people who can get an appointment with a GP within 48 hours varied by PCT (between 76% and 92%) Only half of trusts provided adequate access to out-of-hours mental health support 29
  • 30. Not all people receive useful information on their care • Some people do not receive enough information about their care, e.g. 21% of people discharged from hospital said they were not given sufficient information about their condition or treatment • Information is sometimes given in a way that people cannot understand, e.g. 29% people with disabilities using social care services felt communication did not help them to understand things properly 30
  • 31. Choice and control has improved, but progress is mixed • Nearly half of people (47%) recall being offered a choice of hospital at their first outpatient appointment, a big improvement compared with 30% in 2006 • Yet 1 in 4 people using acute mental health care were not as involved in their care as they wanted • And councils are not doing enough to give people full control of their care with direct payments 31
  • 32. Summary 32
  • 33. What does the analysis tell us? • Overall steady improvement in performance in all parts of the sector • We see some real improvements that matter to people • Some organisations lag behind the pack • Common issues where improvement is needed, including keeping people safe and training • Some people are supported in having choice, control and independence, but variation is high 33
  • 34. Leadership challenges • Right across the system, an approach that focuses on the individual, carers, and families is needed • How can services best strategically commission in order to deliver the benefits of joined-up care? • Against the backdrop of future pressures, how can services continue to work in partnership to deliver person-centred care? 34
  • 35. We will play our part A new regulatory system − centred on registration − keeping the spotlight on outcomes the public wants to see We will… • Focus on the people who use services and their carers • Set clear expectations of providers through registration • Identify serious issues by responsive and vigilant assessment • Act swiftly, using our enforcement powers where needed • Drive improvements through performance assessment and our special reviews and studies 35
  • 36. Where to find out more Read our full report or summary booklet Visit our website: • Watch videos of people telling their stories • Browse key findings • Get accessible versions 36