As rhetorical questions go this one is up there with the best of them. The reality is that the health and social care sector is going to be subject to the full force of ratings or performance assessments in less than a month in circumstances where CQC as at 17 September 2014 has not explained definitively how they are going to be set, let alone challenged.
What we are expecting is a slew of guidance documents from CQC through the remainder of September and into October describing how the system will work, or perhaps we should say, may work given the uncertainties that surround the new rating methodology.
Given that the fundamental standards are not being introduced until April 2015, the immediate question is why the ratings are being introduced in such a rushed fashion from October 2014 in relation to adult social care (including hospices), mental health, GPs and GP out-of-hours and the acute hospital sector. It would have been more sensible to have phased in ratings, with the NHS leading the way in October, followed by the other sectors in April 2015 to coincide with the introduction of the fundamental standards. However, such mumblings are not going to delay the October start date and providers will have to adapt fast.
What is apparent from a paper to the CQC Board Meeting on 17 September 2014 about updating the Provider Handbooks is that the new rating system is a complex beast that will tax CQC’s staff in the extreme. We are told that it is a combination of ratings principles (not rules) to ensure consistency balanced by inspection teams using their professional judgement.
Some of the proposed ratings principles are as follows:
- If two or more of the five key questions are rated “inadequate”, then overall the aggregated rating will normally be inadequate;
- If one of the key questions is rated “inadequate”, then the overall rating will normally be limited to “requires improvement” at best;
- If two or more of the key questions are rated “requires improvement”, then the overall rating will normally be “requires improvement”;
- At least two of the five key questions would normally need to be rated “outstanding” and three “good” before an aggregated rating of “outstanding” can be awarded.
There are additional principles in relation to the aggregation of the “requires improvement” and “inadequate” ratings which you will be pleased to hear are outside the scope of this general article.
Anyway, what all this means is that “outstanding” will be very hard to attain. None of the hospitals rated by CQC have attained “outstanding” and of 238 adult social care locations that were inspected under the pilot only 7 were judged outstanding i.e. 3% of the total. For practical purposes, the “good” rating will be the more attainable one and providers will wish to avoid “requires improvement” and “inadequate” ratings for obvious commercial and reputational reasons.
At the non-compliant end of the rating spectrum, CQC has stated that where it issues a compliance action, the rating linked to the area will be limited to “requires improvement” at best. Where enforcement action is taken such as issuing a warning notice or imposing a condition of registration, the rating linked to the area of the breach will be “inadequate”.
In the paper to the CQC, there are the following examples when inspectors may use their professional judgement:
- Where the concerns identified have a very low impact on people who use services;
- Where CQC has confidence in the service to address concerns or where action has already been taken;
- Where a single concern has been identified in a small part of a very large and wide ranging services;
- Where a core service is very small compared to the other core services within a provider.
These statements will be helpful to providers who have concerns about the proportionality of their particular ratings.
So where does this leave providers?
CQC states that it wants to ensure consistency for providers and inspectors in terms of how it measures quality (CQC’s key lines of enquiry) and what good looks like (the ratings characteristics). To achieve this, there will be no further changes to the core elements of the assessment frameworks “until all services have been comprehensively inspected and rated at least once.” Therefore, we are looking at the new framework continuing until April 2016 before any major changes are implemented. There will then be an evaluation by CQC to determine whether the bar needs to be set higher, so that “today’s ‘outstanding’ becomes tomorrow’s ‘good’, and today’s ‘requires improvement’ becomes tomorrow’s ‘inadequate’.” So from October 2014, providers should start counting down the days until the next set of changes are introduced to the ratings framework.
Given the uncertainties around the new rating system and the apparent limitations of the proposed rating review process (providers can challenge the process but not the merits based on what was described in the April 2014 Provider handbook consultation), it will be essential that providers scrutinise their draft inspection reports carefully to decide if there is a case to challenge CQC on the facts, the findings and the draft ratings. Timely legal advice will be essential in charting the new ratings territory. Please feel free to contact us at Ridouts. We’re here to help.