Like it or not ratings for CQC regulated services are here to stay. Most recently CQC has signalled its intention to roll out ratings for a number of additional services; which were previously inspected but not provided with a rating, such as substance misuse centres and independent community health service providers. But as this expansion of ratings is scheduled to be rolled out within the wider healthcare sector how much reliance should be placed on these perceived determinations of quality?
Quite apart from looking into how an inspection team has reached its findings in order to feed into ratings; the ratings themselves are by they very nature primitive in providing its reader with a comprehensive understanding of the quality of service provision. Since the ratings themselves are here to stay and will continue to be of increasing importance across all providers of care, irrespective of their specialism. It is wise for every provider of care to ready themselves to challenge findings of inspection teams in this increasingly simplified landscape where a provider lives or dies by virtue of their aggregated rating.
In order to successfully challenge a draft report, providers need to fully engage with the factual accuracy process which allows the provider to challenge the accuracy of the report as drafted. In our experience the most effective way of challenging the ratings is to forensically critique each line of the report and where there are grounds to challenge supply both the detail and supporting evidence to substantiate each claim.
An interesting legal decision is of relevance to this discussion (R (SSP Health Limited) v CQC) initially involved a judicial review challenge of the rating review process which is the next stage of challenge following the factual accuracy check process. Justice Andrews ruled in the case that there was a flaw in CQC’s internal processes, which whilst fair, was not always clear that processes had been properly followed. Justice Andrews further stated that the flaw in CQC’s processes where the provider is alleging that evidence is available which conflicts with that made within the report should be independently reviewed and evidenced as such. Justice Andrews stated that if she was to be asked to review the decision of the lead inspector in this case- where the decision inaccurately reflected strong evidence to the contrary submitted by the provider- she would have quashed the decision and reverted it back to CQC to review. Even this decision- which seemed at first to be a victory for providers who challenge the sometimes entrenched positions of CQC inspectors- is illustrative of the deference to the regulator in its decision-making processes, however they are conceived. CQC stated in response to this decision that it was already in the process of ensuring that its processes were adequately independently reviewed and it reflected this in its guidance to the factual accuracy process. It is still akin to marking your own homework irrespective of how independent the reviewer may claim to be; there is a possibility, which I would suggest is likely, that deference will be shown internally at CQC to the lead inspector’s findings.
The process of challenging a rating following the factual accuracy process stage is a ratings review which the earlier case mentioned focused on. It is of little consequence since this process of review does not deal with any substantive challenges over and above those which might be asserted in relation to the inspection team failing to follow its own processes.
Returning to the ever-presence of ratings within the healthcare sector it cannot be stressed strongly enough of the importance of challenging the factual basis upon which ratings are loosely based. It may sound flippant to refer to the basis of ratings in this manner but ratings, at times, appear to have been reached first and the evidence drafted in such a manner so as to support such a finding. It follows that there is an element of cherry-picking data which reinforces the inspector’s opinions about a service.
This is the system that health and social care providers are working within, soon to be joined by a larger cohort. The most important stage in challenging these ratings is properly engaging with the factual accuracy process, which despite its flaws, presents the provider with the best chance post-inspection, of ensuring that the rating is as high as possible. Ensuring that the underlying detail contained within the report is accurate should also be prioritised since they can be used as evidence of a history of non-compliance if not challenged. Whilst ratings often appear to misrepresent the actual quality of service provision; it is within this framework which healthcare providers must engage to protect their position.
