On 9 April 2014, CQC issued for consultation its Provider handbook for NHS acute hospitals. The consultation runs until 4 June 2014. The major change being consulted on is the new rating system for NHS hospitals. The shadow ratings which are currently being awarded will be replaced by full ratings from October 2014. What is not in dispute is the need to inspect and report on NHS hospitals in a thorough and fair manner, while providing the public with a means of understanding how well their local hospital is doing relative to others. The problem is that NHS acute hospitals are large, complex organisations in which standards can and will vary from service to service and from day to day.
A rating system might just about work for a care home but how can you implement an effective rating system for an NHS acute hospital trust? With considerable difficulty is the answer. The CQC proposal will see 6 levels of ratings generating multiple judgements. Each NHS hospital providing all eight core services will be awarded 54 ratings. At the Trust level there will then be a further 5 ratings culminating in an overall rating of inadequate, requires improvement, good or outstanding. An acute trust with three full service hospitals will have a total of 167 ratings which somehow will translate into an overall trust rating.
CQC has tried hard to present a workable rating system but close scrutiny raises more questions than are answered. When the handbook talks about inspection teams following “an algorithm…to ensure consistent decisions” you know it is going to be a challenging read. In fact, all it means is a set of principles will “normally apply.” CQC inspection teams will balance the algorithmic approach “using their discretion and professional judgement in light of all the available evidence.” There appears to be a degree of confusion on the part of CQC about its approach to ratings given that it states in its report “Our new approach to the inspection of NHS acute hospitals” published on 6 March 2014 in relation to shadow ratings, “Note that our approach to ratings uses judgement in aggregating ratings, rather than adopting an algorithmic approach.”
What CQC appears is saying is that it will apply some general rules on ratings but judgements will inevitably have a subjective quality to them. That is only being honest and there is much to be said for avoiding arbitrary schemes that produce nonsensical results. However, the consultation document does not instil confidence that CQC has a firm handle on how ratings will be applied. Vague and impenetrable statements are made about the rating system without any clear exposition as to how a rating at a particular level might be arrived at. There are some high level key lines of enquiry but nothing specific about the 8 core services. When they come to publish the final version in September 2014, CQC really does need to set out the guidance clearly and succinctly.
The King’s Fund and Manchester Business School published a report on 19 March 2014 which discussed the impact of the ratings system in the Waves 1 and 2 inspections. They commented on the fact that there has been ‘relatively little guidance in the inspection framework on how to arrive at these judgements and ratings’ concluding that ‘the process of reaching judgements and assigning ratings was largely implicit.’ Ratings lacked consistency as ‘domains and grade descriptors were interpreted differently within and across inspection teams.’ It is little wonder that CQC has put in place a“national quality control and consistency panel” to review ratings in draft inspection reports to try to achieve a degree of consistency.
First and foremost there needs to be a genuine review structure to challenge unmerited ratings. CQC will say that there is to be a rating review process so the sector should not fear an unaccountable regulator. However the reality is very different. The first point to note is that the rating review process will only be available to a provider after publication of the inspection report and following a quality summit at which a high level action plan will have been discussed and thrashed out. With some justification, a chief executive might say it is not worth challenging a report that has already been placed in the public domain. Secondly, a review can only consider cases where the inspection team has failed to follow published policies and procedures and even then only ratings in relation to levels 1, 2, 3 and 4 (at the hospital level) not levels 5 and 6 (at the trust level). A trust, therefore, cannot challenge ratings on the merits or at trust level, based on the current proposals. How can this represent a fair and accountable review mechanism?
So how should acute providers respond? We would highlight the following:
- Acute providers must prepare for the inspection conscientiously and effectively. Inaccurate or misleading information in the data pack supplied in advance of the inspection should be challenged. Trusts should supply information that properly reflects the operation of their services.
- Trusts should participate fully in the inspection visit and not passively watch from the sidelines.
- Careful scrutiny should be given to the contents of the draft inspection report. Trusts should not challenge for the sake of it but inevitably on inspection there will be matters of dispute. Inaccurate facts and unjustified judgements and ratings should be challenged at the “factual accuracy” stage. The public would expect no less. Indeed, CQC states in thehandbook, “Trusts cannot request reviews on the basis that they disagree with the judgements made by the inspection team, as such disagreements would have been dealt with through the factual accuracy checks [and warning notice representations]”.
It is apparent that CQC, Monitor and the NHS TDA are working closely together in fulfilment of the shadow “single failure regime” which will become statutory once the Care Bill becomes law. More services than ever before are being placed in special measures. The CQC Chair, David Prior, recently went so far as to say that up to 30 trusts might end up in special measures.What CQC says will be treated by Monitor and the NHS TDA as the “single version of the truth”. The stakes are higher than ever.
Providers should not be lulled into a false sense of security that ratings can be challenged at the end of the process when the report will have been published and damage done to the reputation of the trust and its senior officers. Prepare for the inspection, watch out for the draft report and take action, as necessary. Your future and that of your services may depend on it.