Regulating in a complex changing landscape

04 September 2017

The BGS has submitted this response to the CQC's proposed changes to the way that health and social care services are regulated. The consultation includes consideration on how best to register, monitor, inspect and encourage improvement in a changing healthcare environment.

The British Geriatrics Society (BGS) is the professional body of specialists in the healthcare of older people in the United Kingdom. Our vision is for a society where all older people receive high quality, patient-centred care when and where they need it. This informs and underpins all of the comments in our consultation response.

We recognise the benefits of including on the CQC’s register all those with accountability for care. We believe that the proposal to extend accountability, and make the information that reflects this wider accountability more accessible, will help to drive good practice and be of real value to older people, their families and carers, as well as for professionals and the wider public.

However, we also recognise the need for these changes to registration requirements to be as straightforward and simple as possible in order to avoid any unnecessary burden on organisations that are already accountable to multiple regulators.

Criteria for identifying organisations that have accountability for care

Making it easier to register new organisational forms and innovative types of services is welcome. We are pleased that this will better recognise the reality of the complexity of service provision across health and social care.

Our members work with patients, their families and carers who are frequently in the position of having to navigate their way through a range of service provision in order to identify and access the care they need; for example, when social care is needed and they are self-funding. Being able to see the history of a service when it comes under new ownership, or when new contracting arrangements are introduced or other changes occur is therefore a welcome step to increasing accountability and transparency.

BGS recognises that such an approach is of value to the CQC in its regulatory role as well as in increasing transparency. We view the proposed changes to criteria for identifying organisations as an important development which we hope will play a part in driving up standards of care.

As a UK-wide membership charity we hope that CQC will be working with its sister regulators to ensure a similar approach to identifying organisations that have accountability for care is introduced in Scotland, Wales and Northern Ireland.

Specific information about providers should be displayed on our register?

We welcome the move to fuller information being available on the CQC’s register.

We would like the register to show some form of information about person-centred care. We are conscious of the potential for the questions asked by the CQC, which provide the content of the register, to act as a ‘nudge’ and to influence change over time. We would be very happy to meet with the CQC to discuss ways in which the quality of care for older people living with multiple long term conditions might be better reflected on the register through the development of some new questions to providers.

Monitoring and inspecting new and complex providers

Proposals to monitor and inspect complex providers that deliver services across traditional hospital, primary care and adult social care sectors

BGS welcomes any regulatory change which supports better coordination and integration of services. A more joined-up approach to monitoring and inspection supports the need for fully integrated health and social care services which BGS has been calling for. For older people living with frailty their treatment is planned and delivered by multidisciplinary teams who face the constant challenge of needing to work across a mix of health and social care settings. Our members work across sectors, for example a geriatrician may have a post where they spend half their time working on acute hospital wards and half their time working in the community, including with older people living in care homes. We believe the proposed approach supports NHS England’s Five Year Forward View and the journey towards integrated services.

Provider-level assessment in all sectors to encourage improvement and accountability in the quality and safety of care

What factors should we consider when developing and testing an assessment at this level?

A provider-level assessment should have a strong focus on the extent to which the provider is delivering person-centred care for older people.

This should apply to assessments across the range of settings. For care homes we recommend that our guidance on Effective healthcare for older people living in care homes is taken into account in CQC’s changes to assessment and rating.

Encouraging improvements in the quality of care in a place

How could we regulate the quality of care services in a place more effectively?

BGS welcomes the focus here on integration across local areas. Close collaboration and an integrated approach across providers play a critical role in ensuring positive health outcomes for older people with frailty whose health can deteriorate quickly. For information we have attached a link to a recent report we published jointly with the Royal College of GPs: Integrated care for older people with frailty The report provides examples of the innovative ways in which geriatricians, gps and other healthcare professionals are collaborating in order to improve healthcare for older people. Some of these new ways of working together should be taken into account in considering the role of regulation in helping to support improvements in the quality of care across a local area.

We also believe that more use of some of the existing data will increase regulatory effectiveness; for example the National Audit of Intermediate Care carried out by NHS Benchmarking is a valuable source of evidence. Their audit shows that 92% of people maintained or improved their dependency score when they accessed intermediate care in community settings, and 93% maintained or improved their dependency score in bed-based intermediate care. The critical role of occupational, physio and speech therapists needs to be prioritised and taken into account in the regulation of care services at area level.

BGS welcomes CQC’s plans to use its regulatory knowledge and insights to inform Sustainability and Transformation Plans (STPs). Our view is that the development of an approach that supports an overview of quality across national and local areas is one of the levers needed to improve quality of services and support a strategic approach to doing so.


2.1 Primary medical services

Proposed approach to inspection and reporting in GP practices?

We welcome the continued focus on assessing and rating the quality of care for different population groups. One of the specific ways in which quality improvement in the health care of older people will occur is for anyone working with older people to have the right skills, training and specialist expertise to meet the needs of older people with frailty, dementia and complex long-term conditions. We would like assessment to include criteria on specialist training in older people’s healthcare.

We recommend the inclusion of an assessment of the use by GPs of an appropriate tool, such as the electronic Frailty Index (eFI) to identify frail patients, to keep a register of the number of people with a diagnosis of moderate frailty and those with severe frailty. This should include a record of the number of people with severe frailty who have annual medication reviews, have fallen within the past year and who have provided consent to a summary care record. As this requirement has only just been introduced into GP contracts (July 2017) it offers an ideal opportunity for CQC to monitor from the outset the way in which it is being followed.

Proposal to rate population groups using only the effective and responsive key questions? (Safe, caring, and well-led would only be rated at practice level.)

We have reservations about the proposed move to rating each population group against only two of the key questions for a comprehensive inspection of a GP practice, although we recognise that it would make the final report simpler and easier to follow. We know that patients particularly value a caring approach and therefore have concerns about this question being dropped.

Proposal that the majority of our inspections will be focused rather than comprehensive

We welcome the CQC’s proposed move to intelligence-led regulation. We see it as a positive development which will better support the identification of those issues most likely to be of regulatory concern. However we recognise the complexities involved in developing this approach, and the expertise required to make it genuinely effective.

BGS would be very happy for CQC to call on our members’ expertise to help inform the development of the indicators that will be needed to inform some of the data analysis that will help to prioritise the focus of inspections, and generate regulatory insights that inform improvements in the quality of healthcare for older people.

Proposed approach for regulating the following services

i. Independent sector primary care

ii. NHS 111, GP out -of-hours and urgent care services

We welcome the consistency of approach that is proposed, so long as the independent status of independent primary care services is clear to the public. Improvements in the coordination of regulatory activity across a range of providers within a local area is also welcome. It is helpful to see the timetable for implementation.

2.2 Adult social care services

Proposed approach to monitoring quality in adult social care services, including our proposal to develop and share the new provider information collection as a single shared view of quality

We do agree with the approach, but we think it will take more than a change in regulatory approach to tackle the fundamental structural and funding issues that the social care sector faces and we have been calling for a review. We hope that CQC will use its voice and expertise to support the widely called for review. At present we are looking forward to the publication of Government’s response to the report from the House of Lords Inquiry into the long term sustainability of health and social care which included a review as part of its recommendations.

As with the proposed approach to health we believe the use of data and insights is a sensible way to drive improvement. We are concerned at the length of time it may take before it begins to bear fruit. However, we acknowledge that collecting and analysing the data will take time and do not see a way of significantly accelerating the process.

We support the flexible approach whereby the comprehensive inspections may be maintained alongside the more focused inspections that arise from the insight programme.

Proposed approach to inspecting and rating adult social care services

The proposals are positive and we very much hope they will contribute to better health outcomes for older people using adult social care services.

Proposed approach for gathering more information about the quality of care delivered to people in their own homes, including in certain circumstances announcing inspections and carrying out additional fieldwork

At present our members witness on a daily basis the challenges that face older people and the negative impacts on their health, when discharge from hospital is delayed because of difficulties in accessing social care services. It is not only the availability of social care but also the quality which is a key concern to BGS. Many older people are very reluctant to seek outside help. If when they do, the help they receive from social care providers is inconsistent, unreliable or uncaring some people will refuse the help and live with a high risk of a health crisis that is likely to lead to an unplanned emergency admission to hospital. We acknowledge the challenges of gathering information about the quality of care delivered in people’s own homes, but consider it to be an essential and critically important part of the CQC’s regulatory role.


Proposal to share all information with providers

The BGS agrees.

Whether or not this change is likely to incur further costs for providers is not within our area of expertise. On the proposed guidance for providers on interpreting what is meant by “serious mismanagement” and “serious misconduct”, we believe that it is crucially important that providers understand the key distinction.