Avma’s response to the CQC’s consultation, ‘Better regulation, better care’

Agree

Agree

Avma is the UK charity for patient safety and justice, so our responses focus on the impact of proposed changes on patients and service users. Sector-specific frameworks are a good way to ensure that safety and quality are assessed in ways pertinent to the services provided, and we recognise that increasingly, as new models of care are developed and service users move through complex integrated pathways, it is important to provide clarity on different parts of the service. However, as part of the development process it will be crucial that thorough consideration is given to how services users will navigate and understand this information. There must be clarity for service users on what is assessed, as well as assurance of consistency of underpinning approach regardless of sector.

Strongly agree

Having supported patients for over 40 years, Avma knows that the public in general does not have in-depth knowledge of health service regulatory systems and processes. Often patients, service users, and family members only begin to look to understand these processes after something has gone wrong in their care and they begin searching for answers. The system is intricate and individuals can struggle to navigate this complexity, especially if they are also contending with physical or mental trauma.

It may be helpful if ‘patient-friendly’ versions of documents, including assessment frameworks, are available for those individuals who wish to understand this process. It would also be helpful if there are clear explanations, with graphic or video explainers to expand accessibility where possible, to understand how the various parts of the regulatory process connect to deliver a provider rating, and what that means for patients.

Agree

Avma often sees that patient safety concerns can be raised in organisations with very good records of care. We also know that a high number of patient safety reports is not necessarily indicative of a poor service, but can be evidence of transparency when working in an inherently high-risk and unpredictable environment like healthcare. Our focus is ensuring that the approach to rating, and those assessing them, is sensitive to this.

Avma sees that the responsivity of organisations to patients and families after avoidable harm, their ability to listen and engage, and their willingness to learn are key indicators of the level of the care provided. Avma and the Harmed Patients Alliance have worked together to develop a Harmed Patient Pathway which sets out the kind of response patients and families should receive after harm.

Avma also wishes to highlight the crucial importance of listening to patient voices and experience as part of the rating process. Ultimately, service users are a crucial indicator of the care provided. Impartial, professional judgement is necessary, but this must be informed by reliable patient and service user insights. Some of this data could also be derived from medical examiner reports, which provide a mediated and independent view of specific patient events.

Avma strongly agrees with the proposals outlined in the consultation document. Our only comment would be that patients and service users need to be able to clearly understand this work and why it is important, so thought should be given to how best to communicate these processes.

Avma is pleased to see that the CQC is clear that its judgements should not be affected by evidence or other ratings that are significantly out of date; it is crucial that ratings accurately reflect the services provided. We also understand that there is a balance to be struck in achieving a reporting cycle which is proportionate and suitably agile.

However, we do have concerns that when planning assessments and their frequency, especially in large organisations offering multiple services, the CQC will “normally prioritise services with lower ratings”. We are concerned that a rating given at one moment in time is not an indicator of current services, and in fact that it could be possible that a perceived lack of pressure due to the minimised likelihood of reinspection inferred from currently held status could disincentivise continuous improvement. This approach could be seen to encourage higher performing services to rest on their laurels. Higher performing services should be held to the same level of scrutiny as lower performing services, and frequency assessment should not be determined by a previously held rating.

More generally, it is perhaps a useful juncture to consider the intelligence and data CQC reviews and how this might inform ongoing inspection timings. We know the CQC collects a range of data about those they regulate and can use this to trigger an unannounced inspection if a material drop in performance or serious concern is highlighted, but what data do they hold which could be considered and reviewed to create more recent snapshot of service provision when determining which services are prioritised for planned inspections?

Mostly support

Partly support

Avma knows that what patients need most is clear, accurate information about the services they are accessing and the organisations providing them. They also want assurances that when things go wrong, action is taken to reduce the risk of it happening to others. This means a responsive regulatory system which accurately reflects the conditions patients and service users can expect to encounter.

There is some merit in providing an overall quality rating and trust level ratings for all key questions, insofar as it provides a simple overarching indicator. For some patients, this information will be enough. Avma also recognises the importance of organisational culture, which should be driven at a trust-wide (board) level. We can see how clear ratings of performance at this high level can help in driving forward positive change.

However, we do harbour some concerns that a focus on high-level ratings could mask small areas of poor performance. The CQC will need to diligently ensure that this isn’t the case. Avma understands the rationale for no longer aggregating key question ratings to produce an overall rating for individual hospital sites. Increasingly, patients present with complex care needs which are treated across teams and pathways cross multiple hospitals. We also see the need to make the ratings systems clearer for patients. We think that ratings for separate services should remain so that patients can understand the quality of the services they need to access based directly on the condition they require support for. This provides a more useful indicator for patients when considering their own care and treatment options. When avoidable harm has occurred, they will also feel assured that the CQC will look at how patients like themselves are provided for and treated.

As outlined above, Avma has worked with patients and service users for over 40 years. The complexity of the health system to the public, especially the regulatory landscape, should not be underestimated. Even the difference between a trust and hospital site is not routinely understood. Any vulnerability is likely to be further impacted by this complexity and the CQC should focus on how to best explain their work to the public, especially those more vulnerable individuals, so they understand what ratings mean and how they can contribute their experience to help the CQC in their assessments.

There are evidently more challenges for people with a multiplicity of conditions or whose care traverses various services, sites, and organisations. There is a need to assess how well peoples’ information flows between the different services and locations. Services cannot work in silos.

Avma would also like to highlight the breadth of apps and web-based services provided to NHS patients and service users. NHS providers are also increasingly making information of variable quality (in terms of accuracy, being up-to-date, navigable, searchable, etc.) available online. Increasingly, these apps and services form a part of patient experience, and we expect this trend to continue with increased adoption of AI and the NHS app. The CQC must consider the quality of these services as part of assessments and pay close attention to the impact they can have on patient experience, and the experience of those who cannot access services in this way.