CQC’s assessment of integrated care systems: what you need to know

Developing an assessment approach for systems

• The CQC’s new single assessment framework applies to providers, local authorities and ICSs. Some elements of the old framework have been retained, including ratings and the five key question: Safe, Caring, Effective, Responsive to People's Needs, Well-led. Quality statements focus on specific topic areas under each key question, replacing the key lines of enquiry (KLOEs), prompts and ratings characteristics contained in the previous provider assessment framework. Six new evidence categories are used to organise information under the statements.
• The CQC’s interim guidance sets out the overall framework for its oversight of ICSs, focusing on the initial baselining period. The aim of the assessment framework is to understand how ICSs are working to tackle health inequalities and improve outcomes for people. To understand this, the CQC will look at how services are working together within an ICS, as well as how systems are performing overall.
• The CQC's reviews of ICSs will take into consideration their four statutory purposes and will focus on three themes: quality and safety, integration, and leadership.
• From April to July 2023, the CQC will pilot its new assessment approach, starting to form a national view of performance, initially focused on themes in the quality statement on ‘equity in access.’ These findings will inform the annual State of Care publication. All baseline ratings will be completed within two years.
• The CQC is working closely with DHSC on how to deliver further assessments beyond this point.
• In time, the CQC’s teams will be able to see all the data and insight they need on one digital platform, allowing them to focus on risk and improvement.
• The guidance will be built on in collaboration with stakeholders as the CQC develops its model over the coming months and transitions to ongoing assessment. It will form the basis for the more detailed end-to-end guidance later in the year.

Focus of the approach

• The Secretary of State for Health and Social Care will set objectives and priorities for the CQC’s assessments, which it will then publish. They will be addressed as part of a wider assessment of the quality statements in the assessment framework.
• The CQC will look at the four purposes of ICSs and consider and report on the effectiveness of:

1. arrangements for place-level working within the system
2. variations in service quality
3. people’s experience
4. health inequalities and population health outcomes, and wider determinants of health across the system.
    

• As required by the Health and Care Act, ICS assessments will cover:

1. the quality and integration of healthcare and adult social care within each ICS
2. how partners in each ICS (the integrated care board, local authorities and registered service providers) are meeting their own responsibilities within the system 
3. the functioning of the ICS, especially how well system partners are working together to deliver good care and meet the needs of their populations, including through the work of integrated care partnerships.

Themes and quality statements

• The quality statements were developed based on the I and We statements in the Making It Real framework, to reflect people’s experiences and the standards of care they expect.
• The CQC will use the 17 quality statements across the three themes identified by the Health and Care Act 2022 to assess the requirements under the act and how ICSs are achieving their core purposes.

Evidence categories

• The CQC will use a range of information to understand the quality of care being delivered against each quality statement. This is organised under six evidence categories, which are used according to what is being assessed: people’s experiences, feedback from staff and leaders, feedback from partners, observation, processes, and outcomes.
• The evidence categories signal the types of evidence the CQC uses to understand the quality of care being delivered against each quality statement. The evidence categories required to assess each quality statement vary according to what is being assessed. 
• As part of its assessments, the CQC will consider evidence of the quality of health and care services provided across the area of each ICS alongside other evidence of the outcomes of system working. Ratings of individual providers will not directly determine the outcome of an ICS assessment, but will form part of the evidence used for assessments.
• The CQC’s assessment and inspection teams will share information about quality and partnership working within each ICS. Assessments will not directly inform ratings of individual providers, but in some cases, the evidence gathered during an ICS may form part of the evidence the CQC will use for assessing providers. For example, this evidence could be around partnership working or it could inform decisions about further assessment activity required at provider level.

How the CQC will assess integrated care systems

• Before moving to the new assessment model, CQC will first establish a baseline of completed initial assessments for each ICS. During phase one of adopting the new approach, the CQC will initially focus on further developing and embedding the assessment approach, gathering evidence, developing an understanding of relative performance across systems, and building relationships within each of the areas. The CQC will explore opportunities for themed reporting at national level during the first six months and if requested by government, can award ratings for all ICSs.
• During the second phase the CQC will begin formal assessment – gathering all required evidence for each ICS, reporting on findings and awarding ratings. The aim of the second phase is to complete all the initial assessments and award a rating for each one, to be completed within two years. 
• For the initial assessment, the CQC will start by assessing evidence it already has, such as data on the effectiveness of processes and provider performance. This will then be followed by evidence it needs to request, such as survey information held by ICSs on people’s experiences of care. Finally, it will move to assessing the evidence it needs to actively collect, such as on people’s experiences.
• While some evidence such as data on population health and service performance can be collected entirely off site, some evidence can only be collected on site. For example, observing meetings and understanding the culture and staff interactions.
• The CQC will use specialist advisers to inform its assessment activity to ensure reviews are informed by up-to-date and credible clinical and professional knowledge and experience.
• The scoring framework for ICSs is similar to the one used to assess registered providers. When assessing evidence, a score will be assigned to the relevant quality statement. An aggregate will be taken of the scores for each of the quality statements to produce a score for each theme and an overall score and rating. The overall rating will use the CQC’s four-point rating scale (inadequate, requires improvement, good, outstanding). Rather than rating all five key questions, the assessment and rating approach will focus on the context, aims and roles of ICSs.
• When initial assessments of ICSs are complete, the CQC will move to its ongoing assessment approach. This involves gathering and assessing evidence at different points in time and updating quality statement, theme level and overall scores and ratings as necessary. The ongoing assessment model will be informed by risk. If immediate risks are flagged, such as information of concern, this will trigger the necessary action to collect evidence. In time, the CQC’s teams will be able to see all the data and insight they need on one digital platform, allowing them to focus on risk and improvement.

Reporting and sharing information

• The CQC will work with ICSs, DHSC and other stakeholders on the best way to publish its findings.
• The CQC plans to publish reports on its website based on findings against the themes and for each quality statement. Reports will have a shorter and simpler format, focusing on information on what people have said about their experience and how this is used in assessments. They will include a narrative on areas that require improvement, areas of strength, and a commentary on the ICS’s progress.
• There will be a short period between assessment and publication to provide an opportunity for the organisations within an ICS to carry out a factual accuracy check and the CQC will share the draft assessment report with the integrated care board and integrated care partnership.
• Scores and ratings for ICSs will be published once the CQC has sufficient evidence and will include the overall rating, a score for each theme of the assessment, and a score for each quality statement. Whenever a rating changes this will be updated on the CQC’s website.
• The CQC will work with key national and local partners, including health and care providers, professional regulators, Healthwatch, community groups and the relevant health and social care ombudsman, to share data and to gather evidence.

Intervention and escalation

• The CQC’s assessment reports will clearly set out required improvement and best practice. Following the report, system partners (integrated care boards, local authorities, and providers) are expected to come together through a local system improvement summit to review assessment findings and publish action plans, which the CQC will monitor. Improvement summits are intended to be a forum to discuss the findings from the assessments. They also enable ICS leaders to: share learning, good practice and innovation; drive improvement; develop action plans; and work with national bodies where appropriate to secure an improvement offer of support to enable leaders to implement changes across the system.
• The CQC will also raise any concerns with national partners across health and social care (including NHSE, Local Government Association, the Association of Directors of Adult Social Services, DHSC or the Department for Levelling Up), recognising that lines of accountability are different for NHS organisations and local authorities. The relevant organisation will oversee support or make an intervention and, where appropriate, the CQC will help to identify improvement support.
• In its assessment of ICSs, the CQC will use the results of NHSE’s oversight and assessments of integrated care boards. When working together, CQC and NHSE will work to a shared view of quality, work to remove duplication by sharing data and co-ordinating on assessment activity, and focus on quality and how it is maintained and improved alongside financial sustainability.

Analysis

This updated guidance will provide some welcome clarity for ICS leaders ahead of commencement of the CQC’s new powers to assess ICSs from April. The CQC has co-created its new assessment approach with a wide selection of stakeholders, including the NHS Confederation and our members and it is promising to see much of the feedback from these engagements reflected in the interim guidance, including a strong focus on ICSs’ four purposes. It is encouraging that the CQC is taking a phased approach to assessing ICSs, which will allow it to build relationships within each of the areas - something which the NHS Confederation’s ICS Network can help facilitate. It will also allow time to develop the competencies and understanding needed to gain a clear picture of what ‘good’ looks like.

In our view, ‘good’ for an ICS is less about provider-level quality and much more about the extent of system working, strength of relationships, mutual accountability, and self-directed improvement processes including peer review – things which do not come through strongly in the interim guidance. It is welcome that the guidance makes clear that ICS ratings will not simply be aggregations of provider ratings. However, it is less clear how much weight provider ratings will be given as ‘part of the evidence used for assessments.’ Some ICS leaders have expressed concerns about that CQC’s view of system will be provider focused. We therefore hope that the CQC will expand on this in subsequent updates to this guidance.

Some of our members have also expressed concerns about the CQC’s current ability to effectively and credibly assess ICSs. It will need to ensure its staff have the skills, capability and capacity to add value in its assessment of complex ICSs. We would therefore like to see more detail on the CQC’s plans for organisational development.

It is welcome that the guidance references the CQC’s involvement in Patricia Hewitt’s review of ICS governance and accountability and commits to iterating the guidance in line with the review’s final recommendations. This should include the review’s specific recommendations on the CQC as well as the wider accountability structure.

Our members often report having to respond to duplicate data requests, which can act as a distraction from delivery. The pandemic showed that when this slowed down, healthcare leaders had much more headspace to focus on innovation and transformation. We therefore welcome the content in the guidance on enhancing the use of remote monitoring to create a real-time version of the truth, removing duplication and the need for set-piece inspections. We look forward to receiving more detail on the CQC’s approach to collecting and sharing data, including how it will develop its data competencies and work with NHSE and other key stakeholders to develop one version of the truth. It would be helpful to receive more information on the timelines the CQC is working towards in developing a single digital platform. The CQC’s approach should align with the Hewitt review’s recommendations on data and accountability.

Regarding data transparency, it is promising that the CQC will work with ICSs on the best way to publish its findings. We will be seeking clarification on whether ICSs will be required to prominently display their ratings, as is the requirement for registered providers. We have some concerns about the planned approach to ratings. As worded, the framework allows scope for the government to request ratings of ICSs ‘within two years,’ potentially opening up the possibility that ratings are introduced imminently. While ministers have discretion to impose ratings, we believe this should not happen until at least April 2024 so that the CQC can develop the necessary competencies, relationships and understanding of relative performance needed to ensure that ICS ratings add value. We also have serious concerns about an ‘Ofsted-style’ rating system of complex systems based on the four-point scale, which would offer little value and false reassurance – something we have fed back during the co-creation process. If formulated correctly, ICS ratings could become a useful improvement lever. The CQC should work closely with ICS leaders to determine how the rating will interact with provider ratings, which criteria could be used to draw a useful rating, and what the purpose of an ICS rating should be. The guidance mentions working with ICSs along with DHSC and other stakeholders on ‘the best way to publish our findings.’ In our view this should go further, including wholesale co-creation of the approach to ratings over the next year. Noting the intention to begin assessing local authorities from April, we would encourage the CQC to align its approach to assessing ICSs and local authorities as far as possible so that reviews can be complementary.

Finally, it is not clear from this guidance how the CQC intends to fund this programme of regulation. We will seek clarity on this and its implications for longer-term financial planning.