A new strategy for the changing world of health and social care - CQC's strategy from 2021

We have a baseline understanding of quality across health and social care. But we know that the quality of care can vary from day to day. We’ll use our regulatory powers in a smarter, more proportionate and consistent way to make the right decisions and take the right action.

• Our assessments of quality will be different. On-site inspections are a vital part of our performance assessments and essential to observe the care people receive. But they are not the only way to assess quality: we want to move away from relying on a set schedule of inspections to a more flexible, targeted approach. To do this, we’ll use all our regulatory methods, tools and techniques to assess quality.
• We’ll build stronger relationships with services and with local systems. This includes having ongoing conversations about quality, which will give us a better insight and enable us to tailor our approach to be more proportionate.
• We’ll visit when there’s a clear need to do so. For example, this could be when we’re responding to risk, where we only have limited data or we need specific information, where we need to speak to people using the service face-to-face, or to ensure that our view of quality is reliable. For some types of service, we’ll need to visit more often to observe care. Our continuous insight and monitoring activity mean that rather than spending time looking at paperwork when we’re on site, we’ll be able to make the most of our time – we’ll have better conversations with people who live in or use the service, and their families and advocates, and more time to talk with staff.
• We’ll build digital platforms that will better integrate the data we hold, which will enable us to interpret data in a more consistent way. We’ll use innovative analysis, artificial intelligence and data science techniques proactively to support robust and proportionate decision-making, based on the best information available.

Our ratings will be more dynamic – we’ll update them when there is evidence that shows a change in quality. We won’t always need to carry out an inspection to do this.

• Ratings will evolve to reflect how people experience care so they’re more meaningful and focus on things that matter to them. We’ll be clear about what information we use and how we use it in our judgements and decisions about ratings.

We all have a common drive to improve people’s care. From the point of registration, we’ll develop ongoing, collaborative relationships with services, built on openness and trust. We want this to enable effective and proportionate regulation so we can focus our work where quality needs to improve and minimise any unnecessary workload.

• We’ll work with service providers and other regulators and partners to coordinate data collections. To reduce the duplication and workload for services in collecting and submitting data to us, and to other organisations, we’ll only ask for the information we need and that we can’t get elsewhere. We’ll use information from other sources and share the information we gather ourselves through data-sharing agreements. We’ll collect data once and use it many times. We want this to help staff to focus on providing care safely and finding opportunities to improve.
• We’ll improve the way we connect with services digitally. Starting from the point of registration, where we do need to collect information directly we will make it easier for services to give us the information we need and simpler to update what they’ve already told us. We’ll also make it easier for services to access more of the information we hold about them by having it in one place.

We want everyone we work with to benefit from our regulation. The way we regulate will become more constructive and supportive – using what we know to help services to tackle problems early and providing up-to-date, high-quality information and ratings.

• We’ll share the data and information we hold on services with organisations that represent or act on behalf of people who use services, and with our partners and others where it will help them in their own work to improve people’s care.

Like the services we regulate, we’re evolving and adapting to changing models of care, such as integrated care systems and digitally-enabled care. The move to looking at how services work together in a local system is a change in our approach that better reflects how people experience care – we think this is a smarter way to regulate.

• We’ll work with service providers, partners and other regulators to align our activity, understand how care is changing and ensure that our regulatory model keeps pace with changes.
• By improving the way we register services, we’ll be better able to hold organisations to account for people’s care. We’ll expand our definition of what we consider to be a provider of care and what it means to carry on a regulated activity. This will make sure that we register all the parts of an organisation that are responsible for directing or controlling care; and importantly, this will make sure they can be held accountable.
• Our assessments will always focus on what matters to people as they access, use, and move between services. We’ll also look more closely at aspects that we know have a positive effect on quality such as the culture of a service, how it works with other services in a local system, and how it drives improvement.
• We’ll focus our assessments on how services and local systems are working to ensure equal and appropriate access to good health and care services for everyone. The information we gather will enable us to better understand the risks of inequalities in people’s experiences of their pathway through care and their outcomes. We’ll take action where we see a need for improvement.

We want our ratings and information to help people to make informed choices about their care, and to give services an assessment of their quality to encourage them to improve.

• We’ll use our clearer definition of quality as a reference for what good and poor care looks like. We’ll explain clearly how we use this to assess the quality of services and how we decide what information to collect as evidence. This definition will be at the heart of our regulatory processes and will help us improve consistency in what we do – so people can be confident that good means good wherever they are in the country and whichever service they are using.
• We’ll move away from long reports written after inspections, and instead provide information and data to better meet the needs of all audiences, including people who use services. Information will be easier to understand and more accessible. We want people to be able to get information in ways that suit them.

Having the right organisational culture is crucial to improving safety. This means safety must be a top priority for all – regardless of seniority or role. A strong safety culture needs everyone working in health and care, as well as people who use services, to play their part. In a strong safety culture, risks aren’t overlooked, ignored, or hidden – and staff can report concerns openly and honestly, confident that they won’t be blamed.

• We’ll work with others to agree and establish a definition and language about safety and how this could apply in different health and care services. This will create a better understanding of risk across all health and care – so that we all know what’s not acceptable – and therefore help to reduce avoidable harm, neglect, abuse and breaches of human rights. When we talk about safety we’ll make sure it reflects what’s most important to people when they use services. More clarity will enable services to prioritise the essentials and have clearer expectations when we assess them.
• We’ll be looking for cultures that have learning and improvement at their core. In a good safety culture, it’s accepted that all incidents – positive, negative, or wholly avoidable – provide opportunities to learn and improve. It’s important that we also embody a learning culture and demonstrate this in our relationships with providers and all our work.
• Our assessments of safety will have a sharper focus on checking for open and honest cultures. We’ll encourage health and care staff to speak up about safety issues where they work, including where there may be safeguarding issues. We’ll expect all services to have stronger safety and learning cultures and that learning, and improvement should be the primary response when anyone speaks up. We want staff to feel confident that we’ll also listen and act when they raise concerns with us, and we’ll intervene quickly where appropriate.
• We can do more to help services improve safety by sharing the insights, learning, and exemplary practices that we’ve identified. We’ll use our independent voice to highlight the changes and improvement that services have made to improve safety as a direct result of our regulatory actions.

Knowledge is crucial to having the right safety cultures, but there are different levels of knowledge and expertise in different types of service and sectors.

• We’ll look at how services and systems assure themselves that they have the right knowledge and expertise, and how they are investing in improving safety.
• We’ll improve and increase our own safety expertise in CQC to ensure our approach is in line with the latest safety thinking. Together with our unique data and insight, this will enable us to challenge and highlight failures in services and in systems.

People should be able to influence the planning and prioritisation of safe care and be truly involved as equal partners in their care at all levels. This collaborative approach has the potential to transform safety and to ensure that people’s human rights are upheld.

• In our assessments we’ll look for processes to show that leaders and staff are committed to involving people in their own safety throughout their health and care journey, and the impact this has on their outcomes. We’ll check that services actively take into account people’s rights and their unique perspectives on what matters to them in the way they choose to live their lives and manage risk. This includes having the information they need to help them be equal partners in their care and play a part in their own safety.

We know that some of the greatest safety risks – both physical and psychological – happen when people struggle to access the right care, when they’re transferred between services or after they’re discharged. We also know that some services are more likely to have greater safety risks than others.

• We’ll review how effectively we are assessing and monitoring safety – from registration through to enforcement. We’ll use our improved safety expertise to make sure we’re taking the right approach. As part of this, we’ll review how we gather data to ensure greater consistency across sectors regardless of who it is reported to.
• Learning and improvement must be the primary response to all safety concerns in all types of service and local systems. Where we have concerns, we will direct services and systems to respond and show us – and people who use the services – what action they’ll take to learn and improve. We’ll share this information with the public as part of our up-to-date view of quality.
• Services that are not open to learning can’t be safe. We’ll use our powers and act quickly where improvement takes too long, or where the changes won’t be sustainable. We’ll take action where services are unable to identify systemic issues in their own organisational culture or fail to learn lessons from widely publicised failures happening across health and care.
• We’ll change how we regulate safety in all services to reflect new ways of delivering care and as more services work as part of a local system. We’ll check how well services work together – those that are truly focused on safety will be determined to ensure a safe journey of care for people moving on to a different service, or when being transferred between services for ongoing care.
• Where we see systemic safety issues in a local area, we’ll speak out to encourage meaningful change. We’ll share the learning from our insight on themes, trends, and best practice to help services and local systems improve their safety. We’ll also share with regional organisations our data and information about safety in local systems, to support their oversight of safety in their area.

To improve safety, service providers may need support and guidance. In some sectors, there’s a national team of experts who provide guidance and alerts about safety. But this type of national support and oversight doesn’t exist in all sectors.

• It’s crucial that all health and care services have consistent access to the right support and insight to help them build strong safety cultures, learn from safety and safeguarding incidents, and improve their practice. We’ll work with others to develop solutions to ensure that all services have support and leadership during difficult times, and that they have the right tools to always provide safe care. We’ll need to understand where this oversight is best placed and develop the right frameworks as needed.
• We’ll use our insight and independent voice to promote a national conversation on safety across health and care sectors and systems. We can use this to drive improvements in safety cultures and reduce harm.

The support that’s available to improve the quality of care varies between and within health and care sectors and across England. We’ll work collaboratively to support all parts of a local system to focus on improvement.

• Where there are gaps in improvement support, we will facilitate national improvement coalitions with a broad spectrum of partners within both health and adult social care, including those representing people who use services. These coalitions will work collaboratively to improve the availability of support, both nationally and at a local system level. This will build on existing partnerships and programmes around improvement rather than duplicate efforts. We’ll champion consistent access to direct, tailored, hands-on support for all services who need it.
• Local systems need to drive improvement in their areas. We will support these efforts and assess how well they are doing this, including how well they are ensuring everybody has fair and equal access to care, an equally good experience and good outcomes. We’ll strengthen our ongoing relationships at a local level to promote collaboration on improvement across areas, working with local and national partners from the relevant improvement coalitions.

We want to see improvements that benefit people. We’ll play an active part in this by setting clear expectations and empowering services and local systems. But we’re clear that while enabling access to support, we will retain our core regulatory role, which means using our powers to act where we see poor care.

• We’ll encourage continuous improvement in quality by being clearer on the standards that we, and people who use health and care services, expect. Services and local systems will need to demonstrate a culture of improvement and contribute to improvement in their local area. As part of this, we’ll expect them to address inequalities in access, experiences and outcomes.
• We’ll develop collaborative relationships with services, helping them to find their own route to improvement. This will involve facilitating access to improvement support and pointing services to sources of guidance, best practice, and other providers and organisations that can offer advice and support. We’ll hold improvement conversations with services and offer a range of resources to support them to decide for themselves the best way forward rather than telling them what to do. We will develop our skills, capability, and culture to enable this shift.
• In collaboration with others we'll identify the areas that need to improve as a priority – both at a local and national level. Using our independent voice, we’ll deliver a programme of activity to drive change in these areas, based on evidence of what works. We’ll share good practice and examples of the factors that drive improvement, and the findings from our in-depth reviews. We’ll prompt action through events and workshops, and by publishing guidance, tools, and frameworks that support improvement.
• We’ll empower services and local systems to improve themselves by offering analysis and benchmarking data. This will enable them to self-assess how they’re performing against similar services and areas. Our benchmarking information will also show us where we need to focus our work to drive improvement.

Innovative practice and technological change present an opportunity for rapid improvement in health and care. We have a role in creating a culture where innovation and research can flourish.

• We’ll encourage and champion innovation and technology-enabled services where they benefit people and where the innovation results in more effective and efficient services. We know the path to innovation can be difficult; we want to use what we know as a regulator to create an environment where services can try new ways to deliver safe, high-quality care. We’ll aim to support their efforts to innovate through clear advice and guidance.
• We’ll understand and keep pace with changes, both in new technology and new ways to deliver care. We’ll work in partnership with services and other stakeholders to develop a coordinated, effective, and proportionate approach to regulating new innovations and technology. When we do this, we’ll consider where the use of new technology to deliver care might not suit some people, and what services need to do to make sure that nobody is disadvantaged.
• Research can help improve the quality of care, and people often value the opportunity to participate in research, whether clinical trials or other studies. We’ll encourage services to play an active part in research to improve care for all, foster innovation and enhance people’s experiences of care.

We have valuable knowledge and insight about improvement – we’ll use this to inform our regulatory approach.

• We want to promote an improvement culture across health and social care. Through our assessments of services and local systems, and across all our work, we’ll identify and investigate the things that are most important to ensuring good quality care. We’ll use the evidence we collect to support improvement.
• We’ll invest in research and make better use of external evidence to have a better understanding of the conditions that drive quality improvement, including evidence and best practice from other industries. We will also strengthen our evidence on the extent and nature of inequality in people’s experiences of care, and the good practice to help reduce this.
• We’ll use the best available evidence to inform our approach to regulation. We’ll develop and extend our own internal improvement activity and capability. As part of this we will embed a culture of learning and evaluation in CQC to maximise our impact on the quality and outcomes of care for people.