CQC’s strategy from 2021: equality impact assessment

We have published our new strategy.

Our purpose has not changed – we’ll always be committed to ensuring people receive safe, effective, compassionate, high-quality care, and encouraging improvement. But we need to make changes to the way we regulate so that it’s more relevant and has positive outcomes for everyone who receives care. We need to be more flexible to manage risk and uncertainty. This is because:

• Health and social care services are evolving rapidly, with new ways of working in partnership across different sectors. It’s now more important for health and care services to work together as a local system to deliver care – to meet the needs of the local population and of each individual person. 
• People are living longer, often with multiple, long-term conditions, which means delivering care is increasingly complex. We must adapt and work in new ways to look at the quality of people’s care on their journey through the health and care system – in individual services and across different providers and organisations.
• There’s still inequality across different areas of the country and among different groups of people, in how they can access health and care services, how they experience care, and their outcomes. The COVID-19 pandemic has renewed the need to tackle these inequalities.

Tackling inequalities is a fundamental part of our new strategy. We want everyone to have access to safer and better-quality care and we will champion this in everything we do. We want to understand why there’s such variation so that we can help drive change and reduce inequalities in health and care.

This equality impact assessment

We have considered the potential impact of the changes in our new strategy on how we regulate, and how this could affect the equality and human rights of people who use health and care services and on providers of services.

We considered the impact on people who experience difficulty in accessing care, those who are the most disadvantaged in our society, have had distressing or traumatic experiences, and those who are most likely to have a poorer experience or poorer outcomes. This includes people with a learning disability or autism, people with communication needs, people living in poverty, those whose voices are not often heard, those who are detained under the Mental Health Act, and people who are at risk of abuse or other human rights breaches. We also considered people’s lived experience in terms of a combination of health conditions or impairments and other characteristics, such as ethnicity, gender, sexual orientation or age. We also listened to what people told us in our consultation on the strategy.

This is to ensure we don’t miss any opportunities to improve equality, and that our new strategy doesn’t introduce barriers that would prevent everyone from receiving high-quality care in the services we regulate. The impact assessment also fulfils our general public sector equality duty under the Equality Act 2010 and our duties as a public authority under the Human Rights Act 1998.

Themes in the strategy

Our strategy is built on four central themes that determine the changes we are making in our regulation.

• People and communities
• Smarter regulation
• Safety through learning
• Accelerating improvement

We also have two core ambitions to assess local health and care systems, and a specific focus on doing what we can to reduce inequalities in health and social care. Therefore, inherently our strategy is designed to address inequalities in health and social care.

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People and communities

We want to be an advocate for change, with our regulation driven by people’s needs and their experiences of health and care services, rather than how providers want to deliver them.

This means focusing on what matters to the public, and to local communities, when they access, use and move between services. Working in partnership with people who use services, we have an opportunity to help build care around the person: we want to regulate to make that happen.

We’ll develop our role in reviewing how well local systems work together to meet people’s health and care needs and preferences.

Opportunities

Our assessment of people’s care will look at every stage of their journey through the health and care system, looking at both individual services and across different providers and organisations.

This will give us an opportunity to develop a more comprehensive picture of people’s lived experience of services, their experience through the pathways of care, and how well their needs and preferences are met, particularly when moving between services. It will enable us to better understand what we and others need to do to make improvements where people have poor access to care and poorer outcomes.

Risks

Our assessments of local systems may not focus on the right issues, which could drive behaviours that worsen inequalities in health and care

Actions we will take

• We’ll adapt our health inequalities tool to record how well services work together to reduce inequalities.
• We’ll build our understanding of the needs and preferences of local populations, particularly people who have difficulties in accessing care and poorer outcomes. This will help us hold services to account effectively and ensure services improve for all.
• Our assessments of local systems will provide independent assurance to the public of how they are working together to deliver high-quality care, particularly in respect of human rights and inequalities in health and social care.
• We’ll capture information about people’s experience of care in a range of accessible ways that suit their needs. This includes digital access through web-based methods and apps, and enabling people to tell us about their care by speaking in person with our inspectors, Experts by Experience or voluntary groups.
• We’ll focus on how well local systems perform against the important things that matter to people in their community, especially those that face the most barriers to accessing good care and those with the poorest outcomes. This will help us encourage services to respond positively to inequalities in experience of care.

To deliver on our commitment to increasing equality, we will ensure all CQC colleagues are aware of issues relating to equality, diversity and human rights

Risks

The way in which we develop, implement and review our learning programmes and guidance may not enable us to regulate services effectively or ensure we capture the experiences of people who have difficultly accessing care or poor outcomes.

Actions we will take

• The scope of our learning and guidance will expand to have a more explicit focus on reducing health and care inequalities.
• Working closely with other partners and stakeholders, we’ll ensure our guidance and training is comprehensive, up to date and reflects best practice. This includes the National Guardian’s Office on issues around Speaking Up.

We’ll improve how we safeguard people when we hear accounts of abuse or risks to people’s human rights.

Opportunities

Making better use of the information we have, including people’s experiences, will determine the action we take when people are at risk. This is particularly the case for people who we seldom hear from or who find it difficult to speak up about their experiences of care.

Having a single shared framework of what good quality care looks like, improving how people can let us know about concerns and how we handle information gives us an opportunity to respond quickly and effectively when we identify risks.

Risks

We may not have the right information or be able to use it effectively when assessing people’s experiences of care; in particular, people with impaired capacity, people placed for long periods away from their families, and communities and people who find it difficult to speak about their experiences.

Actions we will take

• We'll implement the lessons we have learned from our reviews where people’s human rights have been breached, and we’ll continue to review the effectiveness and impact of our response.
• We'll work with all our partners and people who use services to develop and disseminate an agreed shared view of quality that makes clear what standards people can expect from their health and care services.
• We'll develop our processes to ensure that people’s experiences of care get the correct weighting in our regulatory decision-making.
• We'll identify better ways to gather experiences from a wider range of people and develop the skills and tools that we need to do this. This will include having better conversations with people who live in or use the service, and their families and advocates, and more time to talk with staff. We will improve our capacity and capability to get the most out of feedback.

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Smarter regulation

We will be smarter in how we regulate. We’ll keep pace with changes in health and care, providing up-to-date, high-quality information and ratings for the public, providers and all our partners.

We’ll regulate in a more dynamic and flexible way so that we can adapt to the future changes that we can anticipate – as well as those we can’t. Smarter use of data means we’ll target our resources where we can have the greatest impact, focusing on risk and where care is poor, to ensure we’re an effective, proportionate and efficient regulator.

We will be more responsive and flexible in how we regulate services

Opportunities

Being smarter in how we regulate and having a stronger focus on equality and human rights issues as part of our assessments of quality provides us with an opportunity to help improve health and social care services for all people.

A more dynamic approach to collecting and using information will enable us to more regularly capture the views of people using services, including those who are seldom heard, those with protected equality characteristics and those most likely to experience poor care.

Risks

An approach that prioritises digital engagement could exclude people in some groups and add to the exclusion of others.

Actions we will take

• We'll use a wider range of tools and methods to gather information on equality and human rights. We’ll make better use of this data to understand risks to good care, and ensure we are responsive to and act on equality or human rights issues as they arise.
• A more flexible approach will enable us to visit some types of services more often to observe how care is delivered, particularly where people are at higher risk of a poorer experience of care and/or poorer outcomes.
• When designing how we regulate new models of care and types of services, we’ll consider equality and human rights issues early and the impact on diverse groups of people.
• We'll make sure we consider the best ways to obtain information from people, including those who prefer other ways to communicate than we might routinely use (or find them more effective).

We will make better use of artificial intelligence and data analytics

Opportunities

Developing our approach to make better use of artificial intelligence and data analytics will enable us to carry out more focused analyses of the impact of our regulation on specific groups of people. This will help us understand the health and care inequalities experienced by a broad range of people.

Risks

There is a risk that our analysis of data could introduce unintentional bias in our assessments.

We could have an incomplete or inaccurate understanding of people’s lived experience of care and will not be able to fully play our part in reducing health inequalities.

Actions we will take

• We'll direct resources to deliver a risk-based approach to data analysis and decision-making about what action is needed. For example, being more proactive and less reliant on information from inspections for people most likely to receive poor care or people with protected characteristics.
• We'll link the wide range of information that we gather with information that people give us and take action if our analysis indicates the presence of bias or inaccuracy in terms of the consideration of health and care inequalities.
• When developing, reviewing and re-designing what we do, we’ll involve providers, stakeholders, Experts by Experience and a diverse group of people who use services.

We'll evolve and simplify our assessment and ratings processes as part of our new approach

Opportunities

There is an opportunity to reflect the lived experience of all people, including those more likely to receive poor care in our up to date view of quality.

Actions we will take

• People's experiences of care will be used more in how we assess and rate services. This will include variation in people’s experiences, for example where some groups of people receive good care when others don’t.
• When we share our view of quality, we’ll do this >in a way that meets people’s needs by being more relevant, understandable, accessible and inclusive.
• Our up to date view of quality will highlight how services are reducing health and care inequalities.

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Safety through learning

We want all services to have stronger safety and learning cultures. Health and care staff work hard every day to make sure people’s care is safe. Despite this, safety is still a key concern for us as it’s consistently the poorest area of performance in our assessments.

It’s time to prioritise safety: creating stronger safety cultures, focusing on learning, improving expertise, listening and acting on people’s experiences, and taking clear and proactive action when safety doesn't improve.

We’ll develop our approach to ensure everyone plays their part in a strong safety culture, including people working in health and care and people who use services

Opportunities

We can develop a detailed focus on services and/or systems where we know there are higher risks of people being unable to speak out about poor care and where people’s care involves interactions with a diverse range of services.

We’ll also be able to raise the profile and importance of encouraging, enabling and supporting people to Speak Up where they have concerns and to become partners, working collaboratively to challenge risk.

Risks

Our approach may not identify all services that have a poor safety culture, such as services for people with a learning disability or autistic people.

Actions we will take

• We'll be clear to all health and care services that we consider maintaining people’s equality and human rights is an important part of a strong safety and learning culture.
• We'll develop our approach to safety with specific reference to the experiences of people who are most unlikely to be able to raise concerns about poor care and who may experience poorer safety outcomes - such as people with a learning disability or autistic people.
• We will assess whether there is the right safety culture, whether people are actively involved in decisions about their own safe care, and that staff are confident to Speak Up about safety issues.
• We'll develop methods to enable us to focus on the types of care setting where people are more likely to be unable to speak up for themselves and where there’s a greater risk of a poor culture going undetected.
• We'll develop our understanding of where there are gaps in oversight of safety in the health and care system, and work closely with service providers, strategic partners and other stakeholders, to ensure that people’s equality and human rights are maintained and good care is provided for all.

We will promote and encourage improved safety cultures in health and care services

Opportunities

There is an opportunity to embed equality and human rights within a good safety culture, leading to safe care for all.

A focus on safety could help to minimise avoidable harm for all, particularly those potentially at greater risk because of barriers that prevent or inhibit them from speaking up about poor quality care.

Risks

Services may interpret a safety culture in a way that is too risk-averse, that limits people’s choice to manage their own risks, and that negatively affects people’s human rights.

Our ambition to improve safety cultures may drive services to focus on the wrong things, such as a focus on the number of incidents. This could have a disproportionate impact on specific groups of people who receive care and on staff in some settings.

Actions we will take

• We'll work with others to agree and establish a definition about safety, human rights and equality, and an understanding of what a safety culture means in practice.
• Working with providers and stakeholders, we’ll develop solutions to ensure all services have consistent access to the right support and insight to help them build strong safety cultures that uphold equality and human rights.
• We’ll make clear what we expect of health and care services to meaningfully involve people in decisions about their care, so they can live their lives and manage their own safety risks – particularly people in marginalised groups and those with rare and complex conditions.
• We’ll share what we find with services and work with them to improve their safety culture and how we regulate for safety and equality and human rights – and we’ll take action where necessary.
• We’ll use our insight and independent voice to promote a national conversation on safety.

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Accelerating improvement

We will do more with what we know to drive improvements across individual services and systems of care. We’ll use our unique position to spotlight the priority areas that need to improve and enable access to support where it’s needed most.

We’ll empower services to help themselves, while retaining our strong regulatory role. The key to this is by collaborating and strengthening our relationships with services, the people who use them, and our partners across health and care.

We want to drive improvement across all health and social care services

Opportunities

Speaking up about priority areas of care that need to improve provides an opportunity for us to work with providers across health and social care and improve the experiences of everybody who uses services.

Risks

We may find that some of our colleagues do not have the confidence, knowledge or skills to raise equality issues and health and care inequalities.

Actions we will take

• We'll identify the areas that need to improve as a priority, at a local and national level, by working with providers and other stakeholders, including Experts by Experience and people who use services.
• We'll use our independent voice to highlight concerns and share good practice and examples of innovation that drives improvement that can help reduce inequalities at a local and national level.
• We'll ensure our colleagues have the tools, skills and expertise about equalities, human rights and health and care inequalities.

We recognise that innovation and research in health and social care can help to reduce health and care inequalities and improve services

Opportunities

Our new strategy provides us with an opportunity to encourage innovation in services, which can reduce inequalities.

Risks

We may inadvertently promote innovations, such as the use of artificial intelligence, that have inherent biases built in.

Actions we will take

• We will champion innovation that benefits all people.
• We'll create a supportive regulatory environment for services where they can try new approaches to care that reduce inequalities.
• We'll use research and external evidence to have a better understanding of the conditions that drive quality improvement that can reduce inequalities.
• We'll explicitly encourage services to consider the potential impact on equality and human rights in innovation and improvement, particularly on marginalised and seldom heard groups.