This consultation has closed
This consultation closed at 5pm on Thursday 4 March 2021.
We’ll change how we regulate to improve care for everyone.
We were established as an independent regulator with a clear purpose: to ensure health and care services provide people with safe, effective, compassionate, high-quality care and to encourage those services to improve.
We’ll always be committed to this purpose, it’s as vital as ever. But the world in which we regulate has changed significantly since we were created. The COVID-19 pandemic has accelerated that change: new and innovative types of service started up using digital channels, and new restrictions have changed how services can deliver care.
In this new world, we must also transform. We need to make changes to the way we regulate so that it’s more relevant and has positive outcomes for everyone, as people’s expectations of care have changed. We need to be more flexible to manage risk and uncertainty. We’ve learned a lot from our response to the pandemic, and we’re using this to put us in a better place for the future and support services to keep people safe.
We have a responsibility to change people’s lives for the better
As people get older, they often have multiple, long-term conditions. Delivering care is increasingly complex. The organisation of health and social care services is evolving rapidly, and many are working in partnership across different sectors. The crisis has emphasised just how vital this is. It’s now more important than ever for health and care services to work together as a system to deliver care – to meet the needs of the local population and of each individual person.
But the approach of delivering care as a ‘system’ is very different to the ‘single provider service model’ that CQC was set up to oversee in 2009.
It’s not enough to look at how one service operates in isolation
It’s essential that people who use services, those who work in them, and health and care organisations work together as a system to design and deliver care. It’s how services work together that has a real impact on people’s outcomes. We need to adapt to this. Our assessment of people’s care must look at every stage of their journey through the health and care system, looking at both individual services and across different providers and organisations.
The way people receive care has also changed – powered and supported through new technology. The growth of artificial intelligence, advances in data analytics and the increase in mobile communication all point to a future of care built on a dynamic partnership between health and care services and the people who use them. We need to understand where digital services can meet people’s needs and improve their outcomes – and change the way we regulate them.
The pandemic has renewed the focus on inequalities in health and care
We’ve seen inequalities across different areas of the country and different groups of people. Reducing inequalities in people’s outcomes is a fundamental part of our new strategy. We want everybody 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 across the country in how people get the care they need, so we can help to tackle it.
We’re committed to reducing inequalities, eliminating discrimination, advancing equality, and protecting human rights. We want our new strategy to help health and social care providers and systems to do this.
Our strategy is built on four themes that together determine the changes we want to make. Running through each theme is our ambition to improve people’s care by looking at how well health and care systems are working and how they’re acting to reduce inequalities.
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, we have an opportunity to help build care around the person: we want to regulate to make that happen.
People need to clearly understand how their voice can make a difference to the safety and quality of the services they use.
We’ll transform how we encourage and enable people to share their experiences of care with us in a way that works for them. We’ll transform how we capture, use and analyse people’s feedback. We want to build trust with the public and motivate people to share their experiences by showing how we’ve acted on what they told us.
- We’ll enable people to give feedback in different ways that work for them – whether that’s giving information to us directly, or speaking with our Experts by Experience, our inspectors, Mental Health Act Reviewers, Local Healthwatch or our local voluntary and advocacy partners. We’ll also make it easier for people to give feedback using digital channels.
- We’ll develop the skills and tools that we need to enable all people to share their experiences. But we’ll have a specific focus on people who are the most disadvantaged in our society, have had distressing or traumatic experiences, and are more likely to experience poor outcomes and inequalities. This includes people with a learning disability, people with communication needs, people living in poverty, those whose voices are seldom heard, those who are detained under the Mental Health Act, and those who are at risk of abuse or other human rights breaches.
- A priority will be improving our capacity and capability to get the most out of feedback. We’ll identify more and better ways to gather experiences from a wider range of people. We’ll change the way we record and analyse people’s feedback, so it’s easier for us to quickly identify changes in the quality of care – both good and bad. This means building systems that enable us to track and prioritise people’s experiences throughout our regulatory and other processes. We’ll be clear about the value and weight we give to quantitative and qualitative information when using it with other evidence. This includes the stories that people tell us about their experiences of services and pathways of care.
People and communities want us to act on their feedback and understand how we’ve acted on it – and we want people to know how much we value their feedback.
- When we publish information about quality, we’ll be clearer about how we’ve used people’s experiences, and the action that we and others have taken as a result.
- When people take the time to share their experiences with us we’ll provide a response to them that clearly explains how we’ve acted on what they tell us and how it has informed our view of how a service is performing. We’ll provide our response in the way people need it.
We know that people are often afraid to speak up. We want to help build a new understanding among the public, health and care providers, and our partners, that welcomes, values and acts on feedback to improve care for all.
- We’ll improve the way we assess how services encourage and enable people who use their services to speak up, and how they act on this feedback. It will be unacceptable if providers are not doing this. We’ll also focus on this when we look at how local systems are listening to their local communities so they can improve access to services that meet people’s needs.
To help empower people to drive change, it’s important for them to know who we are and understand what we do.
We want to put people at the centre of all conversations about the quality of care they receive. Having an agreed and shared view of quality will enable a joined-up approach that’s applied to individual services, corporate providers, and across system boundaries in both health and social care. It will empower people to have more control in their care and encourage services to improve.
- We’ll proactively raise public awareness of CQC and be clear about our role as a regulator. We’ll invest in the most effective ways to do this within different population groups.
- We’ll be clear what standards people can expect from their health and care services, and how their feedback can drive change. To do this, we’ll provide a clearer definition of what good and outstanding care looks like, based on what people say matters to them. Everybody will be able to easily access, understand, and use these definitions. We’ll use them as the basis for assessing services and the information that we collect as evidence.
- We’ll encourage people to use our information in ways that are relevant to their lives. Our up-to-date view of the quality of care in a service will help people and their families make informed decisions when they are choosing where to go for their care. This means they can be confident in the knowledge that our information reflects the quality of care that they can expect, on the day they receive it.
Providing independent, trusted and high-quality information about the quality of care is a fundamental part of our work.
- We’ll change how we provide information so that it’s more relevant, up to date, and meaningful for people who use services, and reflects their experiences. We’ll ensure people have access to information in the way they need it, through improved communication channels, and using clear and accessible language.
We know care is better when it’s developed through the eyes of people who use services and delivered in partnership with them. We think the same of regulation. We want to regulate to drive more personalised and coordinated care.
- We’ll work closely with people who use services and those that represent them to understand their needs, and to co-design and develop how we work and the services we provide to the public. Any changes we make will start with understanding what people expect and need from care services and pathways, and from CQC. We want to involve people in a meaningful way, so we’ll encourage and enable people to do this in ways that work for them.
Local health and care services and commissioners need to understand the diverse needs of their populations. They need to work together as a system to meet these needs and improve health and wellbeing. We need to ensure that services in local areas are working with other parts of their community to enable better outcomes and reduce inequalities.
- When we assess services, we’ll look at how they work with each other, and in partnership with communities, to make improvements. We’ll look at how effectively they involve people in designing and improving services. We’ll look at how they embed equality, diversity and inclusion, and corporate social responsibility in everything they do to benefit local health and wellbeing, society, the economy, and the environment.
- As well as assessing individual services, we’ll assess how they work together as a system in an area. It will be unacceptable for services not to be working in this way. We’ll focus on how well systems perform against the things that matter to people and communities and the outcomes for people in that community – important things such as being able to move easily between different services.
- We’ll hold local care systems to account for the quality of care in their area and clearly call out issues when we see them. At the same time we’ll highlight good practice.
We will identify and call out unwarranted variation and inequalities in health and care. We know that a person’s health and wellbeing is significantly affected by factors outside health and care services.
- We’ll support local systems to understand the needs of their local populations, especially those that face the most barriers to accessing good care or those with the poorest outcomes, enabling them to respond positively to inequalities.
- We’ll work with other agencies, voluntary and community organisations, system partners and other regulators to develop a shared understanding of the factors that contribute to inequalities, and the levers that we and they can use to tackle them.
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 now 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 want to provide a more consistent, up-to-date, and accurate picture of quality; using the best information will help us to keep people safe and to protect, respect and uphold people’s human rights.
- We’ll have a more dynamic approach to regulation. Inspections 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. Site visits are a vital part of performance assessments and essential in some settings to observe the care people receive. But we want to use all our regulatory methods, tools, and techniques to assess quality continuously, rather than relying only on scheduled all-inclusive on-site inspection visits. We want our local teams to have a regular view of the services they manage, based on their continuous knowledge and not on a particular date in the calendar.
- We’ll use our powers to visit services when we need to respond to risk, when we need specific information, when we need to observe care, and when sampling to check that our view of quality is reliable.
We want everyone we work with to benefit from our regulation. The way we regulate will become more relevant – using what we know to help services to tackle problems early and providing up-to-date, high-quality information and ratings.
- We’ll use the best information we can get about a service to keep ratings and our information about quality up-to-date, rather than relying on the outcome of periodic all-inclusive inspections to change them. This includes a better understanding of people’s feedback and experiences of care. We’ll use this alongside a combination of targeted inspections, national and local data from other organisations and partners, insight from our relationships with providers and partners, providers’ own self-assurance, and accreditation.
- We’ll change our assessments to be more dynamic, and update ratings more often, so that everybody will have an up-to-date view of quality.
We now have IT systems that can handle large amounts of data, which will enable us to use artificial intelligence and innovative analysis methods. This replaces more manual handling of data and will ensure we interpret data in a more consistent way.
- We’ll use our regulatory powers in a smarter, more proportionate way so we take the right action at the right time. Based on the best information available, and enabled by technology, we’ll be proactive in using innovative analysis, including data science techniques, to support robust and proportionate decision-making. Combined with the experience, knowledge, and professional judgement of our inspectors, this means we’ll be alert and ready to act quickly in a more targeted way and tailor our regulation to individual services and circumstances.
- We’ll share the data and information we hold on services with voluntary and other organisations where it will help them in their own work to improve people’s care.
We all have a common drive to improve people’s care. From the point of registration, we want to 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 regulatory work where quality needs to improve.
Digital channels will make it easier for services to work with us and other partners. Our aim is to gather information differently and reduce the duplication of requests by developing how we work with others. This will help staff to focus on providing care safely and finding opportunities to improve.
- We’ll work with providers and other regulators and partners to coordinate data collections. To reduce the duplication and workload for providers 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 to explore how we can improve our digital interfaces with services. Where we do need to collect information directly, this 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.
- Being smarter with data will enable our regulation to be more proportionate and consistent. We’ll have regular contact with services through our ongoing relationships, and spend more time monitoring and analysing data using technology. This means our visits will be more targeted and effective, with a sharper focus on what we need to look at. So, rather than spending time looking at paperwork when we’re on site, we’ll have better conversations with people who use services and care staff, and we’ll have more time to observe how a service is delivering care.
Like the services we regulate, we’re evolving to adapt to changing models of care, such as integrated systems and digitally-enabled care.
The move to looking at how services work together in a local system is a change in our approach; we think this is a smarter way to regulate. We’ll work with providers and partners to understand how care is changing, ensuring that our regulatory model keeps pace with changes.
- The way we register services will allow us to make organisations more accountable 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; importantly, this will make sure they can be held accountable.
- We’ll look at how services meet their social and ethical responsibilities, such as environmental sustainability.
- 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 providers are working together to ensure fair access to health and care services for everyone. The information we gather will enable us to better understand risk relating to inequalities in people’s health outcomes and we’ll take action where we see a need for improvement.
- We’ll add to our existing knowledge and experience, and build capability and capacity in our people, our systems, and our processes. We want to learn and improve to be a flexible and responsive regulator, while staying true to our purpose.
We want our ratings and information to help people to make informed choices about their care, and to give services an assessment of their performance to encourage them to improve.
- We’ll evolve our ratings. As well as ensuring they provide an up-to-date view on quality, we want to make ratings reflect how people experience care so they’re more meaningful and focus on what matters most to them.
- We’ll move away from long reports written after inspections, and instead provide information and data targeted to an audience. Information for the public will be easier to understand and more accessible. We want people to be able to get information in ways that suit them.
- We’ll regulate in a smarter way by providing a clearer definition of quality and the standards people can expect, which is based on what people say matters to them. Everybody will be able to understand and use it 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 the information that we 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.
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 know that the right organisational culture is crucial to safety.
A strong safety culture needs everyone working in health and care and 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. In this type of culture, it’s accepted that all incidents – positive, negative, and wholly avoidable – provide opportunities to learn and improve. We want this approach to be universal with leaders, staff and people using services all involved. Safety must be a top priority for all – regardless of seniority or role.
- There’s no national agreement on what we mean by safety in different health and care sectors and services. We’ll work with others to agree and establish a definition and language that explains what we mean by safe care and how this could apply in different services. This will create a better understanding of risk across all health and care – so that we know what’s not acceptable – and therefore help to minimise harm. More clarity will enable services to prioritise the essentials and have clearer expectations when we assess them. When we talk about safety we’ll make sure it reflects what’s most important to people when they use services.
- Our assessments of safety will have a sharper focus on checking for open and honest cultures. We’ll be looking for cultures that have learning and improvement at their core.
- 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 as a direct result of our regulatory action. We’ll highlight trends and patterns across health and care so that services have the information they need to improve.
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. Shifts in safety culture won’t happen without the right expertise at all levels across health and social care – including at CQC.
Changing a safety culture also needs good leadership to make it happen. We all need to understand why safety is important at a practical level and how we can each individually improve it in our area of work, and to create an excitement and movement around it that motivates people every day to improve.
- When we assess services, we’ll be looking at the type and levels of expertise in services. We’ll check how they assure themselves that they have the right balance, and how they are investing in improving safety, including training, support and how they use data.
- We’ll improve and increase our own safety expertise to ensure our approach is in line with the latest safety thinking – whether from health and care in England, from elsewhere, or from other industries and sectors. Together with our unique data and insight, this will enable us to challenge and highlight failures in services and in systems.
People have a right to expect safe health and care services. We think that making sure people experience the safest care is everyone’s job.
To do this, leaders, their staff, and the people using their services all need to be involved. People should influence the planning and prioritisation of safety and be truly involved as equal partners in their care at all levels. This means that services need to 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 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 people have 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. Sometimes the care system works against health and care staff, making it hard to take the right and safest action.
- With new ways of delivering care and more services working as part of a local system, we will change how we regulate safety in all services.
- We’ll focus more on the types of care setting where there’s a greater risk of a poor culture going undetected. We’ll develop ways to understand what’s happening in these services as, we know that people are often unable to speak up for themselves, and more likely to be failed by a poor culture.
- Learning and improvement must be the primary response to all safety concerns in all types of service. Where we have concerns, we will directly make services respond and show us – and the people who use their service – what action they’ll take to show they are learning and improving. We’ll share this information with the public as part of our up-to-date view of quality.
- We’ll review how effectively we are assessing and monitoring safety – from registration through to enforcement. We’ll use our improved safety expertise to assure ourselves that 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 is responsible for reporting or receiving the information.
- Where we identify risks to people using a service, we’ll intervene more quickly. If we have evidence of risks, including what people are telling us, we’ll take action earlier to make sure that services are focusing on protecting people before they experience poor care and avoidable harm. This includes protecting people’s human rights. To do this, we’ll make better use of people’s feedback on services. Key to this will be having the best comparable data and ensuring we are sharing it with our partners.
- 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 change isn’t 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 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 between services.
- 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 systems improve their safety. We’ll also share our data and information about safety in health and care systems with regional organisations, to support their oversight of safety in a local 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. Although there are bodies who might provide support or receive data about safety incidents, this oversight or champion role isn’t joined up, meaning these sectors risk being left behind. It’s crucial that all health and care services have consistent access to the right support and insight to help them on their journey to build strong safety cultures, learn from safety incidents, and improve their practice.
- We want to understand where there is a lack of support and expertise for safety. 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.
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 want to 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.
The support that’s available to help services improve the quality of their care varies between and within health and care sectors and across England. Some services have limited access to support; we want all sectors to have equal and consistent access to the support they need to improve.
We want to play a much more active leadership role in driving improvement, advocating for the issues that matter to people who use services.
- We want to establish and facilitate national sector-wide improvement coalitions with a broad spectrum of partners within both health and care, including those representing people who use services. These coalitions would work collaboratively to improve the availability of support, focusing on areas where there are gaps, both nationally and at a local system level. We’ll champion consistent access to direct, tailored, hands-on support for all providers who need it.
- We’ll encourage our national partners to offer support to local systems to help them improve. We’ll also strengthen our ongoing relationships at a local level to promote collaboration on improvement across areas, working with partners from the relevant improvement coalitions. The aim is to ensure all parts of a local system are focused on improvement, including addressing health inequalities.
As health and care evolves, what was considered good a few years ago isn’t good enough today; what is good today won’t be good enough in the near future. People have higher expectations about safe, high-quality care – and so do we.
We’ll do more to make improvement happen, taking action in priority areas that need support the most. We will hold improvement conversations with services and offer a range of resources to support them.
- We want to encourage continuous improvement in quality. We’ll be clearer on the standards that we, and people who use health and care services, expect. We’ll set a higher bar for what we expect of services rated as good, which should match what the public expects. As part of this, we’ll expect services to keep on improving so that they remain good. We’ll also expect services to contribute to improvement in their local health and care system.
- We'll identify the areas that need to improve as a priority – both at a local and national level. We'll work with partners to make change happen through programmes of activity based on evidence of what works. This will include using our independent voice to 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 develop collaborative relationships with services, helping them to find their own route to improvement by pointing them to sources of guidance, best practice, and other providers and organisations that can offer advice and support. We’ll hold improvement conversations with services to support them to decide for themselves the best way forward rather than ‘telling them what to do’. This will enable us to help services who want to improve, while retaining our core regulatory role, which means using our powers to act where we see poor care.
- We’ll empower providers 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, so they can use this to target improvements themselves. 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, but services don’t always understand it or implement it well. Our regulation will keep pace with these changes and promote innovation that will improve people’s care.
- We’ll make sure we understand changes being developed to the way services deliver care. We’ll then work with health and care services and other stakeholders to understand how these can safely improve the quality of people’s care. When we do this, we’ll consider where using new technology might disadvantage some people and what services need to do so that nobody is left behind.
- We’ll work in partnership with services and other stakeholders to develop a coordinated, effective, and proportionate approach to regulating new innovations and technology. We will 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 is 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 have valuable knowledge and insight about improvement – we want to use this to inform our regulatory approach. Through all our work, we want to promote an improvement culture across health and social care.
This activity will be based on evidence about what really works.
- 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 of 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’ll use the best available evidence to inform our approach to regulation. We’ll further develop and embed a culture of learning in CQC to maximise our impact on the quality of care and people’s outcomes.
Measuring the impact on equality
We need to consider equality and human rights in all our work, so we’ve produced a draft equality and human rights impact assessment. It identifies the opportunities and risks for doing this through our new strategy. Importantly, it identifies the actions we’ll take to minimise the risks and make positive change happen.
We’d like to hear what you think about the opportunities and risks to improving equality and human rights in our draft equality impact assessment. For example, you can tell us your thoughts on:
- Whether the ambitions in the strategy will have an impact on some groups of people more than others, such as people with a protected equality characteristic.
- Whether any impact would be positive or negative.
- How we could reduce or remove any negative impacts.