Care Quality Commissionstrategy 2016-2021
Shaping the future: consultation document
RNIB response
RNIB is the largest organisation of blind and partially sighted people in the UK and welcome this opportunity to respond to the consultation.
We are a membership organisation with over 13,500 members who are blind, partially sighted or the friends and family of people with sight loss. More than 80 per cent of our Board of Trustees are blind or partially sighted. We encourage members to be involved in our work and regularly consult with them on government policy and their ideas for change.
RNIB campaigns for the rights of blind and partially sighted people in each of the UK’s countries. Our priorities are to:
- Be there for people losing their sight.
- Support independent living for blind and partially sighted people.
- Create a society that is inclusive of blind and partially sighted people's interests and needs.
- Stop people losing their sight unnecessarily.
Question1b:What do you agree with, or not agree with, about the vision?
RNIB believes that CQC’s role to register, monitor, inspect and rate services is fundamental. We welcome that patients and users of services will continue to play a vital role.Involvement in inspections, and the processes to share concerns and compliments about services should be made as easy as possible.
RNIB welcomes CQC’s aim to “provide a more complete picture about how it feels to receive care across services.” In order to understand the complete picture of care, there must be mechanisms to monitor, inspect and rate all preventative services, and short term interventions. Otherwise CQC is missing the voices of groups of people who use care services that are not currently covered by the Commission.
Theme 1: Improving our use of data and information
Question 2b: What do you agree with, or not agree with, about greater use of data and information?
RNIB agrees that data has a key role to play in providing invaluable intelligence about service provision. Data can help to identify trends and areas of concerns, it can also help to inform decision making.
However, there are also risks with this approach; many factors can affect data, for example, how it is collected, how the data is compiled and how it is interpreted. A reliance on self selecting data, i.e. organisations rating themselves, could mean that they may either be underselling or overselling their services.
To properly maintain, collect, collate and interpret data, involves resources, including manpower and time. It is not clear what happens once the data highlights an issue, or what the threshold is to raise concerns?
We have specifically picked up on some paragraphs set out in the strategy that we would like to comment on:
“For CQC to be intelligence driven, it is really important that people tell us about their experiences of care and that we share this information better with our partners (such as local authorities in relation to safeguarding concerns).”
It must be made easy for people to feedback their experiences of care. This may be via a range of communication means, including phone call, email, letter or the use of social media. People must be made to feel that their comments are valid and will be taken seriously.
Information about the process of sharing experiences, the mechanisms to report experiences must be available in a format that is accessible to the individual.
A person should not be expected to have to share their concerns through multiple channels. There is currently no one central point for patients or users of services to feed in their experiences. For example, patients can report any concerns directly to their specific eye clinic, or care provider; or via PALS, a formal complaints system, or local Healthwatch. If their complaint is not satisfactorily dealt with at local level, people may contact the relevant ombudsman. It is important that all of these reporting mechanisms are monitored and that there is a mechanism in place for identifying any trends. All these disparate routes for logging complaints could mean that critical mass is not achieved (i.e. through one particular route) and trends are missed.
“we will also expand our Experts by Experience programme and involve more members of the public in our work than ever before.”
As an organisation that is led by blind and partially sighted people, RNIB believes patient participation is vital. RNIB welcomes the expansion of the experts by experience programme. In the health setting there is a range of ways in which patients can get involve. There is a number of NHS England schemesincluding, NHS Citizen and the citizen assembly,local Healthwatch enter and views, and PLACE (Patient-led Assessments of the Care Environment).
PLACE has experienced some problems with recruitment of patients. However, we know that hospital take the findings very seriously, and that the results are published annually by HSCIC. We have also foundlocal Healthwatch enter and views to have been effective in improving access to hospitals for blind and partially sighted people.
There is a strong role for the commission to play to ensure that the findings of all of patient expert programmes are shared andcompared so that any concerns can identified early on. Learning’s from across all patient expert programmes should be used to ensure that best practice is shared when recruiting, training and supporting blind and partially sighted people in participation programmes.
Participants in patient participation programmes often express frustration that they don’t receive received feedback on what has happened as a result of their involvement. It is important to feedback to patients what difference their involvement has had.
Every step should be taken to ensure that the expert by experience programme is accessible to maximise the inclusion of blind and partially sighted people. CQC must ensure all its inspection materials and materials used to promote inspection activities are made available in accessible formats in each setting that is under inspection.People with sensory impairment/disabilities should be encouraged to take part in inspections across all settings
“CQC insight! – new model for how to obtain and use CQC data and information “CQC Insight will highlight the critical data that inspectors and analysts need to follow up directly with the provider. It will increase the range of data based on the views of people and their families about their experiences of care.”…..”The model will have a set of indicators in line with the five key questions we use when we inspect services.”
From the consultation document it is not entirely clear what data CQC will be monitoring and analysing.
The use of data can be very useful in monitoring services. However, because there isn’t enough detail in the strategy, our response on whether or not CQC insight is able to help to meet the remit will depend on how hightriggers are set, what data will be monitored, how reliable the data is, and what system is in place once a trigger is made.
It is also not clear how external organisations can feed andshare data, or whether the data will be used to help identify appropriate thematic reviews.
If CQC is toamass and monitor current data collections, then they must play a wider role in calling for better audits/data collection, so that outcomes can be measured across the patient pathways. RNIB is aware that there are ongoing issues with existingdata sets, particularly in eye care. Providers must be encouraged to useelectronic clinical management systems to record activity and outcomes at a patient level – currently ophthalmology data focuses on activity levels but lacks data relating to clinical outcomes and patient reported outcomes.
It is also not clear what the process is (what actions will be triggered) when the data is analysed and identifies any worrying trends, or areas of concerns. Resources need to be allocated to respond to any trends indentified in order for a more in-depth analysis to be carried out and then for any further investigations.
There is also not enough detail in the strategy on how or when the CQC will be reporting on the data findings.
Theme 2: Implementing a single shared view of quality
Question 3b:What do you agree with, or not agree with, about a single shared view of quality?
A single vision for quality is welcome in terms of its potential to reduce variations in care. However, any agreed vision of quality must have flexibility in order to beresponsive to the differences between core and specialised services.
The adoption of a single shared view could also mean that it is easier for patients, users of services, and friends and family to compare services.
The definition of quality, set by CQC to determine whether a service is safe, effective, caring, responsive and well-led, is fairly comprehensive. The definition of responsive, used by CQC is that“services are organised so that they meet people's needs.” However, whether a service is organised to meet the needs of the people using the service or for the wider population are two separate issues. Therefore anyshared definition of quality must be explicit that it encompasses both understandings.
For example, there are a number of local authorities that have told RNIB that they provide a high quality vision rehabilitation service. That the service provides tailored mobility training to a person, that meets the individuals needs. However, RNIB have received concerns from the public that they have not been able to receive vision rehabilitation support in these local authorities area. Once we have analysed referral rates, it becomes apparent that because of rationing, or poor assessment processes, that people are simply not being referred into the service. RNIB would strongly argue that that therefore these vision rehabilitation services are not meeting CQCs definition of quality, as the services are not being responsive to the wider population of blind and partially sighted people’s needs.
Vision rehabilitation provides crucial training and advice to people with a visual impairment on how to maintain and live in their home safely, and how to negotiate the many obstacles and risks outside of their house. Vision rehabilitation provides people with the skills and confidence they need to maximise independence, to access and participate in their community.
Early support means that people are able to learn and develop the right skills to ensure that they are able to continue with the work, activities and the way of life that is important to them. This can reduce or prevent a person from needing far more costly care provision.
RNIB has evidence that people with a visual impairment are not being referred onto vision rehabilitation services. This has led in some local authority areas for services to be reduced, because of a ‘lack of demand’. RNIB is extremely concerned about this.
RNIB appreciates that local authorities, commissioners, and health care providers are under pressure to save money, but this should not be at the expense of a person not receiving the support that they need.
Theme 3: Targeting and tailoring our inspection activity.
Question 4b:What do you agree with, or not agree with, about targeting and tailoring our inspection activity?
RNIB appreciates that there is a need under current resources to target and tailor inspections. The care and hospital environment can be volatile and circumstances change. The quality of services provided can change quickly. It is difficult to set out a position on targeting and tailoring inspection activity, without understanding what the risk based approach looks like.
RNIB appreciates that there is a role to enable providers to play more of an active role in assessing their own service, but it is not clear what the incentive is to do so. What is the incentive for encouraging providers to sustain and improve service provision? Will there be an expectation on providers or the CQC to monitor and report on the implementation of improvement plans which are meant to align with the CQC existing framework.
It is also not clear how Key Lines of Enquiries (KLOEs) will be used in inspections. Will they only be used when CQC carries out an inspection, or will the expectation be on the providers to do these themselves?It is important that inspections take place not just in main hospital trusts, but that they reach out to satellite clinics, community providers, etc.
The need for an appropriate composition in relation to the inspection team is vital, for example Specialist Professional Advisors should be used in specialised commissioning inspections.
We welcome the fact that the CQC recognises that changes need to be made, particularly to linking information to care pathways and where people move between services, as part of the wider inspection activity. RNIB would welcome any monitoring that CQC can do on this matter concerning eye care pathways.
RNIB also welcomes that future activities will be driven by inspection findings in particular care sectors, and that for adult social care “we will continue to develop our model to reflect the diverse range of services and changing public expectations of care, including how we gather evidence effectively on services provided in people’s homes.”
However, RNIB is not clear as to whether CQC register, monitor, inspect and rate preventative services that include vision rehabilitation services. The Care Act has a strong emphasis on preventative services that are beyond the provision of information and advice. However, there is not one body which is responsible of monitoring the services provided. Please see response to question 3b for further information on vision rehabilitation services.
Theme 6: Developing methods to assess quality for populations and across local areas.
Question 6b:What do you agree with, or not agree with, about assessing quality for populations and across local areas?
RNIB welcomes that the CQC will still be developing thematic reports into 2016/17, but we strongly feel that these should continue to be produced throughout the strategy period. CQC Insight should inform the thematic reviews, as well as feedback and comments from the public and the voluntary sector.
RNIB is calling for a thematic review looking at the health and social care pathway for people with treatable sight conditions, and those who go onto lose their sight.
In terms of treatable sight conditions, the review should look at the eye care pathway, looking at what happens when people are diagnosed, treated and then followed-up for further treatment/monitoring. RNIB is concerned that some people may be losing their sight unnecessarily because of delayed or cancelled follow-up appointments (in particular, hospital initiated cancellations due to insufficient capacity to meet demand for services).
The review should then follow through to examine what is happening in social care to people who cannot be treated, who have lost their sight and received their certificate of vision impairment.
RNIB is publishing evidence on both delayed appointments and the provision of vision rehabilitation support in England in the next six months, and we would be delighted to share our findings with CQC.
Question 8 Are there any other points that you want to make about any of the proposals in this document?
NHS Accessible Information Standard in 2016
2016 marks a turning point year for blind and partially sighted people for whom a new health and social care standard should revolutionise the way NHS and social care providers communicate with users of their services.
However, the revolution relies on all service providers making changes to their processes and procedures for communicating with patients. RNIB is concerned by reports from around the country that indicate many GPs and hospitals are unlikely to meet mandatory deadlines.
The CQC has taken on a role to support the implementation of the new standard, but the practical way in which this role will be taken forward and the mechanisms for enforcement are not as yet clear. During our engagement work with NHS providers, it is clear they take CQC inspections very seriously, to the extent that aspects of their service that aren't inspected get less priority.
RNIB is engaging with CQC to identify opportunities to work together to ensure our expertise is available where needed. It is clear now that the clarity that CQC can give both in terms of inspection regimes and public information, is likely to play a decisive role in how seriously health and social care providers implement the new standard.
We hope that CQC will be able to use the challenges and opportunities created by the new NHS accessible information standard to develop a new vision that ultimately empowers patients.
CQC is accessible
CQC processes need to be accessible to blind and partially sighted patients and users of services, to enable them to fully participate and fulfil their role in CQC's vision.
Inclusion relies on two things, firstly engaging with people with different kinds of accessibility requirements, and secondly successfully building in mechanisms that accommodate needs into the design of websites, apps, printed information, media communications and public information campaigns.