By Matt Quinn, Manager and Dan Donaghy, Director, UK Public Sector Enterprise Operations team
The impending establishment of Integrated Care Boards (ICBs) as statutory entities from April 2022 means that regulators are adapting their regulatory models. This is to ensure a proportionate response for a ‘Systems’ based world. This also heralds a period of flux for health and social care regulation in England at a time of unprecedented demand and operational pressure precipitated by the pandemic. Health and social care organisations will need to respond to this new regulatory regime and change their operating models to ensure their leadership, financial, safety and quality performance meet regulatory expectations. In this blog, we discuss some suggested areas of change informed by our recent work in the area.
How has the regulatory environment changed?
The Care Quality Commission (CQC) have recently published a new strategy that focuses on assessing local systems and how these systems tackle health inequalities and prevention.1 NHS England / Improvement (NHSEI) have also recently established the new Systems Oversight Framework (SOF).2
These new regulatory regimes encourage collaboration between providers, as well as assessing cross-system quality and how ICS leadership or individual organisations have contributed to this. CQC is in a fortuitous position to be able to assess cross-system quality and performance due to its extended remit for adult social care, primary care and independent sector providers, organisations that are not covered by the SOF framework.
NHSEI SOF: NHSEIs System Oversight Framework has introduced a number of metrics which are due to measure different aspects of performance at different levels across a system
CQC: CQC are replacing set piece inspections with a more longitudinal form of assessment driven by risk-based analytics, and importantly, an ‘always on’ view of safety and quality (figure 1). This means more emphasis on an ongoing relationship with regulated providers. It also means health and social care providers must start to think about how they are able to share regulatory information both in real-time and between system stakeholders.
Figure 1: Areas of focus identifies by the CQC
Source: Deloitte LLP
The regulatory model will focus significantly on user/patient voice, and how services respond to this in a dynamic way. The CQC will also be focussing on wider system-based thematics, like inequalities and access, given quality is an equitable response to need. The revised regulatory model also has a renewed emphasis on the assessment of safety cultures, front-line learning and continuous improvement mechanisms. Individual provider performance will still be a priority, but so too will understanding the impact of individual actors on overall system performance.
There is also provision within the current draft legislation for CQC to regulate ‘systems’ themselves building on their experience of Provider Collaboration Reviews during 2020-21. Systems in this context could be either ICBs, ICSs or both but will also include elements of social care provision from local authorities. It’s fair to say that providers and systems will feel this change in tone and priority very soon.
What should ICSs do to respond?
To address these new regulatory requirements ICSs/ICBs should continue to redesign both system and organisational level Target Operating Models linking this new regulatory reality with the good advice and guidance in the ICS Design Framework.3 In our experience these should incorporate the following elements:
Developing an Insight Driven Organisation (IDO)4: A shift to align the organisation around its capability to collect, assimilate and analyse large amounts of data on a real-time basis (an IDO maturity curve is outlined in figure 2 below). This data should then be used to direct transformation/ improvement activity. This will enable ICBs to provide real-time information to regulators.
Figure 2: Insight driven organisation maturity curve
Source: Deloitte LLP
This data model also needs to be able to illustrate the impact a single organisation has on both system performance and the performance of other providers in the system. Services that impact one another across health and social care pathways in the ICS should also be monitored. The IDO should also be set up to ‘quantify’ collaboration. Lack of collaboration between organisations will now be viewed as a breach of governance within the SOF, and the CQC will increasingly be asking providers (and maybe ICBs themselves) to demonstrate how this interconnectedness is being planned for, monitored and assessed at a system level. Part of the answer will be having sound Population Health Management capability, but this will only be part of the response.
Embedding and acting upon user/patient voice: The ability to collect and use the user/patient voice in a continuous process will be fundamental. This should be embedded both in how services are designed but also in how they are transformed and monitored. Regulators will be looking for services that are dynamic and based on user requirement information. A useful capability that could be explored is ‘social listening’. This involves collecting and analysing data from social platforms (and other sources). Systems could also deploy operational tactics to embed a user-voice culture such as ‘mystery shopper’ initiatives. The consumer industry is a valuable learning resource and techniques can be adopted and mimicked from a variety of different industries. Systems will need to be able to evidence this involvement and co-design, as well as a positive feedback loop when services are operational, to satisfy regulatory questions in the future.
Relationship Management: To enable an ‘always on’ approach to regulation, ICSs could mirror regulator’s relationship management structures. They should invest in the management of these relationships to develop a ‘no surprises’ culture supporting a more fluid exchange of information rather than point-in-time inspections – which in any case will not be the way regulation will operate in the future. Practically, this means systems will need skills in relationship management toward the regulators, and leaders will also need to deliver a just and learning culture where working with regulators is part of an ongoing conversation with the oversight body, not a confrontational or periodic exchange.
Safety cultures: Regulators will look to promote safety cultures across systems, (some of whom have been looking at this for some time).5 In practice, systems should build a capability that undertakes thematic review of safety, conducts research and develops plans around areas like human factors in safety incidents.6 ICBs should also support the expansion of complaints handling systems and an improvement culture where failures are seen as learning opportunities. This will require partnership in the commissioning of services at the provider network level and beyond – especially where services stretch across NHS and Local Authority boundaries.
Actively addressing care inequalities: There will be more emphasis on assessing whether the provision of health and social care addresses care inequalities in access, experience and outcome terms. The CQC is already testing how this can be done using funding from the Department for Business Energy and Industrial Strategy (BEIS) regulatory pioneer programme.7 To respond to this ICSs should be looking to develop a capability that thematically reviews the wider determinants of health and care, and be able to evidence how this has led to a transformation response. This presents opportunities for partnering with local authorities from a public health perspective and the third/private sector to establish transformation partnerships. For example, the CQC, will be looking at providers, services and system management through these inequality lenses to judge quality and safety for the public.
Regulatory Quality Assurance Model: ICBs should seek to assure themselves that they adhere to the standards and expectations they have been set. This will ensure that there are ‘no surprises’ regarding regulatory assessments. A number of private healthcare providers self-assure in this way through applying in-house developed software that mirrors current regulatory frameworks and this is common practice in other highly regulated industries such as pharmaceuticals/MedTech and financial services. This should form part of the wider operating model which in itself should be influenced by the changing nature of regulatory expectations (Figure 3).
Figure 3: Elements of the ICS operating model that will help respond to the changing regulatory environment
Source: Deloitte LLP
Conclusion and next steps
This blog has outlined at a glance how the UK health and social care regulatory landscape is changing. It also outlines how ICSs might design responses to this regulatory shift into their new Target Operating Models. Ultimately ICSs will have to consider the design of their system-level target operating models carefully to ensure the aspirations of the Health and Care Bill are delivered and they can respond to the new and developing models of regulation they will find themselves delivering within.