The CQC now has new powers (since 1 April 2023) to assess Integrated Care Systems (ICSs).  As outlined in CQC’s recently published interim guidance on this, these assessments will be carried out using a sub-set of the quality statements in the single assessment framework which CQC will be using across all its work. This will involve using 6 evidence categories to assess ICSs against 17 quality statements (describing what ‘good’ looks like) mapped across 3 overall themes - quality and safety, integration, and leadership. 

Pilot CQC assessments of ICSs are due to start in the Autumn, with baseline assessment of all ICSs to follow thereafter.  With ICSs still relatively new in themselves and the CQC new to assessing systems, it will be a steep learning curve all round. 

In this briefing, we look in more detail at what ICSs can expect from these CQC assessments.

How the CQC assessments will work

The CQC’s new power to assess ICSs stems from the Health and Care Act 2022.  Although the legislation itself does not go into the mechanics of the assessments, the CQC’s interim guidance (which is subject to approval by the Secretary of State for Health and Social Care and is likely to be followed by fuller guidance further down the line) provides quite a lot of detail about what ICSs can expect.

What will the assessments cover?

As the guidance sets out, CQC’s assessments of ICSs will cover:

• the quality and integration of healthcare and adult social care within each ICS;
• how partners in each ICS - the Integrated Care Board (ICB), Local Authorities and providers - are meeting their own responsibilities within the system; and
• the functioning of the ICS, especially how well system partners are working together to deliver good care and meet the needs of their populations, including through the work of Integrated Care Partnerships (ICPs).

This will include looking at how ICSs are achieving their core purpose - i.e. to improve outcomes in population health and healthcare; tackle inequalities in outcomes, experience and access; enhance productivity and value for money; and help the NHS support broader social and economic development. 

How will the assessments be done?

To assess ICSs, the CQC plans to use a sub-set of the quality statements which sit within the new single assessment framework which will eventually be used for all CQC assessments.  The quality statements have been created from the perspective of people’s experiences of care and describe what ‘good’ care looks like.   

17 quality statements will be applied across the following 3 themes:

• Quality and safety - quality statements to include: supporting people to live healthier lives; learning culture; safe and effective staffing; equity in access

• Integration - quality statements to include: safe systems, pathways and transitions; how staff, teams and services work together

• Leadership - quality statements to include: shared direction and culture; capable, compassionate and inclusive leaders; freedom to speak up; workforce equality, diversity and inclusion

In order to assess how each ICS measures up against each quality statement, the CQC plans to use 6 evidence categories. The guidance gives some examples of the types of information that might fall within each of these, as follows: People’s experience (e.g. feedback from people with experience of a pathway across services); Feedback from staff and leaders (e.g. direct interviews, surveys, evidence from self-assessments); Feedback from partners (e.g. including partners involved in the wider determinants of health and wellbeing such as housing or environmental services); Observation (e.g. observing meetings/forums that coordinate health and care in the system such as place-led meetings or integrated board and partnership meetings); Process (e.g. policies, strategies and metrics such as audits); and Outcomes (e.g. quality of life assessments, population data).

The guidance says that CQC will start by assessing the information it already has (e.g. outcomes evidence for ICSs), followed by evidence it will need to request (e.g. specific policies/strategies, survey information held by ICSs) and, finally, evidence the CQC will need to actively collect (e.g. about people’s experiences, through case tracking and focus groups).

What about ratings? Whilst the Health and Care Act 2022 gives CQC the power to review and assess ICSs, it does not require it to give ratings and CQC will not be able to go ahead with rating ICSs unless or until the government gives the green light for this to happen.  Nevertheless, the guidance goes into some detail about how the CQC would go about doing this if/when it is able to do so.  As will be the case for registered providers, the process would involve the CQC applying a 4-point rating scale to reflect how the ICS measures up against each of the quality statements, with a score of 1 if the evidence shows significant shortfalls, up to a score of 4 where the evidence shows an exceptional standard.  The scores for the quality statements would then be aggregated to produce an overall rating for the ICS (‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’) plus an overall score which would indicate where the ICS sits within that rating category.

Prior to publication, draft assessment reports will be shared with the ICB and ICP to enable them to complete a factual accuracy check.

Assessment reports will then be published on the CQC’s website, including the CQC’s findings in relation to each of the themes and for each quality statement, as well as commentary on the progress of the ICS, examples of best practice and areas for improvement.

Once the assessment report is published, system partners will be expected to come together through a local system improvement summit to review the assessment findings and publish action plans, which the CQC will monitor. CQC may then share any concerns with relevant national partners (for example, with NHS England, DHSC or the Local Government Association) for them to oversee support or make an intervention if needed.

What are the timescales?

As a first step, between now and July 2023, CQC plans to carry out a national review across all ICSs, focusing on just one of the quality statements - equity in access.  This will involve a review of publicly available data and ICSs have also been invited to take part in focus groups looking at this topic.

From Autumn 2023, CQC will start to pilot its assessments of ICSs. The learning from that pilot will then be fed into CQC’s final published approach to ICS assessments.

CQC will then proceed to carry out baseline assessments of all 42 ICSs and the resulting assessment reports will be published (together with ratings, subject to what the government decides on that). There are not yet any set dates for when these baseline assessments will start.

Looking ahead beyond the baseline assessment period, the CQC will move to ongoing assessment of ICSs. This will be a risk-informed approach, involving gathering/assessing evidence at different points in time and updating the information it publishes about an ICS as and when needed.

What does the Hewitt Review say about this?

The recently published independent review of Integrated Care Systems - the Hewitt Review - which was commissioned by the government to look at the oversight and governance of ICSs, talks positively about the CQC’s enhanced role here.

It describes CQC reviews of ICSs as “effectively a ‘well-led’ review” and suggests this work should be led by a ‘Chief Inspector of Systems’.  It also suggests that CQC should assess the level of maturity and effectiveness of each ICS as a whole and recommends a number of factors to be considered here, including how far the system is making progress in shifting resources towards prevention, population health and tackling health inequalities.   It also suggests that both CQC and NHS England have a vital role in oversight and accountability of ICSs, but should ensure their improvement approaches are as complementary as possible.

On the subject of ratings, the Hewitt Review is supportive of ICSs being awarded ratings by CQC, but suggests giving the new arrangements more time to bed in before that happens: “In their first year the focus of CQC should be on calibration of their assessments and supporting improvement and sharing best practice amongst systems within their reports rather than assessment and rating.”

It will be interesting to see what the government says on these points when it responds to the Hewitt Review.

How we can help

Our specialist CQC lawyers have many years of experience of advising health and social care providers on the full range of issues that CQC regulation brings with it, including supporting boards and senior leadership teams in preparation for ‘well-led’ assessments.  We can bring this extensive sector knowledge and experience to advising and supporting ICSs and particularly ICBs and ICPs in relation to their upcoming CQC assessments, including:

• Pre-assessment compliance support, such as helping to identify CQC’s likely key focus areas for your ICS
• Senior leadership preparation sessions, covering what CQC will be looking for in terms of ICS leadership and governance, including interview preparation for leaders/senior managers
• Support for operational teams around the CQC’s role and processes, including the assessment framework and what information they may be asked to provide to CQC
• Support with factual accuracy check responses to draft CQC assessment reports, including working with in-house teams to help ensure that final reports and ratings are a fair and accurate reflection of your ICS