CQC’s changes for flexible regulation: equality impact assessment

Impact

• Currently, site visits are the main way that we gather information related to people’s lived experiences of health and social care services.
• As we move away from relying on a set schedule of large inspections, we need to ensure we have sufficiently accessible alternative ways to gather people’s views. This is particularly true during the ongoing pandemic.
• Some respondents to the consultation expressed concern that the proposals to move away from a set schedule of inspections would disadvantage people who can’t communicate with CQC independently.
• It is important that we do not exclude or add to the exclusion of people in how we enable them to communicate with us. This includes people who cannot or do not wish to use digital methods and those who feel that face-to-face is the most effective way to communicate.
• Some respondents to the consultation were concerned that the proposed approach would risk overlooking specific population groups because the use of data to assess quality would not identify their needs or experiences clearly.
• We therefore need to ensure that feedback from harder-to-reach and vulnerable groups is included within the data we collect.

Mitigation

• We'll capture information about people’s experience and views on equality in a range of ways that are accessible and easy to use. We can build this into how we produce our ratings in stronger ways.
• By moving away from using site visits as the main way to gather information, we’ll be able to reach a broader cross section of people using services and implement better ways to collect and use information relating to equality.
• When we develop alternative methods of gathering the views of people who use services, we need to consider the best ways to obtain evidence and that we do it in a tailored, accessible and confidential way, including face-to-face when most appropriate.
• We need to involve service providers, Experts by Experience and a diverse group of people who use health and care services when we review and redesign our regulatory model.

Impact

• Moving towards a targeted and risk-based model for assessing, rather than inspection frequencies based on previous rating, can have a positive impact on equality. We’ll need to incorporate the evidence and ensure it influences our assessment of quality and ratings in a timely and accurate way.
• To do this, we’ll need to develop our current regulatory approach. This includes using up-to-date information to help us target our regulatory work to where it is most needed, including in relation to equality.
• The equality information in data sets that we use can be poor quality. For example, data from care providers has low completion rates of equality monitoring of people using their services. This can make it more difficult to analyse whether people are receiving equal outcomes from care.

Mitigation

• We can make the right intervention at the right time, rather than waiting for set scheduled inspections. This is a more flexible approach that will enable us to be more responsive to equality issues as they arise.
• By using the data we receive proactively, we can focus more on risks to safe care, including equality.
• We'll work with providers to make sure they collect and submit robust data about services for people with protected equality characteristics and extend this to socio-economic status. We can also link to evidence from people who use health and care services.
• By working with other stakeholders, we can maximise how we use the data on equality that they already hold.
• We'll publish ratings and assessment outcomes in a range of ways that make them accessible and easy to understand to help people make informed decisions about their care.

Impact

• Some respondents to the consultation believed that removing ratings for population groups for GP services is a step backwards in our recognition of the importance of how different groups experience care in these services. They thought it would result in a loss of focus on these groups and a reduction in detailed information that is helpful to providers, people who use services and the public.
• The six existing population groups (older people, people with long-term conditions, families, children and young people, working age people, people whose circumstances may make them vulnerable, and people experiencing poor mental health) do not cover all groups of people who could be more likely to have a poorer experience of care or health inequalities.
• The six groups are equally weighted, which does not always reflect the demography of a GP practice’s patient list.
• Removing population group ratings will make published outcomes more accessible and easier for the public to understand, which will support them in making informed decisions.

Mitigation

• Providing care to specific population groups is often influenced by wider local health systems. We have already started to adapt our Health Inequalities tool, which forms part of the Provider Collaboration Review programme, to record and respond to how well health and social care services work together to ensure equality and reduce inequalities. Understanding this can be critical for the health and wellbeing of people in different groups.
• We also focus on health inequalities within the wider review topics.
• By not having fixed categories of population groups there is an opportunity to look at a wider range of health inequalities more flexibly, depending on the local circumstances (including how services are organised and the demographics of the patient population).
• GP practices are increasingly working in collaboration through Primary Care Networks. So, removing the fixed population group categories will provide an opportunity for us to consider how providers within a network have worked together to identify and respond to the needs of their population.
• This change doesn’t mean that we’ll stop looking at how practices provide personalised and proactive care to their local populations and considering people’s different needs when receiving primary medical care. This will still be a key part of our assessment activity.
• As part of how we implement our new strategy, we are reviewing our assessment frameworks. This will include strengthening our approach to health inequalities as well equality issues.

Impact

• Under our current assessment framework, equality is captured primarily under the responsive and caring key questions.
• At present, these are not ‘assessed’ at the trust level but are an aggregation of ratings at service level.

Mitigation

• We have the opportunity to carry out much stronger assessment of a range of issues at the trust level, which is not solely an aggregation of service-level findings or limited to areas.
• We need to develop our approach to assessing the well-led key question at trust level to make sure that we look at the overall organisational performance on quality and safety effectively as part of that assessment. This will need to consider a range of areas that are key themes in our new strategy, including health inequalities and equality issues.
• We aren’t proposing any changes at service level and we will continue to look at issues at the point at which people receive care.

Assessing quality

Impact

• It is important that we do not exclude or add to the exclusion of people in how we enable them to communicate with us. This includes older people who cannot or do not wish to use digital methods and those who feel that face-to-face is the most effective way to communicate.
• We therefore need to ensure that feedback from harder-to-reach and vulnerable groups such as older people is included within the data we collect.
• Covered by Cross-cutting equality issues

Mitigation

• Covered by Cross-cutting equality issues

Removing ratings for population groups in GP practices

Impact

• Some consultation respondents believed that removing ratings for population groups for GP services as a step backwards in our recognition of the importance of how different groups experience care in these services. Some believed it would mean a loss of focus on these groups and a reduction in detailed information that is helpful to providers, people who use services and the public.
• However, the six existing population groups (including older people) do not cover all groups of people who could be more likely to have a poorer experience of care or health inequalities.
• Covered by Cross-cutting equality issues

Mitigation

• Covered by Cross-cutting equality issues

Changes to NHS trust level ratings

Impact

• Covered by Cross-cutting equality issues

Mitigation

• We aren’t proposing any changes at service level and we will continue to look at issues at the point at which people receive care (for example, in a dementia service).
• Covered by Cross-cutting equality issues

Removing ratings for population groups in GP practices

Impact

• Some consultation respondents believed that removing ratings for population groups for GP services is a step backwards in our recognition of the importance of how different groups experience care in these services. Some believed it would mean a loss of focus on these groups and a reduction in detailed information that is helpful to providers, people who use services and the public.
• However, the six existing population groups do not cover all groups of people who could be more likely to have a poorer experience of care or health inequalities. For example, carers and people with caring responsibilities (other than those caring for children) are not currently identified as an existing population group.
• Covered by Cross-cutting equality issues

Mitigation

• Covered by Cross-cutting equality issues

Assessing quality

Impact

• It is important that we do not exclude or add to the exclusion of people in how we enable them to communicate with us. This includes people with disabilities who cannot or do not wish to use digital methods and those who feel that face-to-face is the most effective way to communicate.
• Some respondents to the consultation were concerned that the proposed approach would risk overlooking specific population groups because the use of data to assess quality would not identify their needs or experiences clearly.
• We therefore need to ensure that feedback from harder-to-reach and vulnerable groups such as people with disabilities is included within the data we collect.
• Covered by Cross-cutting equality issues

Mitigation

• Covered by Cross-cutting equality issues

Removing ratings for population groups in GP practices

Impact

• Some consultation respondents believed that removing ratings for population groups for GP services is a step backwards in our recognition of the importance of how different groups experience care in these services. Some believed it would mean a loss of focus on these groups and a reduction in detailed information that is helpful to providers, people who use services and the public.
• However, the six existing population groups do not cover all groups of people who could be more likely to have a poorer experience of care or health inequalities. For example, people living with disability are not currently identified as an existing population group.
• Covered by Cross-cutting equality issues

Mitigation

• Covered by Cross-cutting equality issues

Changes to NHS trust level ratings

Impact

• Covered by Cross-cutting equality issues

Mitigation

• We aren’t proposing any changes at service level and we will continue to look at issues at the point at which people receive care (for example, in a learning disability service).
• Covered by Cross-cutting equality issues

Assessing quality

Impact

• It is important that we do not exclude or add to the exclusion of people in how we enable them to communicate with us. This includes people for whom English is not their first language who cannot or do not wish to use digital methods and those who feel that face-to-face is the most effective way to communicate.
• Some respondents to the flexible regulation consultation were concerned that the proposed approach would risk overlooking specific population groups because the use of data to assess quality would not identify their needs or experiences clearly.
• We therefore need to ensure that feedback from harder-to-reach and vulnerable groups such as people for whom English is not their first language is included within the data we collect.
• Covered by Cross-cutting equality issues

Mitigation

• Covered by Cross-cutting equality issues

Removing ratings for population groups in GP practices

Impact

• Some consultation respondents believed that removing ratings for population groups for GP services is a step backwards in our recognition of the importance of how different groups experience care in these services. Some believed it would mean a loss of focus on these groups and a reduction in detailed information that is helpful to providers, people who use services and the public.
• However, the six existing population groups do not cover all groups of people who could be more likely to have a poorer experience of care or health inequalities. For example, people from Black and minority ethnic groups not currently defined as an existing population group.
• Covered by Cross-cutting equality issues

Mitigation

• Covered by Cross-cutting equality issues

Changes to NHS trust level ratings

Impact

• Covered by Cross-cutting equality issues

Mitigation

• We aren’t proposing any changes at service level and we will continue to look at issues at the point at which people receive care (for example, in a specialised women’s service).
• Covered by Cross-cutting equality issues

Removing ratings for population groups in GP practices

Impact

• Some consultation respondents believed that removing ratings for population groups for GP services is a step backwards in our recognition of the importance of how different groups experience care in these services. Some believed it would mean a loss of focus on these groups and a reduction in detailed information that is helpful to providers, people who use services and the public.
• However, the six existing population groups do not cover all groups of people who could be more likely to have a poorer experience of care or health inequalities. For example, people who have undergone gender reassignment are not currently identified as an existing population group.
• Covered by Cross-cutting equality issues

Mitigation

• Covered by Cross-cutting equality issues

Changes to NHS trust level ratings

Impact

• Covered by Cross-cutting equality issues

Mitigation

• We aren’t proposing any changes at service level and we will continue to look at issues at the point at which people receive care (for example, in a gender dysphoria service).
• Covered by Cross-cutting equality issues

Impact

• Covered by Cross-cutting equality issues

Mitigation

• Covered by Cross-cutting equality issues

Removing ratings for population groups in GP practices

Impact

• Some consultation respondents believed that removing ratings for population groups for GP services is a step backwards in our recognition of the importance of how different groups experience care in these services. Some believed it would mean a loss of focus on these groups and a reduction in detailed information that is helpful to providers, people who use services and the public.
• However, the six existing population groups (one of which, Families, children and young people, includes expectant and new parents) do not cover all groups of people who could be more likely to have a poorer experience of care or health inequalities.
• Covered by Cross-cutting equality issues

Mitigation

• Covered by Cross-cutting equality issues

Changes to NHS trust level ratings

Impact

• Covered by Cross-cutting equality issues

Mitigation

• We aren’t proposing any changes at service level and we will continue to look at issues at the point at which people receive care (for example, in a maternity service).
• Covered by Cross-cutting equality issues

Impact

• Covered by Cross-cutting equality issues

Mitigation

• Covered by Cross-cutting equality issues

Removing ratings for population groups in GP practices

Impact

• Some consultation respondents believed that removing ratings for population groups for GP services is a step backwards in our recognition of the importance of how different groups experience care in these services. Some believed it would mean a loss of focus on these groups and a reduction in detailed information that is helpful to providers, people who use services and the public.
• However, the six existing population groups do not cover all groups of people who could be more likely to have a poorer experience of care or health inequalities. For example, people who identify as LGBTQ+ are not currently identified as an existing population group.
• Covered by Cross-cutting equality issues

Mitigation

• Covered by Cross-cutting equality issues

Impact

• Currently, site visits are the main way that we gather information related to human rights in health and social care services. As we move away from relying on a set schedule of large inspections, we need to ensure we have sufficiently accessible alternative ways to gather people’s views. This is particularly true during the ongoing pandemic.
• Some respondents to the consultation expressed concern that the proposals to move away from a set schedule of inspections would disadvantage people who cannot communicate with CQC independently.
• It is important that we do not exclude or add to the exclusion of people in how we enable them to communicate with us. This includes people who cannot or do not wish to use digital methods and those who feel that face-to-face is the most effective way to communicate.
• Some respondents to the flexible regulation consultation were concerned that the proposed approach would risk overlooking specific population groups because the use of data to assess quality would not identify their needs or experiences clearly.
• We therefore need to ensure that feedback from harder-to-reach and vulnerable groups is included within the data we collect.
• Some respondents to the flexible regulation consultation expressed concern that the proposed approach would lead to fewer inspection visits, which would be detrimental to CQC’s ability to observe organisational culture and obtain a robust impression of the care environment.

Mitigation/opportunity

• We’ll be able to capture information about people’s experience and views on human rights in a range of ways that are accessible and easy to use. We can build this into how we produce our ratings in stronger ways.
• We’ll continue to carry out site visits. We know that poor cultures can exist in all types of services, but we’ll focus particularly on the types of care setting or providers where there’s a greater risk of a poor culture going undetected. This may mean we make more frequent site visits to those settings. We’ll use our powers to visit services when we need to respond to risk, when we need specific information that can only be gathered through a site visit, when we need to observe care and to ensure that our view of quality is reliable.
• By moving away from using site visits as the main way to gather information, we’ll be able to reach a broader cross section of people using services and implement better ways to collect and use information relating to human rights.
• When we develop alternative methods of gathering the views of people who use services we need to consider the best ways to obtain evidence and that we do it in a tailored, accessible and confidential way, including face-to-face when most appropriate.
• We need to involve service providers, Experts by Experience and a diverse group of people who use health and care services when we review and redesign our regulatory model.
• We need to ensure that we focus on the types of care setting where people are unable to speak up for themselves and where there is a greater risk of a poor culture going undetected, with site visits continuing to be a central tool in ensuring that human rights are being respected.

Reviewing and updating ratings

Impact

• Moving towards a targeted and risk-based model for assessing, rather than inspection frequencies based on previous rating, can have a positive impact on human rights. We’ll need to incorporate the evidence and ensure it influences our assessment of quality and ratings in a timely and accurate way.
• To do this, we’ll need to significantly develop our current regulatory approach. This includes using up to date information to help us target our regulatory work to where it is most needed, including in relation to human rights risks.

Mitigation/opportunity

• We can make the right intervention at the right time, rather than waiting for set scheduled inspections. This is a more flexible approach, that will enable us to be more responsive to human rights issues as they arise.
• By using the data we receive proactively, we can focus more on risks to safe care, including human rights risks.
• By working with other stakeholders, we can maximise how we use the data on human rights that they already hold.

Removing ratings for population groups in GP practices

Impact

• Removing ratings for population groups for GP services could be perceived as a step backwards in our recognition of the importance of how different groups experience care in this setting and would imply a loss of focus on these groups.
• However, the six existing population groups do not cover all groups of people who could be more likely to experience poor care.

Mitigation/opportunity

• Providing care to specific population groups is often influenced by wider local health systems. We have already started to adapt our Health Inequalities tool, which forms part of the Provider Collaboration Review programme, to record and respond to how well health and social care services work together.
• This change doesn’t mean that we’ll stop looking at how practices provide personalised and proactive care to their local populations and considering people’s different needs when receiving primary medical care. This will still be a key part of our assessment activity.
• As part of how we implement our new strategy, we are reviewing our assessment frameworks. This will include strengthening our approach to human rights issues.

Changes to NHS trust level ratings

Impact

• Under our current assessment framework, human rights are captured primarily under the responsive and caring key questions.
• At present, these are not ‘assessed’ at the trust level but are an aggregation of ratings at service level.

Mitigation/opportunity

• We have the opportunity to carry out much stronger assessment of a range of issues at the trust level, which is not solely an aggregation of service level findings or limited to areas.
• We need to develop our approach to assessing the well-led key question at trust level to make sure that we look at the overall organisational performance on quality and safety effectively as part of that assessment. This will need to consider a range of areas that are key themes in our new strategy, including human rights issues.
• We aren’t proposing any changes at service level and we will continue to look at these issues at the point at which people receive care (for example, in a maternity service).

Human rights duties compliance

• Freedom from inhumane or degrading treatment

Mitigation/opportunity

• Freedom from inhumane or degrading treatment

Human rights duties compliance

• Freedom from inhumane or degrading treatment

Mitigation/opportunity

• Freedom from inhumane or degrading treatment

• Freedom from inhumane or degrading treatment

Mitigation/opportunity

• Freedom from inhumane or degrading treatment