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What will you be doing over the next 5 years?

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Well, the recent Barclays Bank online provider surveys showed that 65% of care home operators believe the National Living Wage
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will affect the viability of their business. Paul Birley, Head of Healthcare at Barclays says, that ‘3 years ago our survey said the biggest issue was reputational risk, last year it was fee cuts. This year staffing and recruitment is uppermost in most providers’ minds’. Phil Burgan of MMCG Care Homes says ‘it’s a polarised sector, the haves and the have nots and the have nots won’t survive. I believe 20,000 to 50,000 beds will go in the next few years’. All very depressing stuff and even if some of this plays out, it means that so many providers will, over the next 5 years, be juggling with business viability, struggling to pay the wages but resisting reducing staff numbers in order to maintain quality, and/or organising a measured and timely withdrawal from the market.
In the meantime, we see that the Care Quality Commission (CQC) will be using the next five years to reinvent itself. This will

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probably be its third iteration having started in 2010 with a light touch approach, moving on to ‘losing’ the NHS predominance in the hierarchy who dealt only with compliance and applied high level aggressive behaviours to show their teeth and replacing it with people who know about care. There is still a long way to go because CQC does not like challenge and continues to face towards the public, the media and politicians at the expense of the reputation and potentially the sustainability of the sector.
So, it is evident that CQC needs to get this iteration of its strategy right. In practical terms it needs to warm up to challenge and be prepared to respond with the evidence to support its argument and be transparent about its mistakes. It too, needs to say sorry, especially to providers who put their businesses on the line and have the courage to challenge successfully. A good way to lose the fear factor and gain respect is to work with providers, not against them. Advice and guidance is no bad thing and contributes to a more respectful and understanding atmosphere. The care sector wants and needs a regulator.
Let’s have a look at whether what needs to be done is reflected in what CQC proposes should be done over the next five years. The consultation period is almost over at the time of writing this but it will be interesting to study the comparison. In their consultation, CQC have chosen 6 main themes:

1. Improving its use of data and information
2. Implementing a single shared view of quality
3. Targeting and tailoring its inspection activity
4. Developing a more flexible approach to registration
5. Assessing how well hospitals use resources
6. Developing methods to assess quality for populations and across local areas

Frankly, the data issue is difficult for the social care sector whereas hospitals are much easier to collect data on. Given this

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objective, we don’t wish to see the regulator filling the vacuum by latching onto the limited data available to them and believing it without testing it. Already there is pressure for providers to ensure their NHS Choices information is monitored and kept up to date but the shot in the foot from the Care Act 2014 is that providers are also under pressure to ensure their local authority information portals are also monitored and kept up to date. If they do not, then local commissioners will not be able to see vacancies in care homes and channel placements.
The need for a single shared view of quality has been around for ever and CQC have not really worked on this since it was made a requirement in the Social Care Act 2008. Certainly, providers have been asking for this for years but by pulling away from inspecting Local Authorities (LA), CQC may well have made it very difficult for them to make any progress unless they reverse their decision to keep away from LAs. The sector as whole would also like to see NHS commissioners included in the regulatory perspective as well as LAs. Without this in place first, then it is difficult to see how CQC will be able to influence a single view of quality.
There is a lot of alliteration in the next strategic objective but it could so easily be taken as meaning cutting to size and narrowing the focus. If this is so, the danger is that the frequency of onsite inspections may reduce, largely because CQC has to operate within a tightening budget (we have seen evidence of this when experts by experience hourly rates were under threat of halving). If they do reduce, the casualty will be the provider and their clients, because the greater the period between inspections the more likely the quality of care will diminish. We saw this happen under the previous regulator.
Of course the registration process needs major attention; it has been nothing but a nightmare for years. The fact that this has become a strategic objective suggests that thankfully CQC recognise how important it is to improve the process and loosen it up where the registrants are already known to them.
The efficient use of resources should always be in the top line of strategic business planning. In terms of how this translates to social care, hospitals would do well to focus on their discharge processes to minimise delays and thereby save money as well as beds. The money saved can move across to social care via the Better Care Fund.
The final objective needs some careful thought. A lot has been said about creating care pathways for people so that the journey for them is transparent and clear, having a single care manager and point of contact. The Symphony Project in Somerset is what this is all about and the Better Care Fund is the financial vehicle. It can only work if health and social care are fully integrated and there is a single budget to fund the care pathway. There is an opportunity not to be missed for the regulator to encourage integration both financially and culturally but for it to bite CQC will find it necessary to get much closer to the commissioners in both health and social care in order to gain a useful understanding of the quality of the experience for service users and the part played in that by commissioners.
There are clearly some touch points between what is seen as needed and what CQC see as their objectives for the next 5 years.

Roger Wharton – Care Association Alliance

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