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From YouTube: CQC board meeting – December 2017
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A
Okay,
good
morning,
everybody
welcome
to
our
December
board.
Meeting
we
have
a
apologies
from
Lewis
Appleby
and
from
mortar
mortar
is
on
paternity
leave.
I
think
the
board
might
want
to
which
mortar
and
his
wife
will
give
mortar
and
his
wife,
sir,
our
congratulations
on
their
baby.
It's
great
news
and.
A
Good
right
declarations
of
interest
other
than
we
all
love
babies,
any
any
other
declaration
of
interest.
Anybody
wants
to
make
good
right
minutes
of
meeting
of
the
15th
of
November.
Are
there
an
accurate
record
or
everything
we
discussed?
Okay,
good
on
the
action
log.
There
are
three
items,
one
scheduled
for
the
RG,
see
in
January
and
then
two
to
come
back
in
February,
so
nothing
for
this
board.
Was
there
any
other
matter
arising
that
isn't
on
the
agenda
that
anybody
wanted
to
raise?
C
B
Quickly,
apologies
so
thank
you
very
much.
David
I
just
wanted
to
highlight
a
couple
of
things
as
we
run
through
the
run
through
the
papers,
so
on
slide
three
in
the
pack
I'm
just
to
draw
attention
to
the
continued
improvement,
improving
performance
of
the
registration
team
in
completing
applications-
we're
not
quite
at
ninety
percent,
which
is
our
target
at
the
moment,
but
we
are
progressing
much
better
than
we
did
last
year
and
that
is
in
the
face
of
increasing
numbers
of
applications
as
well.
B
B
Just
to
reassure
you,
I
mean
what
we've
highlighted
in
the
paper.
Is
that
the
expectation
that
we
will
return
to
services
within
given
periods
of
time
linked
to
the
ratings
that
they
previously
had?
We
are
declaring
in
today's
report
that
we're
not
going
to
hit
the
90
percent
target
for
that
by
the
end
of
this
financial
year.
However,
what
I
wanted
to
reassure
the
board
on
was
the
most
important
thing
that
we
do
is
that
we
need
to
be
responding
to
the
risks,
and
that
is
the
way
that
we
are
progressing.
B
So
that
is
the
way
that
I'm
encouraging
the
teams
to
deploy
the
limited
resources
that
we've
got
to
make
sure
that
we
are
doing
that
properly
and
the
reason
why
the
inspection
number
the
inspection
productivity
dips
is
because,
if
we've
got
fewer
inspectors,
the
monitoring
that
we
have
to
do
of
the
entire
portfolio
obviously
needs
to
continue.
So
there
are
fewer
people,
looking
the
numbers
of
inquiries
and
notifications,
safeguarding
alerts
and
concerns,
and
those
numbers
are
increasing
as
well.
B
So,
balancing
between
inspection
activity
and
monitoring
activity
is
is
something
that
we're
we're
trying
to
to
do
throughout
and
then
finally,
I
just
wanted
to
draw
attention
that,
despite
the
fact
that
we've
got
all
of
those
pressures,
the
performance
on
publishing
reports
we're
continuing
to
creep
ever
closer
to
the
ninety
percent
and
key
performance
indicator
target
and
are
hitting
86
percent
at
the
moment.
It's
something
that
we
continue
to
monitor
because
it's
obvious
are
very
important
that
once
we've
completed
inspection,
we
are
able
to
share
both
the
detail.
B
We
will
have
given
initial
feedback
to
providers,
but
the
detail
of
the
feedback
to
providers,
but
also
to
put
that
publicly
on
that
on
the
website.
So
it's
available
for
people
and
we
know
how
important
it
is
to
people
that
they
have
access
to
our
reports,
particularly
in
adult
social
care,
because
they're,
using
that
to
inform
their
decisions
around
choices
of
either
care
homes
or
tomassoni
care
services.
So
those
were
the
things
that
I
wanted
to
highlight.
B
A
D
A
question
about
something
one
of
the
live
graphs
about
the
volume
living
choirs
about
unregistered
providers
and
I,
wonder
whether
that
doesn't
look
scaler
things,
perhaps
a
big
number
of
inquiries,
but
I
wonder
what
that
represented
by
where
underlying
work,
and
also
from
confirmation
that,
when
we
do
work
on
unregistered
providers,
presumably
the
cost
of
that
has
to
be
getting
to
be
born.
Bother.
The
fees
paid
by
the
registered
providers
is
that
right
and
that
wondered
whether
there's
any
reflection
on
either
of
those
two
points
on.
B
The
point
about
the
impact
on
workload.
What
we
agreed
at
the
last
meeting
was
that
we'd
bring
back
a
bit
more
detail
in
the
court
and
the
third
quarter
report
which
and
the
board
will
get
I
think
in
February,
but
just
to
give
you
a
brief
indication
in
what
we.
What
that
it
is
actually
quite
a
considerable
piece
of
work
and
there
are
increasing
numbers
of
referrals
being
made
to
us.
The
team
need
to
assess
whether
there
is
indeed
a
regulated
activity
that
has
been
delivered.
B
Sometimes
things
are
reported
to
us
and
actually
it's
not
a
regulated
activity,
and
but
we
need
to
assure
ourselves
that
that's
the
case.
In
some
circumstances.
It
then
progresses
in
terms
of
us
encouraging
people
to
go
through
the
application
and
and
that's
all
fine
and
and
we
get
them
into
the
process,
but
in
other
circumstances
people
are
willfully
avoiding
regulation
and
we
do
take
action
against
them
as
a
consequence
of
that
and
clearly
enforcement
action
is
on.
The
civil
basis
is
quite
time-consuming
as
well.
So
there
is
a
significant
amount
of
work.
B
That's
involved
in
that,
and
we
are
looking
at
how
we
can
improve
the
information
about
that
as
we're
going
on.
Yes,
we've
kind
of
created
the
team
so
that
we
can
cover
the
cost.
Certain
we've
got
the
capacity
to
do
that
and
that
will
have
an
impact
on
costs.
I
mean
I,
wouldn't
be
able
to
say
exactly
how
much
that
is
Robert
I'm,
very
sorry,
but
but
yes,
it
is
something
that
we've
got
to
take
into
account
to
make
sure
there
and
where
we
have
got
caught.
B
We
have
got
sufficient
resources
to
be
able
to
do
that.
It
is
I,
think
important
for
those
providers
who
are
registered
with
us,
but
we
do
this
aspect
of
our
work
properly
for
two
reasons:
one
so
that
there's
a
level
playing
field.
You
know
you
don't
have
one
set
of
providers
going
off
and
delivering
regulated
activities
without
regulation
and
therefore
escaping
that
purview.
B
But,
secondly,
if
they
are
then
in
doing
that
and
providing
services
that
are
inappropriate
or
lead
to
significant
concerns,
then
you
know
a
zephyr
that
brings
down
the
reputation
of
all
of
the
other
services,
and
this,
of
course,
is
across
not
just
apple
social
care,
but
primary
medical
services
and
the
services
that
Ted's
team
regulates
too
so,
and
we
need
to
make
sure
that
we
are
picking
these
up
and
that
for
everybody
and
providers,
but,
most
importantly,
the
public.
We
are
identifying
them
and
addressing
the
problems.
E
Thank
you
Peter.
So,
as
of
now,
we've
inspected
36
trusts
under
the
next
phase
methodology.
You'll
remember
this
started
in
August
of
this
year.
We've
started
rolling
it
out,
and
we've
now
been
on-site
into
the
six
dress.
That's
about
15%
of
the
total.
So
we've
started
this
off
at
quite
a
fast
pace
as
you'll
know
where
we
are
planning
in
long
term
to
get
through
all
hundred
thirty
odd
trusts
in
a
year
in
terms
of
an
annual
cycle.
E
We
need
to
do
in
developing
them,
but
I
want
to
pay
tribute
to
the
frontline
staff
been
implementing
I,
think
they've
been
doing
a
great
job
so
far
and
at
the
same
time
we've
been
completing
our
inspections
of
independent
health
care.
As
you'll
see,
we've
now
completed
the
whole
of
the
dialysis
units
that's
been
completed
and
by
the
end
of
March,
we
will
have
completed
reflect
if
I
serve
services
and
independent
services,
and
that
is
on
track
to
complete
on
time.
E
At
the
same
time,
we've
been
working
on
some
of
the
outstanding
issues
such
as
report
time
inthis,
which
which
we
are
still
remains
an
issue
for
us.
Although
with
the
next
phase,
we
are
monitoring
the
report.
Talon
is
much
more
closely
and
I'm
anticipating
that
the
situation
would
improve
dramatically,
as
we
are
now
publishing
next
phase
reports.
So
that's
something
that
will
come
through
over
the
next
few
months.
E
We
still
do
need
to
focus
on
the
delivery
of
the
independent
healthcare
report
sometime
and
that's
we're
doing
work
on
that
to
improve
the
timeliness
of
that
as
well.
So
I
again
the
the
active
the
average
length
of
time
for
the
reports
being
published
behind
the
scenes
is
falling.
It
will
have
an
impact
on
the
KPI,
so
I
hope
early
in
the
new
year
in
terms
of
reporting
back
to
the
board.
That's
all
I
want
to
say
at
the
moment,
Peter.
A
F
Thank
you
I
welcome
a
the
opportunity
to
talk
asleep.
We.
F
Of
course,
because
much
of
what
we
do
is
not
in
the
KPI
so
because
we're
on
time
on
the
schedule
for
the
regulation
of
online
providers,
health
and
justice
work
comes
later
in
the
private
board.
The
local
system
review
work
is
on
time
going
well,
and
his
is
nautical
published
on
the
interim
report
which
came
out
this
morning
in
and
is
in
the
hsj
and
defense
contract
is
on
time
and
being
renewed.
F
So
these
are
all
all
good
news
areas
and
our
inspection
timeliness,
which
has
been
a
major
issue
over
the
last
few
years,
has
improved
dramatically
so
that
our
average
days
to
publication
now
stands
at
31
days
for
October
and
it'll,
be
33
in
November,
which
is
a
vast
improvement.
Given
that
we
spend
so
much
time.
F
F
We've
been
putting
a
lot
of
effort
into
those
locations
which
are
in
breach
over
four
quarters.
We've
got
those
numbers
down,
as
you
see
dramatically,
and
we
have
information
and
a
plan
for
every
single
one
of
those.
But
one
of
the
areas
I've
been
focused
on
in
the
last
month
is
safeguarding
in,
unlike
in
other
social
care,
we
have
a
small
number
of
alerts
and
concerns
and
I
was
concerned
that
we
had
12
which
were
outside
the
KPI.
So
we
looked
at
those
in
detail.
F
In
fact
they
were
all
within
the
KPI,
but
unfortunately
they
weren't
recorded
correctly
on
our
system.
It's
our
fault,
but
having
investigated,
he
drops
the
achievement
down,
but
actually
the
work
had
been
done,
but
unfortunately
they
weren't
recorded
adequately
on
CRM
and
I
mentioned
it
basically
to
be
able
to
tell
you
that
we
have
our
finger
on
what's
going
on.
It's
just,
and
there
was
an
error.
So
we
apologize
for
that.
F
Well,
it
could
well
be
that
in
a
providin
he's
about
to
do
something,
we
tell
them
that
need
to
do
something
in
order
to
satisfy
us
on
and
it's
a
technical
issue
which
is
easily
resolved
and
if
they
can
give
us
the
evidence
that
it's
being
done,
which
might
be
a
certificate
or
or
some
form
of
written
evidence.
It's
pointless,
sending
the
inspection
team
back
in
which
would
cause
disruption
to
our
practice,
but
also
work.
F
And
so,
if
we
have
adequate
evidence
that
might
actually
change
your
rating
because
it
might
be
just
on
a
small
issue
at
the
moment
and
the
relationship
manager,
the
inspector
and
the
inspection
manager
will
be
able
to
judge
whether
that's
possible.
So
we
want
to
do
our
work
with
minimal
disruption
to
the
clinical
service.
So.
F
Course,
yeah
now
you're
right,
it's
just
the
way
we
have
in
the
system.
It
simply
doesn't
record
it
adequately
for
the
kpi's,
but
we
think
we'll
do
more.
Of
these.
As
time
goes
on,
it's
about
monitor
rather
than
the
inspect
itself,
and
then
it's
the
definition
of
what
inspection
is
and-
and
we
can
do
that
when
we've
got
more
information
and
it's.
A
H
You
and
just
brief
update
on
the
finance
to
October.
We
were
5.2
million
and
dispensed
with
a
forecast
of
10
million
and
spent
for
the
end
of
the
year.
We
have
under
recovered
home
income
due
to
changes
in
the
market
environment,
about
two
million,
so
we're
forecasting
a
net
under
spend
of
around
8
million.
H
The
majority
of
the
under
spend
about
80
percent
is
actually
on
the
pain
and
I.
Think
it's
important.
So
people
directors
are
thinking
about
how
they
can
work
with
the
teams
to
make
sure
that
we're
more
up
to
full
establishment
so
that
we
can
then
monitor
workload
and
make
sure
that
we
do
use
our
papers
it
appropriately.
H
B
I
just
say
on
the
recruitment
side
of
things,
one
of
the
conversations
that
we've
had
with
the
people
Directorate
is
about
having
an
always-on
recruitment
so
that
you,
for
example,
given
that
the
level
of
turnover
in
adult
social
care,
you
know
we're,
probably
recruiting
even
a
steady-state
70
inspectors
a
year,
so
making
sure
that
we
can
do
that
on.
A
continuous
basis
is
what
Ruth
and
Bailey
and
her
colleagues
are
looking
at,
which
is
incredibly
helpful
and
very
very
supportive.
B
C
Thank
you,
David.
Thank
you
Peter.
So
the
rest
of
this
report
is
really
an
update
on
things
that
was
published
or
events
have
taken
place.
So
we'd
probably
strongly
with
our
profession
a
report
on
psychoactive
substances
in
communities
earning
the
Probation
Service
recently
has
touched
on
the
update
seed,
inspection
program
and
I.
C
Think
the
first
report
on
that
was
published
in
respective
Taunton
and
Somerset's
and
I
was
down
with
a
Southwest
inspection
team
and
they
were
pleased
and
proud
that
they've
got
that
out
the
door
and
as
evidence
of
the
new
reports,
the
new
inspection
program
in
place,
I
think
Ted,
published
and
quite
an
important
piece
of
work
on
behalf
of
the
organization
writing
to
all
NHS
trusts
in
relation
to
radiology
backlogs
and
some
of
the
issues
which
is
generated
by
the
findings
of
an
inspection
down
in
Portsmouth.
And
but
again
is
this
contribution
to.
C
How
do
we
encourage
improvements
and
now
that
we
disseminate
those
findings
quickly,
so
we
can
avoid
those
occurrences
repeating
themselves
bubble
on
health
care
service.
This
is
the
situation
were
bubble,
unapplied
to
court,
to
prevent
the
publication
of
one
of
our
inspection
reports,
the
required
unanimity
and
their
proceedings
and
then
applied
for
judicial
review.
C
I
I
C
And
so
I
think
the
key
issue
here
Peter
is
from
a
security
perspective.
This
has
been
satisfactorily
resolved
and
just
to
emphasize
a
point
which
is,
there
was
no
challenge
to
the
findings
about
the
safety
of
the
services
which
were
offered,
and
that
seems
to
be
the
most
important
thing
sat
at
the
bottom
Ellis
and,
if
I,
just
inserts
at
this
juncture,
just
a
brief
update
in
public
in
relation
to
four
seasons
before
I
go
on
to
present
the
rest
of
the
reports.
C
What
has
happened
or
last
week
was
that
a
standstill
agreement
has
been
reached
between
each
one
that
hold
the
debt
and
four
seasons,
which
allows
further
detailed
planning
to
go
ahead
to
ensure
the
future
of
both
the
organization
and
the
services
which
are
in
place.
I.
Think
the
important
issue
here
is
that
the
standstill
agreement
buys
some
time
to
allow
the
future
ownership
of
the
company
to
be
determined
and
that's
what
will
take
place
over
this
next
period
that
standstill
agreement
will
last
into
next
year
and
into
the
spring
of
next
year.
C
There
could
be
other
developments,
but
actually
this
allows
for
the
important
conversations
to
take
place
and,
through
our
market
oversight,
function
we'll
continue
to
monitor
and
have
oversight
of
this
work
so
and
there's
been
a
lot
in
both
the
social
policy
and
political
press,
but
an
awful
lot
in
the
financial
press
about
how
this
is
operated
as
well.
Andrea
has
made
public
comment
on
behalf
of
the
organization
about
the
importance
of
continuity
of
service
to
the
people
using
four-season
services
and
and
of
course
that
remains
our
responsibility.
C
A
C
When
this
was
announced,
it
was
a
comprehensive
and
focused
inquiry,
but
one
of
the
issues
that
the
bishop
will
consider
as
part
of
the
inquiry
is
whether
we
have
enough
powers
in
relation
to
our
oversight
of
independent
health
care
and
which
is
one
of
the
reasons
to
mention
it.
Here.
We've
also
published
over
the
past
two
days
the
consultation
document
on
the
use
of
resources
which
takes
us
on
to
the
next
stage
and.
C
C
What
was
the
learning
that
we
could
take
out
of
that
and
then
share
that
and
disseminate
that
very
much
with
the
view
that
other
trusts
might
take
on
some
of
the
good
practice
that
was
demonstrated
though,
and
then
lastly,
Peter
is
the
just
to
refer
to
the
National
Audit
Office
action
plan.
This
is
attached
to
this
report.
C
C
The
National
Audit
Office
made
six
recommendations
in
the
five
recommendations
in
their
reports
and
the
action
plan
attack.
So
this
is
the
action
plan
that
would
put
in
place
to
pick
up
on
the
recommendations
and
take
em
set
that
forward,
so
I
think
I'm
asking
the
board.
If
you
could
just
not
the
action
plan
and
we'll
bring
updates
on
the
progress
against
that
action
plan,
so
the
audit
and
Corporate
Governance
Committee
to
ensure
that
there
is
some
non
executive
oversight
of
the
developments
of
that
work.
I
would
like
to
first
question.
C
I
was
asked
what
what
was
the
improvement
that
the
NA
are
flagged
in
in
their
report
was
the
first
question.
I
was
asked
at
the
Public
Accounts
Committee
and
my
response
was.
It
was
just
a
sheer
hard
work
of
stuff
that
works
in
the
organization,
3000
staff
and
I
think
we
can
go
into
a
lot
of
detail
about
technical
changes
we've
made,
but
I
do
want
to
pay
tribute
to
the
staff
for
the
organization
just
for
the
energy
and
effort
that
has
gone
into
securing
that
improvement.
C
A
I
very
much
agree
to
that
David
and
I
think.
Having
seen
many
nao
reports,
I
think
we
can
be
quite
pleased
with
the
report
and
having
witnessed
sand
P
AC
hearings
that
have
been
pretty
hostile,
I
think
you
can
be
quite
pleased
with
the
the
hearing
that
you
you
had
so
I
think
it's
a
real
reflection
on
everybody
from
you,
your
leadership
and
a
good
position
to
be
there's
a
lot
in
your
report.
As
always,
does
anybody
want
to
raise
anything
Robert.
D
D
Prem
Prem
of
chandran,
which
resulted
in
this
paper
being
produced
and
I
was
very
impressed
by
the
work
of
that
team
in
the
way
that
they
took
the
evidence
from
outstanding
trust,
outstanding
trust
in
this
area
and
put
put
together
some
really
quite
practical
suggestions
about
how
others
could
improve
their
work
and
I
will
have
to
see
how
its
received
in
the
wider
world,
but
I
would
have
thought
incredibly
useful
piece
of
work
and
I.
Just
wonder
coming
out
of
that.
E
In
advance
of
that,
we
wanted
to
stress
the
importance
of
focusing
on
patient
safety
and,
if
you're,
not
giving
the
organization's
the
confidence
to
focus
on
what
we
thought
was
really
important
for
patient
safety
and
be
the
the
guidance
we
put
out
comes
from
clinicians
working
in
the
frontline
in
air
knees
that
are
already
delivering
really
good
care.
Despite
the
pressures,
and
we
wanted
to
share
that
across
the
system,
the
feedback
we've
had
so
far
has
been
very
positive
from
from
from
the
clinical
community
and
I
hope.
E
This
is
going
to
make
a
real
difference
going
into
this
winter.
We
are
going
to
use
that
in
other
services
as
well.
Amy
was
our
first,
but
we've
already
had
a
workshop
on
maternity
services
where
we
brought
together
70
staff
from
the
good
and
outstanding
maternity
services.
This
was
only
last
week
and
we
went
through
similar
issues
with
them.
How
do
how
do
they
ensure
safety
maternity
services,
and
we
will
bring
that
together
towards
some
similar
guidance
new
year,
and
we
will
then
extend
it
into
other
areas.
E
C
That's
being
used
and
again,
another
example
of
learning
from
the
best
and
disseminating
that
very
much
in
the
hope
that
that
learning
to
be
extended
and
adopted
by
by
others
and
as
I,
say,
I
think
I
think
having
done
the
comprehensive
racing
program
we're
now
in
a
space
where
we
have
some
findings
of
things
that
work
and
being
able
to
spread
that
much
more
effectively
and
so
Chris
there's
got
a
program.
Maybe
one
of
the
things
we
can
do
is
is
actually
in
my
report
next
month
is
just
get.
C
D
We
did
a
number
of
supportive
reports
spending
the
practice.
I
thought
the
model
of
this,
which
was
gathering
together.
The
people
actually
do
this
stuff
open.
Today,
then,
meetings
of
inspectors
he
evaluated
through
that
evidence
and
putting
all
that
together,
there
was
a
particularly
powerful
model,
which
is
it
supplements
the
work
we
were
able
to
do
from
our
inspections
and
the
report,
and
that
was
very
good.
A
K
K
So
this
paper
provides
an
update
on
our
progress
in
two
key
areas
of
the
public
engagement
strategy.
It's
the
public
awareness
survey
and
the
results
of
stakeholder
sentiment
survey
that
we've
also
carried
out.
We've
put
more
focus
on
these
two
areas
in
the
last
couple
of
years
and
I
think
the
results
show
that
we've
made
good
progress,
although
we're
not
complacent
I
think
they
do
show
good
progress.
I
just
point
out
a
couple
of
things
in
the
paper
that
I
think
it's
worth
highlighting
on
page
two
section
one.
K
We
first
measured
public
awareness
in
2012
and
we
started
to
increase
our
work
in
this
area
really
in
2014,
and
you
can
see
that
public
awareness
has
grown
from
22%
in
2012
to
the
65
percent
result.
We've
got
this
year,
so
I
think
we're
performing
well
against
similar
organizations
in
our
area,
we're
not
quite
to
Ofsted
levels,
but
which
was
our
ambition,
but
we're
aiming
for
that
and
that
I'm
sure
we'll
get
there.
K
Secondly,
also
on
page
two
public
engagement
is
obviously
carried
out
throughout
CQC,
and
particularly
by
inspection
teams
who
are
supporting
public
engagement
locally
and
we're
encouraging
and
enabling
people
to
do
it
all
over
the
organization.
But
I
think
these
results
tell
us
that
awareness
is
higher
amongst
the
public
population
groups
that
we've
specifically
targeted
as
part
of
our
work
in
public
engagement.
K
The
combination
of
those
three
things
really
works
well
and
is
relatively
low
cost
compared
to
some
of
the
spending
by
our
partners,
who
have
run
public
awareness
campaigns
in
other
areas
such
as
NHS,
Blood
and
transplant.
There's
a
potential
to
spend
millions
in
this
area,
but
we're
not
doing
that.
We're
spending
relatively
small
amounts
of
morning
I
think
having
a
considerable
impact.
K
We
realized
there's
more
work
to
do
with.
We've
found
that
in
the
area
of
some
of
the
population
groups,
the
awareness,
although
it's
risen,
for
example
the
non-white
population-
that's
risen
from
41
percent
to
50
percent
in
2017,
but
it's
lower
than
the
rest
of
the
population
groups
that
we
are
targeting.
So
we
need
to
do
some
work
in
that
area
and
there
are
also
lower
awareness
levels
in
London,
which
is
traditionally
a
much
harder
place
to
to
create
impact
than
the
rest
of
the
country.
K
So
we
need
to
look
at
those
in
terms
of
the
perceptions
of
CQC.
On
page
3,
we
ask
a
series
of
questions
related
to
trust
and
confidence
in
CQC,
and
what
you
can
see
is
that
most
people
surveyed
have
trust
and
confidence
in
CQC,
but
importantly,
that
confidence
and
Trust
Rises.
If
people
are
aware
of
CQC
already
and
have
used
our
inspection
reports
and
ratings.
So
what
that
tells
us
is
that
it's
very
important
to
raise
awareness
amongst
the
public
of
what
we
do,
because
it
increases
trust
and
confidence
in
us
as
a
regulator.
K
The
other
area
that
I
wanted
to
just
talk
about
briefly
was
the
stakeholder
sentiment.
Surveys,
which
I
think
tells
us
that
most
stakeholders
that
we
are
engaging
with,
where
we've
put
considerable
effort
into
this
area
over
the
last
couple
of
years
with
the
voluntary
community
sector
and
most
of
the
stakeholders
feel
that
CQC
has
improved.
They
have
a
positive
impression
of
us
and
they
describe
us
as
being
a
more
engaging
organization,
and
that's
thanks
to
the
support
we've
had
throughout
CQC
for
taking
part
in
that
engagement
and
encouraging
those
relationships.
K
A
Thank
You
Jill
any
questions
or
comments
from
anybody.
Oh-
and
this
is
some
page
for
the
first
bullet
points
on
that
for
consideration
when
it
seems
to
be
a
very
important
part
of
the
environment
within
which
we
work
affects
whether
the
public
find
out
find
us
useful,
and
that
is
whether
outward
they
perceive
that
a
virtuous
so
adult
social
care
services.
They
proceed
to
have
choice
and
therefore
they
lead
the
reports
if
they
believe
they're
stuck
and
don't
have
a
choice
like
with
most
of
the
NHS.
A
If
you
think
you're
stark,
then
you
you're,
you
might
read
about
B,
because
you've
got
to
go
through
B,
but
it's
less
of
a
so
I
think
this
is
quite
a
big,
a
bigger
public
policy
issue
than
us,
though.
It's
quite
interesting
with
GPS,
a
small
number
of
people
read
the
pulse
because
they
don't
think
they've
got
a
choice
of
going
to
another
GP
when
they
have
I.
A
I
I
agree.
My
sense
Steve
is
that
more
people
are
accessing
primary
care
through
other
sources
than
their
registered
GP
practice.
So
there
may
be
and
I
agree
with
your
point:
Paul
it's
it's
a
minority
of
people,
but
you
know
the
walking
centers
and
all
the
other
other
available
options.
I
think
people
are
using,
probably
more
than
they
used
to.
Is
that
right
or
my
not
right?
It's.
F
D
Well,
you
perhaps
we
ought
to
consider
a
little
well
what
we
expect
the
public
to
do
with
our
report
and
whether
they
should
be
fashioned
in
that
way,
and
one
of
these
occurs
to
me
as
a
members
of
public
patients
are
lenders,
the
public
they
have
all
should
have
an
interest
in
the
way
their
local
health
section
is
working.
We
live
in
a
democracy,
there
are
all
sorts
different
ways
in
which
they
could
seek
to
influence.
The
standards
which
take
place.
Health
works
may
be
one
example,
and
maybe
we
ought
to
think
a
little
ball.
K
Just
gonna
mention
that,
as
part
of
the
survey
we
did
us
people
did.
You
take
action
as
a
result
of
seeing
a
report
and
a
surprising
number
of
people
said
they
did.
They
did
use
them
to
take
action,
and
often
it
was
to
encourage
the
service
to
improve.
We
need
to
look
into
that
a
bit
more
to
see
exactly
what
people
meant
Oh.
G
A
Yes,
I
would
I
think
I
was
going
to
say
that
the
work
you've
done
is
known
as
a
vanity
project.
For
us,
it
really
is
important
for
all
users
and
to
Steve's
point
staff
in
the
services
that
they
they
they
and
they
understand.
The
importance
of
our
inspections
and
ratings
have
confidence
in
them
know
where
to
find
them
and
all
that
requires
they
actually
know
all
of
us.
So
this
is
important.
I
think
and
I
thought
some
very
good
piece
of
work.
A
A
A
Excellent
welcome
III
I
think
the
work
you've
been
doing
on
the
the
local
systems
review
is
just
really
really
good
and
I
wanted
to
spend
some
time
this
morning.
Just
understanding
I
know
it's
only
an
interim
report
but
understanding
what
you've
done
and
what
you've
found
so
should
I
just
hand
straight
over
to
you
with
that.
By
way
of
introduction
I
do
you
need
to
put
microphone
on.
J
L
M
L
And
so
forth,
Peter
we've
circulated
in
a
short
PowerPoint
just
giving
some
of
the
key.
The
key
messages
and
I
think
we've
got
about
40
minutes
on
the
agenda
so
and
I
introduced
myself
and
my
colleagues.
So
my
name
is
Alison
Holborn
I'm,
the
SRO
for
this
piece
of
work
and
one
of
the
DC
eyes
at
CQC
and
my
colleague
rich.
L
There
is
quite
a
recent
simplification
of
that
model
that
you
might
remember
the
three
spheres
of
looking
at
how
we
maintain
the
well-being
of
people
in
their
usual
place
of
residence
wherever
that
may
be
so
the
little
sort
of
house
graphic
there
refers
to
that
domain,
then
we
were
looking
at
what
happens
in
the
event
of
a
crisis,
either
a
health
crisis
or
a
social
crisis
and
admission
that
sometimes
follows
that
to
hospital
or
an
alternative,
and
then
what
happens
after
that?
How
are
people
supported
to
return
to
their
usual
place
of
residence?
L
L
So
moving
to
the
next
graphic,
you
can
see
just
an
overview
of
the
progress
to
date
and
to
date,
we've
engaged
with
the
first
twelve
systems.
We've
actually
undertaken.
Ten
site
visits
and
as
of
this
week,
we've
published
six
reports.
So
there's
a
list
here
of
the
reports
that
we've
actually
published
to
date,
so
Halton
Bracknell
forest
stoke-on-trent,
Hartlepool,
none
just
at
Rufford,
there's
quite
a
wide
range
of
areas
around
the
country
that
secretaries
of
state
have
determined
that
we
should
look
at.
L
We've
recently
been
to
York
ethics,
Oxfordshire
and
Plymouth.
Those
reports
are
pending
and
in
January
we've
got
Birmingham
and
Coventry,
and
just
lately,
and
a
lot
has
been
received
from
secretary
of
state
to
announce
the
final
eight
areas
and
those
are
Bradford:
Cumbria
Liverpool,
Sheffield,
Wiltshire,
Hampshire,
Northamptonshire
and
Stockport
okay.
So
that's
all
the
work
in
progress.
So
this
interim
report
that
were
presenting
to
you
and
you've
had
the
chance
to
look
at
is
the
synthesis
of
themes
and
trends
and
findings.
L
From
the
first
six
of
the
published
reports,
we
were
asked
to
produce
this
quite
quickly.
The
pace
of
this
work
has
been
quite
significant,
and
the
importance
of
producing
some
feedback
on
themes
and
trends
quite
quickly
is
really
any
learning
that
can
be
shared
widely
about
themes
and
trends
and
improvements
that
could
be
made,
and
some
of
the
improvements
are
going
to
be
longer-term,
some
of
things
that
could
be
done
today
and
it
was
important
to
bring
that
to
light
and
that's
the
purpose
of
the
report.
L
So
if
we
go
on
to
the
findings
on
the
the
next
page
and
how
we've
grouped
the
key
findings-
and
if
you
look
at
the
report,
you
look
at
the
report
itself,
there's
there's
a
relatively
concise
20,
odd
pages
of
reports,
but
for
synthesizing.
All
of
that.
What
we've
boiled
it
down
to
is
our
key
findings
today
really
focus
around
three
things.
The
first
is
the
whole
question
of
how
system
working
happens
or
doesn't
happen,
and
you
know
I
guess.
L
So
how
systems
work
together
is
is
very
important
and
a
lot
of
recent
policy
and
the
five
year
forward
view
a
lot
of
the
change
and
the
transformation
that
is
happening
is
all
focused
on.
How
can
we
ensure
integration
of
systems?
How
can
we
ensure
that
systems
work
together
so
that
first
pimble,
the
cluster
of
things
we
found
around?
That
seems
to
be
very
important
and
we
found
lots
of
things
around
this.
L
L
Okay.
So
our
observations
are
based
on
going
to
the
science
looking
at
things
case:
sampling,
observing
places
of
care,
synthesizing
data,
quantitative
and
qualitative
interviewing
system,
leaders
interviewing
people
on
the
ground,
interviewing
staff,
interviewing
carers
and
interviewing
those
groups
that
are
representing
the
interests
of
patients
in
the
places
that
we
have
visited.
And
that's
how
we've
arrived
at
this
data.
L
So
I'll
move
through
the
three
just
on
what
we
found
and
what
we
think
the
implications
might
have
been
so
the
first
one
how
systems
work
together,
I
think
it's
really
important
to
say
that
we
did
find
a
really
strong
commitment
and
enthusiasm
from
organizations
and
from
staff
working
across
health
and
social
care
services
who
come
to
work
every
day
to
meet
the
needs
of
people
who
use
services
and
their
families
and
carers.
Huge
amounts
of
dedication,
positivity
and
wanting
to
do
the
right
thing.
L
We
found
that
relationships
between
system
partners
play
a
major
major
role
in
the
coordination
and
delivery
of
joined-up
health
and
social
care
services
that
meet
the
needs
of
that
local
population,
so
where
relationships
are
strong
and
local,
local
leaders
and
local
professionals
have
made
a
lot
of
effort
to
work
together
in
a
joined
up
manner.
The
outcomes
for
patients
are
not
surprisingly,
better
and
demonstrably
better
where
those
relationships
are
not
good.
The
outcomes
are
generally
poor
and
really
I.
L
This
speaks
to
the
second
point
that
system
level
leadership.
Accountability
is
difficult
to
identify
without
a
common
understanding
of
word
system.
Leadership
sits
it's
difficult
for
system
to
achieve
joint
working
and
integration,
so
we
create.
We
have
created
lots
of
fragmentation
over
time.
There
is
a
different
accountability
or
different
attractors
for
different
providers,
there's
different
accountability
and
different
attractors
for
different
commissioners.
The
funding
flows
move
conversations
in
a
particular
direction.
L
All
of
those
things
have
to
be
aligned
more
to
create
the
condition
for
joined-up
system
working.
We
saw
the
consequences
of
systems
not
working
together
at
very
close
quarters,
so
it
was
a
really
fine
example.
This
work,
it's
been
a
privilege
to
do
this
work.
We've
had
stuff
that
are
from
all
corners
of
CQC,
but
work
on
primary
care
and
hospitals
and
community
services
and
mental
health
and
adult
social
care,
able
to
actually
see
those
interfaces
of
care,
but
observing
at
close
quarters
where
things
are
not
working
in
an
integrated
manner.
L
It
leads
to
too
many
examples
of
people
not
being
treated
in
the
right
place
by
the
right
people
at
the
right
time
and
really
unnecessary
pressure
being
placed
on
services
that
are
not
meeting
the
needs
of
people
who
use
them.
So
we
have
woven
a
few
examples
into
this
report,
but
there
are
many,
many
more
examples
and
stuff
of
stuff
from
our
teams
have
gone
out
and
observed
the
human
outcomes
of
this
lack
of
integration
and
lack
of
joined
up
working
so
creating
the
conditions
to
work
in
an
integrated
manner.
L
L
We
have
suggest
some
key
points
there
for
priority
action
for
system
leaders
locally
people
can
work
to
ensure
there
is
a
shared
vision
and
a
system-wide
strategy
developed
and
agreed
by
system
leaders
that
they
communicate
widely
that
they
under
you
know
they
understand
it.
Everybody
understands
it.
The
workforce
understand
something
that
you
can
explain.
L
You
know
to
people
in
the
street
to
people,
families
and
carers,
something
understandable,
and
we
did
see
examples
of
that,
and
we
also
saw
examples
of
the
opposite
of
that,
so
individual
organizational
strategies
should
be
aligned
and
underpinned
by
a
shared
system.
Wine
vision,
which
is
based
on
the
needs
of
that
population,
is
responsive
to
the
needs
of
that
population,
which
will
differ
from
place
to
place.
L
We
need
to
ensure
that
time
is
invested
in
positive
and
productive
system
relationships,
but
deliver
interagency
multidisciplinary
working
so
at
times
of
financial
pressure
and
times
of
workload
pressure
it's
hard
to
achieve
that,
and
we
need
to
do
all
we
can.
The
system
leaders
need
to
do
all
they
can
to
build
those
relationships
and
to
have
the
conversations.
What
is
it
we
should
be
doing
for
our
populations?
L
So,
irrespective
of
the
method
you
you
were
employ
locally
to
do
that
agreeing
and
defining
that
cross
system
leadership.
Accountability
is,
is
vitally
important.
Okay,
so
there
the
two
slides
that
we've
brought
together
just
on
that
whole
first
principle
of
how
systems
work
together.
So
moving
on
to
the
next
area
that
we
mentioned,
one
of
the
big
things
that
we
observed
was
capacity,
market
supply
and
workforce.
L
So
there
are
many
ways
of
approaching
the
the
question
of
choice,
which
is
sometimes
cited
as
one
of
the
barriers
and
people
moving
around
the
system,
but
people's
choice
about
the
Health
and
Social
Care
is
limited
and
many
of
the
systems
we
have
reviewed
due
to
a
shortage
of
capacity
and
range
of
options.
So
the
availability
of
social
care
was
a
challenge
in
all
of
the
areas
that
we
visited,
especially
in
nursing
homes,
specialist
care
homes,
specialists,
mental
health
provision
and
in
domiciliary
care.
L
Workforce
capacity
has
been
a
major
issue
in
every
system
we
visited
the
consequences
of
not
managing
capacity,
market
supply
and
workforce
means
that
choice
is
compromised
and
it
can
only
exist
in
a
system
where
there
is
capacity
and
availability
of
high-quality,
safe,
responsive,
effective
caring,
well
led
care.
So
behind
that
there's
a
whole
heap
of
things
about
how
you
attract
staff
into
these
very
important
roles,
what
the
funding
flows
are,
what
the
capacity
and
the
payment
mechanisms
are,
how
commissioners
engage
with
providers
proactively,
how
they
shape
the
structure
of
supply.
L
These
are
important,
commissioning
drivers
and
competencies,
and
the
system
is
very
pressured.
So
we
have
found
that
Infirmary,
as
we
visited
it's
very
difficult
for
providers
to
attract
the
right
workforce,
especially
in
areas
where
there
might
be
full
employment,
for
example,
it's
multifaceted
and
complex,
but
it's
a
major,
a
major
part
of
our
observations.
So
far,
so
in
terms
of
priority
action
for
system
leaders
on
those
there
is
some
really
good
work.
That's
been
done
nationally
on
choice
and
the
choice
criteria
for
people
moving
between
health
and
care
services.
L
It's
really
important
that
local
areas
adopt
cohesive
ways
of
addressing
that.
So
within
a
larger
footprint,
perhaps
than
a
local
authority,
it's
sometimes
the
same
workforce.
It's
sometimes
the
patient
flows
that
go
across
boundaries.
So
how
do
we
all
adopt
good
practice
for
ensuring
that
people
are
given
a
choice?
But
the
you
know
there
is
a
common
understanding
of
what
what
is
available
within
that
choice.
L
We
saw
some
really
good
practice
and
we
saw
some
lack
of
availability
of
those
things
which
have
a
knock-on
effect,
for
example,
on
admissions
to
hospital,
from
care
homes,
on
people's
end
of
life
choices
and
preferred
place
of
death,
and
these
are
really
important
to
the
quality
of
life
of
people
and
families
and
older
people.
So
it's
important
that
those
high-impact
changes
are
noticed,
are
reported
and
are
implemented,
and
we
saw
some
good
practices
that
but
wide
variation,
I
think
it's
worth
to
say.
L
It's
really
important
also
that
there
is
a
risk
sharing
approach
in
local
areas
around
understanding
the
capacity
and
availability
of
services
in
the
event
of
a
surge
in
demand,
whether
that's
wint
or
any
other
surge
in
demand.
How
do
we
know
where
the
capacity
is
and
how
do
we
know
how
we
can
mobilize
and
availability
or
additional
availability
services
as
needed?
Where
are
the
risk
agreements?
Where
is
the
insight
you
know?
Where
is
the
accountability
in
governance
at
a
system
level,
often
when
their
issues?
L
The
final
point
that
we've
drawn
out
first
presentation,
there's
more
in
the
report,
is
that
a
consistent
theme
was
the
VC
se
sector,
the
voluntary
community
social
enterprise
sector,
developing
clearer,
longer
term
arrangements
with
the
VC
se
sector
is
an
you
know,
has
the
potential
to
offer
major
benefits.
The
sector
is
underutilized
and
often
has
very
short
term
contracts,
high
levels
of
uncertainty
and
yet
are
delivering
some
amazing
work
out
there.
L
So,
for
example,
looking
at
social
prescribing
a
lot
of
the
reasons
for
people
with
frailty
and
long
term
conditions
ending
up
in
the
wrong
place
of
care
is
because
there
is
insufficient
support
and
mobilization
of
community
resources,
and
we
saw
many
examples
of
the
VC
se
sector
in
that
space
delivering
high
impact
high.
You
know
high
productivity
return
on
investment
for
small
amounts
of
money,
and
yet
often
that
work
was
jeopardized
by
short-term
luck.
L
We
saw,
for
example,
in
one
area,
a
one-year
contract
were
voluntary
sector,
had
a
hospital
to
home
service
with
every
patient
that
just
discharged
everybody
who
wanted
to
go
home
with
somebody
with
them
to
get
some
shopping
to
settle
them
in
at
home.
That
was
there
for
them
and
it
was
just
a
real.
It
was
really
valued
and
appreciated
by
the
people
that
received
that
service.
L
So,
finally
of
our
three
points
and
there's
more
in
the
published
report,
we
felt
it
was
important
to
say
that
there's
more
to
look
at
in
looking
at
systems,
it's
really
important
that
we
look
at
systems
and
we
start
developing
the
system,
thinking,
system
awareness
and
understanding
that
health
and
care
services
have
high
levels
of
interconnection.
What
we
do
one
part
of
the
system
impacts
on
the
other
part
of
the
system.
L
One
of
the
things
that
our
unelect
team
did
for
this
piece
of
work,
which
has
had
huge
and
positive
feedback,
was
that
they
produced
with
publicly
available
data
a
data
pack
for
each
of
the
areas
and
early
on
when
we
went
into
some
of
the
early
areas.
The
feed,
but
was
this
actually
really
useful,
and
some
areas
had
never
actually
sat
down
and
looked
at
that
intersecting
information
and
had
a
conversation
about
it.
L
So
we've
done
that
more
widely.
The
analyst
team
have
done
that
more
widely
to
make
that
available
to
more
systems,
just
as
a
conversation
point
to
look
out
the
question
of
what
is
it,
we
should
be
looking
at
if
we're
looking
at
the
health
and
effectiveness
of
a
of
a
system.
So
we
have
seen
examples
of
were,
for
example,
a
focus
on
delayed
transfers
of
care
or
detox
has
improved
the
speed
at
which
people
are
moving
between
services,
because
people
focus
on
it.
They
look
at
it.
They're
measured
by
it,
they're
judged
by
it.
L
Primary
care,
social
care
capacity,
VC
RC
capacity
are
all
really
important
in
the
health
of
communities,
people
and
their
well-being.
So
I
guess.
The
message
we
would
share
in
this
first
iteration
is
that
focusing
just
on
detox
in
isolation
won't
resolve
the
problems
that
local
systems
are
facing.
A
system
that
has
established
joined
up
processes
to
identify
and
support
people
to
stay
safe
and
well
in
their
usual
place
of
residence
through
effective
public
health
prevention
approaches
and
implementation
of
all
sorts
of
initiatives.
L
So
it
felt
important
to
say
that,
because
sometimes
just
focusing
on
one
thing
works
at
the
detriment
of
focusing
on
all
things
and
doing
all
the
things
necessary
to
make
improvement.
So
in
that
final
point,
I
guess
our
areas
for
system
leaders
for
priority
action
is
to
ensure
timely
access
to
data
to
help
the
improvement
agenda.
We've
produced
some
examples
of
these
to
make
available
to
all
local
systems
in
England
to
promote
a
conversation
about
understanding
the
needs
of
your
population.
L
We
thought
some
jsn
A's
address
strategic
needs
assessment
that
were
very
current
and
very
pertinent
to
the
action
that
we
could
see
happening.
We
saw
very
out-of-date
data
and
out-of-date
public
health
focus
as
well,
and
lack
of
joined-up
focus
on
the
needs
of
individual
populations,
so
there
is
a
whole
heap
of
national
guidance
and
support
available
to
local
systems
to
address
delayed
transfers
of
care.
So
things
like
that
guidance.
The
high
impact
changes.
L
All
of
that
is
readily
available
for
people
to
look
at
some
of
that
can
deliver
short-term
benefits.
A
lot
of
the
relational
working
is
going
to
take
the
culture
change.
The
shift
in
focus
is
going
to
take
a
longer
time
to
achieve,
and
we
did
see
transformational
processes
in
place
recognizing
this
and
the
move
towards
some
longer-term
contracts,
for
example.
L
So
I'm
going
through
a
lot
here,
our
chair
I'm,
sorry,
there's
an
awful
lot
here
to
cover,
but
we
moved
to
the
next
piece
information
really
that
I
guess
what
we
need
to
same.
We
have
said
in
this
publication
is
we've
published
this
early
stage,
we're
reporting
at
an
early
stage
of
the
review
program?
We've
only
published
reviews
in
six
of
the
systems,
but
common
things
are
emerging
that
we
believe
should
be
addressed
at
a
national
level
and
we've
been
asked
to
report
at
this
stage
with
any
themes
and
trends
that
might
be
useful.
L
We
will
continue
to
keep
these
under
review
for
the
remainder
of
the
program
and
will
commit
to
a
final
report
in
summer
2018,
which
will
cover
all
20
reviews,
which
is
the
first
time
that
such
you
know,
widespread
review
system
level
has
been
undertaken.
So
we
have
asked
for
we
encouraged
national
leaders
to
think
about
how
they
enable
that
first
point:
how
do
you
enable
and
incentivize
health
and
social
care
partners
to
establish
aligned
objectives,
processes
and
accountabilities?
L
L
For
you
know
an
Okie,
a
key
driver
of
good
outcomes
for
people
on
the
issue
of
social
care
market
plays
particularly
a
matter
of
priority
is
that
we
focus
on
joint
health
and
social
care.
Workforce
strategies,
really
innovative
approaches
to
developing
the
workforce
that
we
need
for
the
21st
century
and
the
demographic
of
the
21st
century
health
and
care
system.
So
we'll
continue
to
look
at
all
of
those
domains:
the
maintenance
of
well-being,
what
happens
in
a
crisis,
what
happens
in
return
and
stepped
down?
L
A
F
No
not
really
I
think
that
was
comprehensive
presentation,
I
think
what
we've
been
doing
is
focusing
on
the
needs
of
people
and
because
there
is
a
difference
in
how
we
approach
people
in
the
adult
social
care,
local
government
world.
They
talk
about
people
and
the
population.
For
a
clinical
point
of
view.
We
talk
about
patients.
This
is
really
about
people
in
a
local
area
and
I've
been
to
these
sites,
we're
in
York
yesterday
and
the
messages
about
people
working
together
and
focusing
on
the
people.
F
There
is
the
key
thing
we
found
some
really
good
practice
and
we
found
some
not
so
good
practice
and
I
think
one
by
the
time.
We've
got
our
final
report
in
the
late
spring
summer
next
year.
You
know
there'll
be
a
comprehensive
list
of
activities,
but
there
are
some
important
emerging
findings
and
Alison's
covered
them.
So
I
think
the
reports
there
Thanks
good.
I
Really
great
report
and
we're
very
been
very
happy
to
help
throughout
the
country.
There's
a
really
great
alignment
with
some
of
our
messages.
I
just
wondered
what
this
was
a
note
in
here.
It
says:
I'm
at
the
focus
on
individual
organizational
outcomes,
is
distracting
from
the
needs
of
the
wider
system
to
work
effectively
for
the
people.
It
serves.
I
wonder
what
was
behind
that.
L
Commissioning
is
often
disjointed
as
well.
So
in
this
set
of
reviews,
we
have
looked
at
the
whole
picture.
You
know
we've
been
able
to
look
at
the
commissioning
environment
as
well
as
the
provider
landscape,
and
you
have
a
whole
heap
of
different
regulatory
frameworks,
different
commissioners
for
different
providers
requiring
them
to
respond
and
report
with
different
data
for
different
things.
I
guess
the
simple
examples
in
a
you
know
in
a
foundation,
trust
in
a
hospital
that
foundation
trust
might
be
held
to
account
by
different
regulatory
bodies.
L
If
the
attractor
was
what
is
the
need
of
this
population,
what
are
we
all
doing
to
address
that
need
if
people
were
judged
on
those
sorts
of
things
as
opposed
to
what
they
actually
are
judged
on?
It
might
move
things
that
are
sort
of
similar
direction,
but
you
know
it's
a
matter
of
fact.
I
think
that
we,
all
all
different
providers,
are
working
to
different
different
sets
of
attractors.
If
we
were
able
to
align
those
attractors
I
think
it
might
work
in
the
interests
of
the
communities
needs.
A
The
nationally
we
have
set
up
a
I
think
quite
a
good
set
of
organizations
back.
It's
including
us.
The
driver
count
abilities
into
organization
and
that's
been
good,
because
she
means
that
boards
and
organizations
are
more
accountable,
including
on
quality.
The
problem
is,
it
drives
accountability
into
organizations
and
people
don't
experience
those
who
care
across
those
organizations.
So
the
problem
we've
got
as
we
and
CQC
is.
We
issue
a
report
that
says
there
needs
to
be
more
system
thinking
and
most
of
our
work
stops.
A
That
from
happening
not
completely
stops
event,
but
it
drives
accountability
into
organization,
and
it's
not
just
us,
but
all
the
other
forms
of
accountability.
We've
constructed
we
as
a
nation
have
constructed
so
the
the
problem
is,
is
we
are
recommending
local
people
do
something
and
stopping
them
from
doing
it
at
the
same
time,
and
that
is
a
real
problem
that
is
the
problem
about
about
having.
If
we
were
ever
to
find
an
outstanding
locality
that
was
doing
something
across
all
these
systems.
A
It
would
be
partly
doing
it
by
ignoring
the
people
above
them,
and
that
is
a
real
problem,
so
I
think
I.
Think
part
of
is
understanding
ourselves
and
what
we
do
for
the
very
best
of
reasons
in
driving
those
accountabilities
and
and
how
we
then
have
to
play
a
role.
I
think
I,
think
and
most
of
our
inspector
reports
do
this.
By
actually
saying
there
are
problems
which
I
always
think
of
as
the
edges
of
those
accountabilities,
but
mainly
the
organization's,
are
left
looking
inwards
at
the
things
we
say
and
not
looking
outwards.
I.
B
How
does
the
service
work
in
partnership
with
other
agencies
and
including
you
know,
the
local
authorities,
safeguarding
teams,
clinical
commissioning
groups,
etc,
etc?
Does
it
do
so
in
an
open
and
transparent
way,
and
also
does
it
share?
Does
the
service
share
appropriate
information
and
assessments
with
other
relevant
agencies?
E
Ted
again
just
to
say
this
is
really
a
very
important
piece
of
work.
It's
a
great
report
but
I
think
it's
really
very
important
report
and
it
has
to
influence
our
regulatory
activity
just
as
Andrea
and
Paul
were
saying,
because
I
mean
clearly
if
we
focus
on
individual
organizations
in
isolation
of
the
system
in
which
they
operate.
We
are
part
of
the
problem
and
we
need
to
be
part
of
the
solution
in
this
and
we
need
to
make
sure
that
we
judge
all
individual
organizations
by
their
effectiveness
within
a
system.
E
Well,
actually,
at
the
moment,
we,
the
systems
are
so
inefficient
in
the
way
they
look
after
people
and
so
disjointed
that
we're
not
making
best
use
of
our
current
capacity.
So
I
think
we
have
no
idea
about
whether
we
need
more
capacity
or
whether
actually
the
capacities
there.
We
just
need
to
use
it
better
and
I.
Think
that's
the
open
question
until
we
get
it
right,
but
you
know
that
that's
part
of
the
complexity
here
thank.
F
F
When
we
look
at
Manchester
Trafford
and
we're
going
to
stop
for
next
year,
I'm
really
optimistic
about
what
they're
doing
jointly
in
Manchester,
working
together
across
health
and
social
care.
I
got
a
real
great
sense
there
that
they're
looking
at
the
people
who
live
in
the
city
and,
in
fact,
if
you
look
at
Manchester,
there's
some
great
stuff
going
on
in
parts
of
central
Manchester,
but
in
other
parts
of
central
Manchester
they're
behind.
So
the
solutions
for
central
Manchester
are
within
central
Manchester.
F
If
you
can
invest
in
social
care,
domiciliary
care,
primary
care
and
community
care,
then
you
can
keep
people
at
home
and
prevent
them
going
into
hospital
and
once
they're
in
hospital
you
can
get
them
out
quicker.
Now
some
of
the
areas
they're
looking
in
in
quite
an
adventurous
way,
which
I
would
support
about
extra
care
and
support,
but
that
might
be
two
or
three
years
away.
F
There
is
a
you
know,
a
problem
now
that
needs
to
be
addressed,
so
what
we've
been
doing
is
learning
listening
and
reflecting
back
to
people
that
when
they
come
together,
most
of
the
areas
actually
have
got
the
solutions
within
themselves.
Of
course,
sky
is
helping
them
with
some
of
the
development
work,
but
I
think
this
is
the
most
interesting
piece
of
work.
F
N
Sorry,
yes,
go
for
it.
I
just
said
to
build
on
Steve's
to
the
point
and
woz
have
been
talking
about
as
well
is
within
all
of
the
areas.
There
is
a
strong,
passionate
and
commitment
set
of
people
and
organizations
that
are
working
towards
trying
to
trying
to
achieve
integration,
and
integration
is
a
word.
That's
used
and
collaborative
working
is
absolutely
pushed
through
every
single
system,
but
it's
it
is
those
the
framework
in
which
they
are.
They
are
in.
N
N
This
is
it's
a
struggle
now
to
build
on
Steve's
point
actually
within
one
of
the
areas
that
we've
been
to,
and
it's
not
not
included
in
this
report,
but
we
we
looked
at
what
their
plans
were
for
the
future
and
and
they
had
to
in
line
with
the
objectives
in
the
air
and
the
key
indicators
of
which
they
needed
to
achieve
by
the
end
of
the
year.
They
needed
to
reduce
their
budget
and
their
spending
on
Social
Care.
Now
what
they
did
is
they.
N
They
were
planning
to
to
take
money
out
of
preventative
approaches,
which
was
actually
stopping
people
from
getting
to
crisis
point
in
getting
into
hospital.
Now
it's
that
it's
that
kind
of
attractor
that
where
the
Houston
Houston
and
one
hands
a
big
fan
of
as
well,
it
is
preventing
people
preventing
systems
from
putting
money
into
the
right
particular
areas
so
that,
where
we've
seen
really
good
system
level
workings
that
focus
on
prevention,
that
she's
stopping
people
get
they're
getting
to
that
point
of
crisis,
and
that's
what
we
want
to
encourage
I.
Think
within
the
other
systems.
G
Squared
with
Paul,
first
of
all,
and
but
the
only
bit
that
wasn't
brought
up
for
me,
was
if,
if
you
look
at
the
retail
industry,
they
don't
allow
the
individual
retail
organizations
to
say
sort
out
our
logistics,
they
bring
out
bringing
expertise.
They
understand
logistics,
I,
wonder
if
there's
something
that
the
capabilities
just
aren't
in
the
systems
to
do
something,
that's
very
complex
and
is
they're
missing
skills
that
are
desperately
needed
to
help
the
system's
work
together.
L
We
know
that
the
operation
of
Health
and
Social
Care
Service
services,
if
it's
a
highly
interconnected
set
of
set
of
systems,
complex
adaptive
system
and
that
we
need
to
behave
as
if
it
is
if
we
want
to
affect
long-term
change.
So
there
are
some
short-term
wins,
but
the
big
changes,
as
you
say,
bringing
in
knowledge
skills,
expertise
on
whether
you
call
it
logistics.
So
you
know
you
exactly
that
that
idea
that
if
I
go
to
a
bank
in
Plymouth,
you
know
I'm
going
to
get
the
same
service
as
I
get
in
in
Preston.
L
Hopefully,
and
actually,
how
do
we
actually
connect
and
join
the
dots
relevant
to
that
system?
Population,
so
I
do
think.
There's
something
about
skills
and
I
would
say
that
it
was
really
interesting.
We've
had
stuff
from
all
parts
of
CQC
involved
in
this
work.
We've
have
external
special
advisers
as
well.
All
of
them
have
said
at
the
end
of
each
review.
What
fulfilling
experience
it's
been
to
do
this
to
actually
have
the
privilege
of
looking
a
system
from
all
sides
and
being
able
to
really
visibly
see
this
is
not
just
I
can
see.
L
Why
there's
that
problem
over
there
around
adult
social
care?
It's
because
of
you
know
these
aspects,
all
these
funding
flows
or
this
or
that,
and
you
know,
I
think
it
does
it.
There
is
a
strong
case
for
what
you
say
that
we
and
all
parts
of
the
system
need
to
have
that
capability
and
the
people
that
recognize
those
aspects
in
the
mix.
Steve.
F
Last
word
I'll
be
brief.
As
usual,
the
it's
not
just
about
capability
and
I
think
the
questions
a
really
good
one.
It's
that
knowledge,
I
think
there's
a
real
problem
in
how
people
are
brought
up
in
their
health
and
their
social
care
systems
in
the
health
where
I
come
from,
and
especially
in
hospitals,
the
awareness
of
people
not
as
patient,
and
not
patients
about
populations
rather
than
individuals
about
people
as
humans,
rather
than
the
heart,
the
lung.
The
brain
is
missing
and
I
think
in
adult
social
care.
F
For
me,
the
health
and
well-being
boards
are
really
really
important.
We
found
in
some
areas
they're
just
not
effective
at
all
and
in
other
areas,
they're
just
reorganizing.
You
then
add
a
layer
of
STPs
on
top
of
it,
of
which
some
of
these
loca
local
authorities
are
tiny
compared
with
the
STP
there's
another
set
of
capabilities
and
skills
to
try
and
foster
those
relationships
so
and
we're
going
through
a
really
difficult
time
and
I
think
this.
This
project
will
focus
a
lot
of
minds
and
thoughts
on
those
20
we're
going
to.
F
But
my
message
outside
this
room
is
this
is
not
just
about
the
20
we're
inspecting.
This
is
about
all
of
the
local
authority
areas,
it's
about
all
of
the
health
areas
and
how
we
can
bring
these
together.
If
people
think
this
is
just
about
the
20
worst
areas,
then
it's
not.
This
is
about
health
and
social
care
for
England
PLC.
F
A
Really
great
piece
of
work,
thank
you
both
for
presenting
it
thanks
to
Ann
and
to
everybody
else,
and
the
team's
got
us
to
this
point.
I'm
not
going
to
summarize
all
you've.
All
you've
been
saying
all
of
the
discussion.
The
only
thing
I
would
say
is
that
slightly
in
response
to
your
point,
Paul
I
do
think
it's
incumbent
on
us
to
make
sure
in
our
work
where
we
can.
A
We
both
highlight
those
organizations
which
are
trying
to
work
outside
their
their
their
boundary,
but
also
highlight
those
that
have
just
put
a
fortress
around
what
they
do.
However,
good
it
is
that
they're
what
they're
doing
inside
the
fortress
it's
a
fortress
and
they
need
to
be
so.
That
is
something
that
I
think
we
seek
you,
so
you
can
do
with
that.
Thank.
A
Thank
you
both
very
much
again.
Is
there
any
other
business
that
the
board
wishes
to
raise,
which
case
sorry,
you
get
you.
If
you
want
to
stay,
have
some
lunch
with
us.
Please
do
but
we've
got
and
there
was
the
public.
You
want
to
ask
some
questions
and
we've
got
about
three
minutes,
so
we
need
to
move
quickly,
so
Robin
I
think
you
got
in
first.
So
do
you
want
to
go
over
there
and
and.
O
F
Well,
thank
you
Robin.
My
conflicts
of
interest
is
I,
wrote
co-wrote
the
original
paper
on
Federation's
in
2006,
which
wasn't
well
received
at
the
time,
but
seems
to
be
what's
happening
now,
which
is
which
is
really
good.
I'm
spending
a
lot
of
time
going
around,
not
just
you
Federation's,
but
larger
providers
of
primary
care
by
scale
and
the
new
accountable
care
emerging,
accountable
care
systems
and,
as
you
quite
rightly
said,
the
word
Federation
means
something
different
to
many
different
ones.
F
P
Well,
my
question
is
very
quick:
one
of
David
Hogarth,
maybe
Karen
Jonz,
would
made
it
though
I
lost
at
the
last
meeting,
I
asked
what
progress
have
been
made
with
the
guidance
on
technology
which
have
been
promised
earlier
in
the
year
and
riyo
responded
haven't
heard
anything
since
so
I
was
just
hoping
it.
Perhaps
you
could
give
me
an
update.
P
B
So
that
has
helped
to
shape
the
question
that
we're
asking
and
how
we
want
to
take
this
piece
of
work
forward.
Both
looking
at
the
information
that
we've
provided
for
providers
of
services
and
also
the
information
that
we've
provided
for
the
public
four
years
ago.
Our
plan
is
to
have
a
further
round
table
and
you
recall
we
did
that
in
the
first
instance
when
we
did
this
over
three
years
ago,
and
we
expect
that
to
be
held
in
February.
M
Miss
Wyman
thank
you
and
reward
of
background
in
public
protection.
After
the
October
meeting,
when
I
wasn't
able
to
ask
question,
I
wrote
to
to
you
with
five
questions
related
to
two
areas.
One
was
concerning
governance
and
conduct
at
Wolverhampton,
NHS,
Foundation
Trust
concerning
the
chief
executive
and
the
other
was
to
do
with
13
care
services
and
their
contract
in
bath.
M
You
very
kindly
considered
by
response,
and
a
few
weeks
later,
you
wrote
a
very
comprehensive
replied,
two
pages.
Thank
you
very
much
lots
of
useful
information
in
there
about
how
you're
going
to
use
the
information
that
I
sent
to
you
and
the
information
I
sent.
Wasn't
new
information.
It
was
me
asking
five
questions
on
information
that
was
already
in
the
public
domain,
and
you
explained
the
various
CQC
processes,
I
suppose
my
question
is
and
I'm
not
trying
to
shoot
the
messenger
because
you
will
have
had
input
from
the
organization
in
formulating
this
response.
M
A
Andrew,
it
would
have
been
more
helpful
if
you'd,
given
notice
of
the
question
and
the
reason
that
I
are
the
question
is
so
be
prepared.
We,
you
know
I'm,
very
sorry
and
don't
be
offended.
I,
don't
remember
what
the
five
questions
were.
I,
don't
remember.
You
writing
I,
remember
that,
but
in
detail,
so
I
really
can't
I
can't
give
you
chapter
and
verse
now
I'm,
not
I'll,
do
it
separately,
but
we
weren't
and
it's
not
our
policy
to
avoid
answering
difficult
questions.
A
If
we
come
and
answer
a
question,
if,
for
a
legal
or
other
reason,
I
would
have
said
so
so
I,
my
reply
was
in
I
suspect
was
intended
to
cover
your
five
questions.
It
may
not
have
done
so
specifically,
but
I'm
really
sorry
I.
Don't
remember,
though,
I
come
back
to
you
separately
on
that.
Thank
you
very
much.
Okay,
thank
you.
Anybody
else
for
anything
which
case.
Thank
you
all
very
much
for
coming
and
happy
Christmas
to
everybody.