Reforming regulation: the road ahead for the Care Quality Commission

Last year the Care Quality Commission’s (CQC’s) work registering and inspecting health and social care providers was severely criticised. Major reviews from Penny Dash, Mike Richards and The Care Provider Alliance identified problems with the single assessment framework, new IT platform and organisational restructure introduced in late 2023. There were care homes waiting more than a year to get re-rated, staff in health and care providers struggling to upload evidence to the CQC portal, and notifications of concern piling up untriaged.

This year, CQC is rebuilding under new leadership (with changes ongoing after the departure of its new CEO last month), and The King’s Fund is supporting them through a new research partnership. Our first project is an evidence review to support CQC as it rebuilds its regulatory model.

We reviewed evidence on what works in regulation and spoke to regulatory experts from other sectors and countries – our report is a treasure trove of evidence and examples. Stepping back, the key messages (see box below) are as relevant to other parts of health and care currently experiencing change as they are for CQC (try replacing the word ‘regulation’ with ‘commissioning’, for example).

CQC’s work to get back on track has been happening at the same time as the development of a new 10 Year Health Plan and a second wider review by Dr Penny Dash of patient safety organisations across health and care. Both outline a future for the health system where quality is a central focus, league tables on quality drive accountability and patient choice, and better data and AI help target inspections.

Our evidence review shows people and data are two sides of the same coin. It is notoriously hard to identify risks in health and care using quantitative data surveillance and a series of studies show CQC’s previous systems failed to pinpoint poor performers. That’s not to say improving the data and making the most of AI is a bad idea. But it’s a reminder that data is only as good as the local knowledge and relationships regulators have to put it in context, make sense of it and work with providers to act on it and improve. A data tool alone will not stop the next Mid Staffs. For CQC, work to reinstate local relationships with providers and equip staff to use these sharpened data tools, are as – if not more – important. As is the strong leadership necessary to turn the issues identified into action and improvement.

Despite all the change, CQC remains one of the longest-standing organisations in the planning and performance architecture –16 years old and counting. Its regulatory approach has shifted over time, and I’m struck from conversations with regulators in other countries and sectors by the range of ways regulators can work: to rate or not to rate? Respond to issues or be proactive? Inspect or rely on self-reports? Focus on themes or assess everything? There are also differences in the size (and cost) of regulators as well as their place in the wider landscape. The evidence doesn’t point to a single best practice model but shows multiple ways a regulator can have impact. We previously identified eight mechanisms CQC can use, and that the best work comes from thinking about all of these.

Across these mechanisms, our review of evidence points to three things that underpin success. While the assessments CQC makes and the organisations it regulates may change (will they restart work with ICSs; what about neighbourhood providers; how can ratings best support league tables?) and technology will continue to evolve, maintaining a clear focus on why they regulate and how their actions support that goal, investing in the people who deliver regulation, and embedding learning are key to building a regulator fit for the future. It’s easy for these things to get lost in a scramble to meet targets and implement systems. We’ll keep sharing insights as we support CQC in this task over the coming years.