CQC inspection regime having an impact but there is room for improvement, landmark report finds

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Care Quality Commission (CQC)’s ‘Ofsted-style’ inspection and rating regime is a significant improvement on the system it replaced, but it could be made more effective, according to the first major evaluation of the approach introduced in 2013.

The new regime for assessing the performance of health and care services was the centrepiece of the then government’s response to the Francis report into the failures of care at Mid Staffordshire NHS Foundation Trust. The research, carried out by The King’s Fund and Alliance Manchester Business School between 2015 and 2018, examined how it was working in four sectors – acute care, mental health care, general practice and adult social care – in six areas of England. 

The new approach was seen as a significant improvement on the system it replaced, which had been widely criticised following several high-profile failures of care. 

The report, funded by the National Institute for Health Research, found that the impact of the inspection regime came about through the interactions between providers, CQC and other stakeholders not just from an individual inspection visit and report. It suggests that relationships are critical, with mutual credibility, respect and trust being very important. The report argues that CQC should invest more in the recruitment and training of its workforce, and calls on providers to encourage and support their staff to engage openly with inspection teams.

The report highlights a number of areas for improvement in CQC’s approach to regulation. It cautions that the focus on inspection and rating may have crowded out other activity which might have more impact. It recommends that CQC focus less on large, intensive but infrequent inspections and more on regular, less formal contact with providers, helping to drive improvement before, during and after inspections. 

The evaluation found significant differences in how CQC’s inspection and ratings work across the four sectors it regulates. Acute care and mental health care providers were more likely to have the capacity to improve and had better access to external improvement support than general practice and adult social care providers. The report recommends that CQC thinks about developing the inspection model in different ways for different sectors, taking into account these differences in capability and support. 

The researchers also analysed data on A&E, maternity and GP services to see if CQC inspection and rating had an impact on key performance indicators but found only small effects. There was also little evidence that patients or GPs were using ratings to make choices about maternity services.

The ‘risk-based’ system using routine performance data which CQC used to target inspections was found to have little connection to subsequent ratings. The report suggests the CQC use a wider range of up-to-date data to develop a more insightful way of prioritising inspections.

The CQC is now implementing a revised strategy for regulation which addresses some of the issues raised in the report. The report welcomes their new focus on developing stronger, improvement-focused relationships with providers and system-wide approaches to regulating quality. 

Ruth Robertson, report author and Senior Fellow at The King’s Fund said: 

‘Over the past few years, the CQC has completed a herculean task by inspecting and rating every hospital, general practice and adult social care provider in England. Although we heard general support for their new approach, we also uncovered frustrations with the process, some unintended consequences and clear room for improvement.

‘We found that CQC’s approach works in different ways in different parts of the health and care system. When CQC identifies a problem in a large hospital there is a team of people who can help the organisation respond, but for a small GP surgery or care home the situation is very different. We recommend that CQC develops its approach in different ways in different parts of the health system with a focus on how it can have the biggest impact on quality.’

Kieran Walshe, report author and professor of health policy and management at Alliance Manchester Business School, the University of Manchester said: 

‘CQC has already taken some of our findings into account in developing their approach to regulating health and social care. Fundamentally, the purpose of regulation is to drive improvement – not just in poorly performing providers but across the board. CQC can now build on its experience and database from the first full cycle of inspection and rating, to create a more targeted and responsive regulatory model.
‘But CQC cannot do this alone. It is just as much up to health and social care providers and other stakeholders, like NHS England and NHS Improvement, to make regulation work in improving services for patients.’

Notes to editors

  1. Impact of the Care Quality Commission on provider performance: room for improvement?  is published jointly by The King’s Fund and Alliance Manchester Business School on Thursday 27 September 2018. 
  2. The report summarises findings from the first major evaluation of the Care Quality Commission’s (CQC) approach to inspecting and rating health and social care providers, which was introduced in 2013. The research was conducted between 2015 and 2018 by The King’s Fund and Alliance Manchester Business School and explored the impact of CQC’s approach in four sectors (acute care, mental health care, general practice and adult social care). It combined a literature review and qualitative fieldwork nationally and in six parts of England with quantitative analyses of national data on provider performance, ratings and activity. The qualitative fieldwork included 170 interviews with a range of staff from health and social care provider organisations, CQC, patient and public groups and other stakeholder organisations such as Healthwatch, NHS England and clinical commissioning groups (CCGs).
  3. As part of the research, we have developed a new framework that outlines eight ways in which regulation can affect provider performance, to help regulators, providers and policymakers understand the impact of regulation. The eight ‘impact mechanisms’ we identified are: anticipatory, directive, organisational, relational, informational, stakeholder, lateral and systemic. More details can be found on p13 of the report. The framework shows that impacts can be produced before, during and after inspection, and through interactions between regulators, providers and other key stakeholders. We used this framework to examine the impact of the first cycle of CQC inspections in acute care, mental health care, general practice and adult social care services in six areas of England.
  4. This report is based on independent research commissioned and funded by the NIHR Policy Research Programme (Provider ratings: the effects of the Care Quality Commission's new inspection and rating system on provider performance). The views expressed in the publication are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health and Social Care, ‘arms’ length bodies or other government departments. 
  5. For more information or to request an interview with one of the authors please contact:
    Andrew McCracken, Head of Press and Public Affairs, The King’s Fund
    a.mccracken@kingsfund.org.uk, 020 7307 2585/2594 (07584 146 035 if calling out of hours)
    Kate McNamee, Head of Global Marketing and Communications, Alliance Manchester Business School
    0161 275 7090, kate.mcnamee@manchester.ac.uk OR 
    Kieran Walshe, Professor of Health Policy and Management, Alliance Manchester Business School 

The King's Fund
The King's Fund is an independent charity working to improve health and care in England. We help to shape policy and practice through research and analysis; develop individuals, teams and organisations; promote understanding of the health and social care system; and bring people together to learn, share knowledge and debate. Our vision is that the best possible health and care is available to all.

The University of Manchester, Alliance Manchester Business School (MBS) 
Established in 1965 and part of The University of Manchester, Alliance Manchester Business School (MBS) is one of the UK’s largest campus-based business schools. It has a long tradition of global business education with centres in Manchester, Dubai, Shanghai, Hong Kong, Singapore and Sao Paolo. Alliance MBS is one of few institutions to have achieved triple accreditation from AACSB International, AMBA and EQUIS, and the Financial Times ranks its MBA 36th globally. The School provides world-class, industry-focused education to undergraduates, postgraduates and executives across the globe. As a research-led school our experts tackle contemporary business and management problems across for main areas: accounting and finance; innovation, management and policy; people management and organisations; and management sciences and marketing. 
The National Institute for Health Research (NIHR): improving the health and wealth of the nation through research. Established by the Department of Health and Social Care, the NIHR:

  • funds high quality research to improve health
  • trains and supports health researchers
  • provides world-class research facilities
  • works with the life sciences industry and charities to benefit all
  • involves patients and the public at every step.