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.’