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 research from The King’s Fund and Alliance Manchester Business School.
In this first major evaluation since the regime was established in 2013 in the wake of the failings at Mid Staffs, the authors suggest 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 was funded by the National Institute for Health Research. It is based on the findings of research carried out between 2015 and 2018 which examined how the CQC regime is working in four sectors - acute care, mental health care, general practice and adult social care – in six areas of England.
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 focuses 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.
It also found evidence that providers would respond to the CQC’s expectations of quality ahead of an inspection, which could have negative as well as positive effects. It may help organisations to prioritise issues, but some providers were found to be focusing a lot of energy on getting through the inspection process rather than on improving the quality of care.
There was also found to be some concern that the organisational focus of CQC’s regulatory model was not well suited to an increasingly integrated health and social care system, or to provider organisations that work in partnerships, chains or networks.
The evaluation found significant differences in how CQC’s inspections 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 its 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 says: “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 adds: “CQC has already taken some of our findings into account in developing its 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.”
The way in which the relationships between CQC staff and health and social care professionals and managers fundamentally affects the way regulation works and its impact was said to be one of the most striking findings from this work.
Providers are now being urged to recognise they have a responsibility to engage collaboratively in order to maximise impact and improvement. This entails encouraging and supporting staff to engage in open, improvement-focused discussions with CQC inspection teams and other stakeholders.
Overall, providers accepted and generally supported the need for quality regulation within the health and care system and saw the approach introduced by the CQC in 2013 as a significant improvement on the system it replaced.
Click here to download the full report.
