CQC inspections may achieve few tangible benefits
A study of how CQC inspections influence healthcare performance has startling insights
A study of how CQC inspections influence care providers' performance has startling insights
In a recent study, researchers from the King’s Fund and Alliance Manchester Business School examined the influence of the Care Quality Commission on the performance of organisations providing care.
They used a mixed-methods approach, combining a literature review, qualitative fieldwork and quantitative analyses of national data on provider performance.
The review contains the startling observation that the analysis of changes in selected routine performance indicators ‘found little or no impact across a range of sectors, services and indicators’ after inspection.
Ineffective prediction of poor performance
Similarly, the data used by the CQC to generate its former Intelligent Monitoring ratings, which were used before an inspection to predict risk of poor performance, had little or no correlation with subsequent ratings inspectors gave of general practices or acute trusts.
'It was observed that inspection processes are not always consistent and differ according to the make-up of inspection teams'
There was a difference in what people said about impact versus these quantitative results. Some 170 interviews were conducted with people from organisations including the CQC, national bodies, providers of acute care, mental health, general practice and adult social care, clinical commissioning groups (CCGs), Healthwatch and public and patient groups.
Eight types of regulatory impact – essentially the mechanisms from which change may result – were identified. Most people suggested that, of these, the anticipatory processes – the work organisations put in before an inspection to prepare for it – had the greatest impact. This will resonate with anyone who has been involved in preparation to meet the CQC’s expectations. Nevertheless, respondents queried whether the CQC guidance is clear and objective, whether preparation is proportionate, or superficial, or detracts from care – questions that many have posed.
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They observed that inspection processes are not always consistent and differ according to the make-up of inspection teams. Regulation was described as ‘a social process’ with variation in inspection practice in and across inspection teams. The relationship between CQC staff and staff in health and social care organisations was important, the implication being that if the relationship worked well, then the CQC was more likely to have a positive effect on the organisation.
We have seen senior leaders leave their posts following poor CQC inspection results, but this review suggests that many changes organisations introduced were not directly derived from recommendations in CQC reports.
Tailor regulation to care pathways
Given the intense inspection and enforcement activity of the CQC, we might expect there to be tangible benefits. However, the researchers concluded that impact was ‘difficult to isolate because regulation is just one of many factors that have an effect – both positive and negative – on provider performance’. So where does this report leave us?
Most of the interviewees agreed there is a need for regulatory oversight, something that was not the case in the past. However, inspections are still largely focused on individual organisations, despite the development of more integrated services. Regulatory processes will need to adapt to address pathways of care and new organisational structures.
A key message from this report is that relationships are vital to effective working and regulation. Debate, critique and proposals for change are better when made without blame, confrontation or hostility.
Staff know their organisations. Many interviewees suggested that problems identified during inspections were already known to them, and were often being addressed, so that the CQC’s reports told them little that was new. If this is the case, we should ask how provider organisations’ staff and consumers can be more involved in review of performance to enhance the regulatory process.
Caroline Shuldham is chair of the RCNi Editorial Advisory Board and has been involved in CQC inspections as a specialist adviser