Last month, the UK government released two highly critical independent reviews of the Care Quality Commission (CQC), highlighting significant operational challenges faced by the regulator of health and social care services in England. Dr Penny Dash, chair of the North West London Integrated Care Board (ICB), published her final review of CQC’s effectiveness, while Professor Sir Mike Richards, former Chief Inspector of Hospitals, examined CQC's single assessment framework (SAF) in his complementary report published on the same day.
The final Dash Review
The final Dash report Review into the operational effectiveness of the Care Quality Commission: full report - GOV.UK reiterated Dr Dash’s previous findings of substantial failings within CQC. It outlined how CQC’s ability to identify poor performance and support quality improvements had declined, weakening the sector’s overall capability to enhance care quality.
The conclusions of the final report essentially mirrored those in the interim report that produced such shockwaves when it was published last summer. Most of the ensuing headlines have focused on the alarming picture of operational underperformance, with the standout statistic being the reported plummet in the number of CQC inspection visits (6,700 inspections in 2023-2024, down from 15,800 in 2019-2020).
This drop-off was compounded by poorly performing IT systems that have hampered CQC’s ability to roll out its expensive and widely publicised new assessment framework, the SAF. Problems with the ‘provider portal’ have led to the now familiar complaints from providers about difficulties in uploading documents, particularly if the named user is away or off sick, or of waiting hours for a password reset. These are not trivial concerns – in addition to causing high levels of stress and frustration for individuals, they have taken staff away from delivering or supporting crucial frontline care.
The ensuing backlogs in registrations of new providers (especially in the social care sector), and delays in re-inspections after a ‘requires improvement’ or ‘inadequate’ rating, also paint a picture of a regulator that is in deep crisis and struggling to cope with demand. These operational failings really matter: The Dash report acknowledges that for some providers, they are business critical, leading to hospital discharge teams refusing to discharge people back to a care home, or local authorities refusing to contract with providers on the basis of an out-of-date rating.
However, away from the more lurid headlines about CQC’s operational dysfunctionality, perhaps the most important lessons from the Dash review derive from its concerns about the substantive content of the SAF, and the reliability of its approach to the critical issue of ratings. At the heart of the review lies the much more fundamental and interesting question of whether, in striving so hard to be a ‘one stop shop’ for all sectors, and in focusing its aim so heavily on the single issue of safety, the SAF is really fit for purpose at all.
Dr Dash’s conclusions about the SAF’s shortcomings are too numerous and detailed to be repeated in full here. However, to give a flavour, they include issues such as insufficient guidance for providers, questionable use of data relating to patient experiences and inadequate focus on care effectiveness and outcomes. In short, Dr Dash has found that the SAF is failing to address the complexities of balancing risk and ensuring quality care across a complex and hugely diverse range of services.
The Dash review was particularly scathing about the practice of calculating overall ratings by aggregating scores from previous inspections – inspections that, in some cases, had been carried out over several years. It concluded that this simply “cannot be credible or right”. Again, this practice has a very profound impact on all stakeholders in the health and care sectors. Inspection ratings are relied on by service users and their friends and family when choosing a particular home or service. For providers, they are a hugely important reputational metric that can impact service user numbers, obtaining financial investment, and staff recruitment and retention. They are widely used by commissioning bodies. They are relied on by insurers to price premiums and frame policy terms. In summary, they drive effective use of capacity across the sectors.
Professor Sir Mike Richards’ review of SAF – key findings
Professor Richards’ report Review of CQC's single assessment framework and its implementation - Care Quality Commission, was commissioned by CQC to look specifically at the effectiveness of the changes CQC made to its inspection approach as part of its 2021 transformation programme strategy. This strategy comprised three major components: a substantial organisational restructure, the creation of a single assessment framework applicable to all regulated sectors (SAF), and the development of a new IT system known as the regulatory platform.
Just like the Dash report, the Richards report found that these initiatives have collectively failed to achieve their intended benefits. As a result, CQC is now struggling to meet its primary purpose – namely, ensuring health and care services deliver safe, effective, and compassionate high-quality care while promoting continuous improvement. The failings manifest in the dramatic reduction in the number of inspections, significant delays in publishing reports, and widespread dissatisfaction among providers regarding the inspection process and report quality. This operational slowdown has weakened CQC’s credibility and its ability to promptly address emerging concerns.
The loss of credibility has been exacerbated by the structural reorganisation of CQC, which has separated policy-makers from frontline staff and reduced direct clinical oversight of inspections. With chief inspectors no longer leading inspections within their own sectors, the changes have also damaged the constructive partnerships that had previously existed between inspectors and providers.
Recommendations
Both reports called for sweeping changes to address these systemic issues:
- Reinstate Sector-Based Leadership: Both reviews recommended appointing at least three chief inspectors to lead focused sector inspections. Professor Richards suggested potentially adding a fourth role dedicated to mental health services.
- Simplify the SAF and make it fit for purpose: Professor Richards has called for the SAF concept to be abandoned. He advocates maintaining the 5 key questions (safe, effective, caring, responsive, well-led) but refining quality statements and evidence categories. Dr Dash has urged a far greater focus on effectiveness, outcomes and use of resources.
- Sort out ratings: Both recommended greater clarity on how ratings are calculated to make results more transparent. Both reports addressed the issue of whether one-word ratings remain appropriate (particularly following the recent high profile move away from this approach by Ofsted). Dr Dash considered that changes to one-word ratings could be beneficial in allowing greater clarity on the different areas of quality. In any event, there was consensus that the government should consider improving transparency of ratings across different services and sites in larger providers.
- Fix the IT Infrastructure: Both recommended immediate stabilisation and improvement of the regulatory platform and provider portal are necessary, alongside exploring alternative methods for rapid assessments.
- Improve Reporting Processes: Recommendations emphasised improving report clarity, quality, and timeliness by aligning with best practices, including the importance of immediate feedback.
- Rebuild Expertise and Relationships: Strengthening ties between inspection teams and providers is critical, as is investing in experienced, credible staff.
CQC response
CQC immediately welcomed the reports and accepted their recommendations CQC responds to reviews by Dr Penny Dash and Professor Sir Mike Richards - Care Quality Commission
It made a number of commitments in its response:
- It immediately announced the appointment of Sir Julian Hartley as its new CEO, replacing interim CEO Kate Terroni, who had stepped down in the summer.
- It has committed to reorganise around sector expertise by appointing three specialist chief inspectors to lead on regulation and improvement of hospitals, primary care and adult social care services. Consideration will also be given to whether a fourth chief inspector is needed for mental health services.
- It has committed to modifying the SAF to make it simpler and ensure it is relevant to each sector. It will retain the five key questions across all sectors but will amend the 34 quality statements to ensure clarity and remove duplication. It will stop scoring individual evidence categories.
- It will immediately work to stabilise and fix its regulatory platform and provider portal (as of 18 November, no new registration applications will be accepted via the provider portal). While it does this, CQC is exploring options for delivering assessment activity away from the current systems so that it can rapidly assess, rate, and publish reports for the public.
- It will make ratings scoring more transparent. (CQC has recently published surveys for healthcare and adult social care providers on ratings characteristics and the level of understanding of its assessment approach).
What next?
The speed with which Sir Julian Hartley and CQC can rebuild trust with stakeholders remains to be seen, but these recent publications are an encouraging sign that the challenges are now understood and are being prioritised.
Unsurprisingly, both reports received the unequivocal support of the government. Indeed, Wes Streeting, the Health and Social Care Secretary, has now asked Dr Dash to conduct two further reviews, moving her focus from operational effectiveness to patient safety and quality. The first review will examine the roles and remits of six key organisations and make recommendations on whether patient safety could be bolstered through a different approach. A further review will focus on quality and its governance. The intention is that this content will guide the government’s next steps as it continues its drive for positive cultural change across health and social care. The findings will also inform the government’s 10-Year Health Plan for the NHS and social care that’s due to be announced next Spring.
The response from providers has also been largely positive. It is clearly in all stakeholders’ interests to have a regulator that is fit for purpose. Encouragingly, there now appears to be a genuine acknowledgment by CQC that providers’ voices need to be heard in the co-production of a regulatory framework that works for everyone.
There is no doubt that the SAF needs an urgent overhaul. The new assessment approach needs to go further than simply identifying failings: the regulator’s role should be to amplify excellent work and establish transparency and trust for those using care services. It needs to show providers and users what ‘good’ looks like and move away from a tick box exercise approach into measuring real outcomes. Perhaps the most urgent issue, however, is restoration of trust. Health and care providers, patients and service users, investors and insurers have all lost confidence in CQC to some degree. The organisation now has a golden opportunity to reset. By focusing on outcomes and acting now, it can restore its credibility and become a real force for quality improvement. Watch this space….
“The information contained in this article does not represent a complete analysis of the topics presented and is provided for information purposes only. It is not intended as legal advice and no responsibility can be accepted by Altea Insurance for any reliance placed upon it. Legal advice should always be obtained before applying any information to particular circumstances.”
