We asked our members for their thoughts and experiences of CQC’s regulation in 2023/24, while it was in the process of trialling and implementing aspects of its new regulatory approach. We have repeated some questions from previous years, but also added in some new questions to test recent changes and areas of heightened public interest.
Experiences of CQC regulation
When asked about different aspects of CQC regulation, trust leaders were least satisfied with CQC’s ability to encourage providers to collaborate and integrate care (59% disagreed or strongly disagreed, and only 13% agreed or strongly agreed). Community trusts were most sceptical about CQC’s ability to encourage collaboration and integration, with 83% disagreeing or strongly disagreeing and none agreeing.
Views were most split on the regulator’s ability to reflect the needs of different sectors. Acute specialist trusts were most satisfied, with 70% agreeing.
Most comments discussed a range of concerns about CQC’s current approach, which are similar to those raised in response to last year’s regulation survey. They questioned the regulator’s credibility, objectivity and consistency, described variable experiences of inspections, and suggested there was insufficient expertise among CQC inspection teams. Comments also referred to a disconnect between CQC’s national and local teams, and to weakening relationships at a local level, partly due to the move to the regulator’s new approach.
"The methodology and quality of inspectors varies considerably. CQC inspectors attend and are judging areas in which they do not have the appropriate expertise or experience. Different trusts have different experience of how inspections are undertaken and there is no basic standard. It is also very difficult to challenge anything that they do, or how judgements are made."
"The trust's relationship with the local CQC team is virtually non-existent and contact has reduced considerably over the last 12 months as the CQC has restructured and developed its new approach. There is a significant risk that the CQC's organisational memory of the trust has disappeared."
Some trust leaders volunteered reflections on CQC’s new approach, saying that their exposure to date had been “relatively benign”, but that it was too early to say what its real impact would be, especially given the delay to system assessments.
"I think it is too early to tell if this new approach is going to be helpful or a hindrance - the process remains unclear and I think we need to see it actually be used and proved accurate before we can determine if it is in fact helpful.”
There were also references to low local visibility and to lack of coordination with other national bodies as a result of the new approach to regulation.
“With the new operational structure in place (with CQC) and with lack of relationship inspector concept within [the] new framework, the CQC engagement meeting opportunities are becoming less frequent than before. We find it beneficial to regularly engage with the regulator and would welcome thoughts on how we continue to build this relationship."
Views on CQC’s single-word ratings
CQC’s four ratings for health and social care services (‘outstanding’, ‘good’, ‘requires improvement’ and ‘inadequate’) were introduced in 2013 (CQC, 2013), following a review commissioned by the then Secretary of State for Health (Nuffield Trust, 2013). When these were introduced, five possible purposes of ratings were identified: to increase public accountability; to aid choice; to help improve the performance of providers; to identify and prevent failures in the quality of care; and to provide public reassurance for the quality of care.
These ratings are the same as those used by Ofsted, whose approach has recently come under significant scrutiny, including criticism by the House of Commons Education Committee, in its inquiry into Ofsted’s Inspections (UK Parliament, 2024).
In this year’s survey we asked for trust leaders’ thoughts on CQC’s ratings. While we understand that a change in CQC’s four-point rating scale would require secretary of state approval, we have recently recommended (NHS Providers, 2024b) that CQC re-evaluates the success of its ratings and considers the addition of a narrative rating qualifier as part of its new provider assessment reports.
We appreciate the complexity of CQC’s ratings used in the context of trusts, including separate ratings at a service and key question level. Given their public visibility and prominence, however, most of our members’ comments relate to overall provider ratings.
While some respondents found the single-word rating approach helpful, clear and understandable to the public, the majority of comments supported a move away from this approach. They believed it was too simplistic, especially for large organisations such as trusts. Some also reflected that it was demoralising for staff and confusing for patients.
"Single word assessments in any assessment framework of complex systems is deeply flawed... In statistical terms it [is] like assuming that a mean is a true representation of the data ignoring range, mode, median, or any nonparametric measure - totally excluding any qualitative methodology.
all single word assessments in any context should be removed."
"Ofsted has been a natural experiment in the inadequacy of one word judgements."
Some respondents favoured a narrative descriptive judgement, which they felt would be fairer and better at capturing differences in the quality of care between trusts with the same rating. They believed that single word ratings lacked context, and did not account for the breadth of evidence provided to CQC.
"The CQC inspections are hugely stressful for all staff involved and mostly tell us what we already know, especially in relation to urgent and emergency care. A more descriptive narrative judgement would be fairer."
Even those who favoured single-word ratings tended to think that these would be appropriate if reviewed more frequently or if supported by a clear narrative.
CQC’s approach during winter 2023/24
CQC has publicly recognised the need for proportionate oversight (CQC, 2024b) in times of significant operational pressure, and committed to supporting NHS leaders as they manage risk “in an environment of heightened demand, resourcing pressures and limited capacity”. It said that during winter it would focus on emergency department inspections, to identify and act on risk, but also encourage a system-wide approach to accountability for issues of concern and promote risk sharing.
We asked our members to share their experience of CQC’s approach during the past winter:
- Just under half (49%) agreed or strongly agreed that CQC has only responded to the areas of greatest risk or concern in their trust, down from 63% last year.
- 21% agreed or strongly agreed that CQC’s recent approach has accounted for the operational context of their trust, down from 29% last year.
In the comments, respondents gave mixed feedback on CQC’s approach over the past winter. Several said CQC had not taken the operational context into account, including industrial action, or the environment in which trusts operate.
"CQC wanted to visit on the Monday after a weekend strike - under pressure they changed but in this scenario they did not consider industrial action / operational pressure."
"CQC approaches inspections on a very superficial level and does not take account of the environment in which trusts operate."
We have welcomed the proposed approach of the regulator last winter, recognising “the need to keep regulatory oversight proportionate” (CQC, 2024b), and have noted their intention to become better able to represent the operational context of providers in the future. We are conscious, however, that CQC is still in the process of implementing its new approach and these changes are not yet being reflected in providers’ perceptions. Our findings suggest that it will take some time before trusts report a change in the extent to which CQC accounts for system issues or operating context.
"Our inspection was solely focused on us as an ambulance service - little regard to system issues."
CQC inspection and regulatory activity
In consultation with CQC, we identified the most common inspection types that CQC had undertaken in the past year, as these differed from previous years. Figure 6 below shows that just under half of respondents (49%) have experienced a maternity inspection in the past year[1], compared with 35% last year, demonstrating the increased national and CQC focus on maternity.
We asked a separate question on whether trusts had undergone a CQC well-led inspection in the last 12 months, and what their view was on the assessment process. The responses we received were very mixed.
Some respondents found the process helpful and said it was very well received internally.
"These reports are always useful in the sense [that] they hold the mirror up to the organisation, even if [we] don’t fully agree with report. The issue is the time and effort and also consistency of inspectors..."
Others said that the assessment and associated report were poor, and that the inspection team involved lacked sector-specific expertise.
"Was not helpful, was driven by erroneous factors. The report was appallingly written, in grammar, style and fact."
"I would not describe it as helpful. Inspectors lacked sector expertise, there was not an observation done of several key meetings - including quality committee. The core services and well led aspects of the service went on over a nearly seven-week period. It felt clear that they knew where they ‘felt’ we were before they had left on day one."
[1] Please note, only acute and combined acute and community trusts responded to this question.