The Care Quality Commission (CQC), under fire for poor performance since the initial Dr Penny Dash review in June, came under even more fire today from both its own review and the final version of the Dash report.
The CQC-commissioned report by Professor Sir Mike Richards said today that the transformation programme that was initiated by CQC in 2021 has failed in all three of its three main initiatives.
“A fundamental reset of the organisation is needed,” the Richards review said.
“CQC will never be able to deliver on its objectives if the current structure is maintained.”
But despite “significant failings” the organisation did get some credit for having started to make some necessary changes, according to Dr Penny Dash in her final report also released today.
But Dr Dash also said: “There is an urgent need for a rapid turnaround of CQC.”
The Richards report was released to complement today’s report by Dr Penny Dash, chairperson of the North West London Integrated Care Board, by looking at changes that CQC made following the publication of its new strategy in 2021 and their impact.
Three failed elements
The three main elements of the failed transformation strategy according to the Richards report were:
- A major organisational restructure
- The introduction of a single assessment framework across all the sectors that CQC regulates (hospitals, mental health services, ambulances, primary and community care services and adult social care)
- The development of a new IT system, named the regulatory platform
The report said: “These three initiatives are clearly interlinked, but this review has shown that all three have failed to deliver the benefits that were intended, despite being initially welcomed by providers.”
The report said that as a result: “Far fewer inspections have been carried out than in previous years; publication of inspection reports have been seriously delayed, and providers have expressed serious concerns about both the inspection process and the quality of the reports.”
One-word ratings
One area that needed to be addressed according to the Richards review was the issue of “one-word ratings.”
The report said: “During the course of this review, the issue of “one-word ratings” was raised on numerous occasions by providers.
“Further consideration should therefore be given to this issue.
“In particular, the level at which ratings makes sense to people using services should be considered.”
Dash report
In June the Dash interim report found inspection levels were still “well below” where they were pre-pandemic, with a lack of clinical expertise among inspectors, a lack of consistency in assessments and problems with the CQC’s IT system.
The following week the CQC said it was developing a handbook to help health service providers understand what they can expect from an inspection.
Today’s final version of the Dash report again highlighted the failures of the CQC but noted that the organisation was making necessary changes.
The Dash review found significant failings in the internal workings of CQC, “which have led to a substantial loss of credibility within the health and social care sectors, a deterioration in the ability of CQC to identify poor performance and support a drive to improve quality – and a direct impact on the capacity and capability of both the social care and the healthcare sectors to deliver much-needed improvements in care.”
Changes being made
Dash stated in her report: “There is an urgent need for a rapid turnaround of CQC – a process that has already started with the appointment of an interim chief executive in June 2024 and the announcement of further changes following the publication of my interim report.
“I am pleased to see the openness and honesty with which the organisation has begun to address the changes required.”
Dash said: “The health and care sector accounts for around 12% of the economy and 21% of public expenditure, and is one of the most significant drivers of health, public satisfaction and economic growth.
“It needs – and deserves – a high-performing regulator.”
Delays in producing reports
Another area of concern for Dash was the delays in producing reports and the poor-quality of reports.
“All sectors told the review that they can wait for several months to receive reports and ratings following assessments.
“The review has heard multiple comments about poor-quality reports – these have come from providers and from members of the public.
“Poor-quality and delayed reports hamper users’ ability to access information, and limit the credibility and impact of assessments for providers.”
The Dash review concluded that in order to restore confidence and credibility and support improvements in health and social care, there is a need to:
- Rapidly improve operational performance, fix the provider portal and regulatory platform, and improve the quality of reports
- Rebuild expertise and relationships with providers
- Review the SAF to make it fit for purpose with clear descriptors and a far greater focus on effectiveness, outcomes and use of resources
- Clarify how ratings are calculated and make the results more transparent
- Continue to evolve and improve local authority assessments
- Formally pause ICS assessments
- Strengthen sponsorship arrangements
A second review considering the wider landscape for quality of care, with an initial focus on safety, will be published in early 2025.
Richards recommendations
Meanwhile, the CQC-commissioned review recommended that the previous organisational structure should be re-instated as soon as reasonably possible.
It said at least three permanent chief inspectors should be appointed with serious consideration given to the appointment of a fourth chief inspector to lead regulation of mental health services and to oversee inspections under the Mental Health Act.
Single assessment
The review also said: “Aspects of the single assessment framework could be retained – with some modifications.
“Other aspects should be suspended and almost certainly scrapped, including the evidence categories and scoring system.
“More work needs to be done to define what good looks like in different services.”
Inspection
It added that: “Priorities for inspection within the healthcare sectors need to be reviewed, given current staffing levels.
It said the CQC should work closely in partnership with leaders of health care and adult social care to design improved approaches to assessment and inspection.
“This would be welcomed by those being regulated. They would also welcome a return to a larger element of peer review in the process.”
Re-organisation
The Richards review said: “The structural re-organisation has resulted in separation of those responsible for developing policy and strategy related to regulation from those responsible for operational delivery.
“Operational reality has therefore not been reflected in policy and strategy.”
“For the past two years, CQC has only had two chief inspectors (both of whom are currently interim), rather than the 3 as set out in legislation.”
It said: “The single assessment framework, while having some positive elements derived from the previous assessment approach, is far too complex and, as currently constituted, does not allow for the huge differences in the size, complexity and range of functions of the services that CQC regulates.
“One size does not fit all.”
“The regulatory platform has had a serious adverse impact on the working lives both of CQC staff and of those working in provider organisations who are expected to upload information onto a ‘provider portal’.
“People who use the platform say that there are, as yet, no signs that these problems are being resolved.”
“Over the past two to three months, CQC has started to take steps to mitigate some of the problems identified in this report.
“However, the organisation needs to go much further.”
Urgent restructure needed
Richards said: “I have been working closely with providers of health and social care and with CQC staff to find solutions to the very real problems identified by Dr Penny Dash.
“CQC’s transformation programme has not delivered what was intended.
“CQC urgently needs to return to a structure where inspections teams are led once again by chief inspectors relating to the different sectors that CQC regulates.
“In addition, the current assessment framework needs to be radically simplified and the major problems with the new IT system need to be rectified.
“I know that work is already underway to address these areas.
“I believe that CQC’s problems can be fixed relatively quickly under the leadership of Julian Hartley, the incoming chief executive.
“Providers have overwhelmingly reaffirmed that they want good regulation, and many CQC staff remain fully committed to delivering this.
“These changes will help the regulator to effectively deliver its crucial work of ensuring that people get high quality, safe care.”
Clear roadmap
And responding to the publication of Dr Dash’s final review into CQC, David Hare, CEO of the Independent Healthcare Providers Network (IHPN), said: “A strong independent regulator is an absolutely vital part of the healthcare landscape – providing both patients and the health system as a whole an informed and objective assessment of healthcare provision.
“We therefore welcome Dr Penny Dash’s final report into the CQC which rightly sets out both the importance and urgency of improving the regulator’s performance.
“This includes not only the need to deliver its fundamental role of carrying out timely inspections of services and the ability to update ratings effectively, but also how to more effectively assess new and innovative service models that are emerging.
“Moreover, with a health system currently under huge strain and in desperate need of new capacity, Dr Dash’s review makes clear that CQC must urgently prioritise clearing the unacceptable backlog in registrations of new health and care providers – helping enable new resources to be brought to local communities and improve patient access to care.
“Dr Dash’s review sets a clear roadmap to getting the CQC back on track, and it is now of utmost importance to patients, providers and commissioners of services that CQC works at pace to implement these necessary changes.
“IHPN looks forward to working with its new leadership team as they seek to turn the organisation around and re-establish the CQC as a regulator that both patients and healthcare providers can have confidence in.
“We also look forward to contributing to Dr Dash’s forthcoming review of the wider patient safety landscape to ensure it meets the needs of patients and the healthcare system as a whole.”