In 2024, an independent review of the Care Quality Commission by Penny Dash found significant failings in the way they work, and the government described CQC as ‘not fit for purpose’. Since then, the challenges the regulator is facing have been widely highlighted, including in a Health and Social Care committee session.
CQC now has a new board and executive leadership (currently headed by an interim CEO, following Julian Hartley’s departure last month) and is working to change their approach to overcome these difficulties, restore public confidence, and ensure the regulator works effectively for providers and patients.
This includes work to rebuild its regulatory model (a new approach is out for consultation), its IT system, and repair the relationships with health and social care providers and its own staff that have been damaged over the past few years.
CQC asked The King’s Fund to support this vital work through developing and running an independent formative evaluation of its future approach to regulation. There is much to learn about good regulation from existing research and evidence.
Working with CQC, as a first stage of our evaluation we identified five challenges they are facing where evidence could help them to improve.
1. Lack of clarity
A frequent issue that providers have raised is the lack of clarity around what standards they are expected to meet or how their performance will be assessed – when a regulator does this well it can drive improvements in care before even setting foot over the providers’ doorstep.
Addressing this requires clearly communicated expectations from national bodies for what good-quality care looks like and how they will assess it. This means providers can clearly understand what the regulator is trying to achieve, how their different regulatory activities will contribute to that, and what the expectations mean for them.
Enabling this requires standards which are co-designed with regulated providers and are ambitious and stretching to promote improvement.
2. Lack of understanding
Another key issue raised by providers was some inspectors’ lack of understanding of the services they were inspecting, which damaged inspectors’ credibility and the trust needed between CQC and providers.
There are three key skill sets that inspection teams need to be credible and effective: sector expertise, regulatory expertise, and relational skills.
Inspection teams need a broad range of experience and the ability to use their professional judgement. Investing in effective training and development for inspectors is vital for good regulation. How regulatory staff work with information, providers and the public to support improvement is just as impactful as processes and procedures.
3. Relationships
Similarly, CQC needs to invest in developing better relationships with those they regulate, and with the wider public. Regulators need to be flexible in the way they work with providers and be able to use different styles of engagement accordingly.
There’s a virtuous cycle of trust between public, providers and regulators: if people trust the regulator, they can feel safe and confident in the care they receive and will also be more likely to trust providers, and so providers will in turn be more likely to listen to the regulator and improve.
4. Risk-based approach
The risk-based approach CQC uses to regulate has also faced challenges. Using data models to identify risk is challenging because of issues like gaps in the data. Risk-based approaches always involve a process of learning and require ongoing evaluation and development. And even though using data is helpful, it is not perfect.
Inspectors still need to talk to people and understand what is really going on, beyond the figures. They also need the right tools and time to use the data properly.
Given proposals for CQC being more data-led in the government’s 10 year plan for Health, this further highlights the need for effective training and development and a nuanced understanding of the inspectors’ role in using data.
5. Adopting new approaches
Finally, when changing a regulatory model, it is important that CQC pilots new approaches and invest in training to support their rollout; evaluating whether new approaches are achieving their intended impact, and ongoing work to embed a culture of learning and evaluation. This is vital to quickly pick up on issues and address them before larger roll outs.
These five challenges are large, but not insurmountable. We proposed several key learning points for CQC as it develops and implements its future model. It is important that any learning from other regulators and/or countries is thoughtfully adapted to CQC’s specific context. There are good examples from Australia and the Netherlands, to name just two, on how to build and maintain good relationships between regulators and those they regulate, but this has to take account of and adapt to the different histories and relationships that have previously existed.
Making sure the purpose of regulation, and its desired impact, are central to the design of the regulatory model is another part of this. Additionally, it’s important CQC clearly communicates its thinking behind the new regulatory model, including how regulatory interventions like registration and inspection are intended to affect providers and people who use services.
Crucially, CQC will need to invest in the staff who do the work and supporting them to develop and maintain sector-specific, regulatory, and relational expertise. These staff are the face of CQC for providers, so it’s essential they are equipped for the task.
If the CQC can embed this learning in its work to address in its future regulatory model, this should support the development of an enabling culture and context and improve the effectiveness of regulation. That will ultimately benefit providers and – most importantly – people who use services too.
