GPs will have been concerned to read that an independent review of the Care Quality Commission (CQC), led by Dr Penny Dash, identified ‘significant internal failings’ that hinder the regulator’s ability to effectively judge how health and social care services are performing.
As GPs strive to maintain a high standard of service for their patients, they need to know that their efforts are fairly and consistently judged by the CQC. They would also want to understand how the CQC’s ratings are generated so that improvements to care can be made where necessary.
Yet, the report’s findings suggest that GP practices may be impacted by inconsistencies in CQC ratings, opaque ratings calculations, and infrequent inspections performed by teams without sufficient clinical expertise.
Overall report findings
Dr Penny Dash, chair of the North West London Integrated Care Board, began her review of CQC in May 2024. In the course of this, she spoke with around 300 people in total, from within the CQC, the services it regulates, and from a range of patient and user groups.
However, despite these concerns, she emphasised that the people she spoke to recognised the need for a ‘strong, credible and effective regulator’, and that CQC personnel were generally professional and dedicated to their work.
What were the key issues?
Remarkably, Dr Dash found that CQC failures were having a direct impact on the activity of health and social care providers, impeding their capacity and capability to deliver services and implement improvements.
Ten key issues were revealed:
- Poor operational performance: A declining level of inspections, leading to a backlog in new registrations, delays in re-inspections, and an increasing age of CQC ratings.
- Significant challenges with the provider portal and regulatory platform: Problems with new IT systems, installed in 2021, hindered roll out of the ‘single assessment framework’ (SAF) and induced frustration for providers and CQC staff alike.
- Delays in producing reports and poor-quality reports: These issues hampered users’ ability to access information, while impacting on the credibility and utility of assessments.
- Loss of credibility within the health and care sectors due to the loss of sector expertise and wider restructuring, resulting in lost opportunities for improvement: After internal restructuring in 2023, operational staff moved from specific sectors into integrated teams, leading to loss of expertise as well as loss of relationships between CQC and providers.
- Concerns around the SAF and its application: issues include poor communication about the assessments and ratings categories, insufficient attention to the effectiveness of care and outcomes, and no reference to the efficient and economic delivery of care. There is also little acknowledgement of the challenges in balancing risk and ensuring high-quality care across an organisation.
- Lack of clarity and concerns regarding how ratings are calculated: overall ratings calculations may include aggregate outcomes from inspections over several years, and providers do not understand how the ratings are generated.
- CQC’s assessment of local authority Care Act duties could be improved.
- Concerns about Integrated Care System (ICS) assessments, which are in the early stages of development.
- CQC could do more to support improvements in quality: for example, by sharing best practice and innovative approaches to care delivery.
- There are opportunities to improve the sponsorship relationship between CQC and the Department of Health and Social Care (DHSC).
How is this impacting on GP practices?
Like all providers of regulated healthcare and adult social care services in England, GP practices must register with CQC and undergo inspections, with ratings assigned following the assessments.
The CQC’s inadequate performance was reported to be negatively impacting GP providers in several ways, including: a ‘lack of consistency’ in assessments across large GP practice groups; reliance on unrepresentative GP patient data; lack of transparency in how ratings are decided; as well as delays and IT problems.
In addition, Dr Dash concluded that a lack of relevant expertise among CQC’s senior leaders and GP practice inspection teams was causing providers to lose trust in the outcomes of reviews.
The recommendations
Dr Dash stressed the importance of a high-performing regulator for the health and care sectors, and a need to restore confidence in the CQC. Among her recommendations were:
- Rapidly improve operational performance, IT systems and report quality
- Rebuild expertise and relationships with providers
- Make the SAF fit for purpose
- Clarify how ratings are calculated
Following the interim report, Dr Dash commented, ‘Our ultimate goal is to build a robust, effective regulator that can support a sustainable and high-performing NHS and social care system which the general public deserves.’
First steps towards improvements
Following Dr Dash’s interim report, the CQC accepted the recommendations in full, committing to take rapid action to rebuild trust and performance with the ‘right structure, processes and technology’ in place.
Wes Streeting was reportedly ‘stunned’ by the extent of CQC’s failings in the report. He promised action, including: the appointment of Professor Sir Mike Richards, former Chief Inspector of Hospitals, to review the assessment framework; increased transparency around CQC ratings; greater oversight; and a further review of patient safety organisations, to be published in early 2025.
The CQC’s internal review by Professor Sir Mike Richards examined the assessment framework and its implementation. He concluded that the organisation needs a ‘fundamental reset’ to meet its objectives, with the recommendations including:
- Revert to the previous organisational structure
- Simplify the assessment framework and abandon the concept of a ‘single assessment framework’ for all the diverse services that CQC regulates
- Provide immediate feedback at the end of inspections, particularly for serious adverse findings
- Urgently review staffing
- Consider whether changes to the ‘one-word ratings’ could be beneficial.
In October, the CQC announced that Sir Julian Hartley will become its new Chief Executive. He said, ‘I will do my utmost to bring all I have learned to serve people who use services and to work with CQC staff and with providers to deliver high quality regulation which drives improvement across the health and care system.’
Please contact the expert team at Medical Defense Society if you have any concerns about CQC reviews and ratings.
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