There is an “urgent need for a rapid turnaround” of England’s health watchdog owing to “significant failings” in how it works, according to a damning review.
The final report of senior NHS leader Dr Penny Dash into the Care Quality Commission (CQC) found changes were needed to “restore credibility” within health and social care.
Dr Dash interviewed more than 100 staff at the regulator, received some 125 emails and also spoke to around 200 senior managers, caregivers and clinicians in the NHS and social care, as well as patient groups.
She concluded there were serious failings in the internal workings of the 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.”
On poor operational performance, Dr Dash pointed to the “stark reduction in activity” highlighted in her interim report, with just 6,700 inspections and assessments carried out in 2023, compared with almost 15,800 in 2019 before the pandemic.
This has resulted in new health and care organisations joining a “backlog” to be registered by the CQC, delays in re-inspecting hospitals and units following a ‘requires improvement’ or ‘inadequate’ rating and some ratings being years old.
“The review has concluded that poor operational performance is impacting CQC’s ability to ensure that health and social care services provide people with safe, effective and compassionate care, negatively impacting the opportunity to improve health and social care services and, in some cases, for providers to deliver services at all,” the report said.
The study also found profound problems with IT systems introduced from 2021 by the CQC, with people saying they caused more delay and were difficult to use.
When it came to inspections, Dr Dash found delays to producing reports, with some hospitals and care providers waiting “several months” to receive reports and ratings following assessments.
The review team heard multiple comments about poor-quality reports, including from patients, such as confusing messages and unclear findings.
Dr Dash argued there has been a “loss of expertise” among staff, including among inspectors, and concerns around the CQC’s single assessment framework (SAF), which was set up to give 34 areas of care quality that could be applied to any provider of health or social care.
Her review found the SAF uses “vague language” and there is “limited information available for providers and users or patients as to what care looks like under each of the ratings categories”.
Furthermore, there is “insufficient attention paid to the effectiveness of care and a lack of focus on outcomes” for users and patients.
Dr Dash found a “lack of clarity” regarding how the CQC calculates ratings and “concerning use of the outcome of previous inspections (that often took place several years ago) to calculate a current rating”.
The report said “providers do not understand how ratings are calculated and, as a result, believe it is a complicated algorithm, or a ‘magic box’”.
In response to the review, commissioned by the previous government in May, Health and Social Care Secretary Wes Streeting said: “Patient safety is the bedrock of a healthy NHS and social care system.
“That’s why we are taking steps to reform the CQC, to root out poor performance and ensure patients can have confidence in its ratings once again.
“This Government will never turn a blind eye to failure. An overly complex system of healthcare regulation and oversight is no good for patients or providers.
“We will overhaul the system to make it effective and efficient, to protect patient safety.”
Mr Streeting has now requested that Dr Dash carries out two further reviews, focusing on patient safety and quality.
The first will explore the remits of six organisations and examine if patient safety can be bolstered through a different approach.
The organisations include the CQC and the maternity programme, Healthwatch England, the Local Healthwatch network, the National Guardian’s Office, the Health Services Safety Investigation Body, the Patient Safety Commissioner and NHS Resolution.
The second review will look at quality and governance, with the findings shaping the Government’s 10-year plan to transform the health service.
Saffron Cordery, deputy chief executive, NHS Providers, said: “Keeping patients safe is the number one priority for NHS trust leaders.
“Trust leaders have said for some time that the regulator needs urgent reform. Restoring the CQC’s credibility will take a lot of work.
“Regulation of NHS services is important but to add value it needs effective leadership, the right expertise and a focus on what really matters. We have highlighted that the CQC must concentrate more on support and improvement.
“With two new reviews announced which will focus on patient safety and quality, trust leaders are ready and willing to work with the CQC and all other key organisations as they strive to provide high-quality services for patients and in their quest to keep improving and innovating.”
The CQC said in response that it would appoint at least three chief inspectors to lead on regulation and improvement of hospitals, primary care such as GP and dental services, and adult social care services.
“Consideration will also be given to whether a fourth chief inspector is needed to lead on regulation and improvement of mental health services,” it said.
The current method for assessing hospitals and other organisations will also be made simpler and enable the CQC to carry out and report on inspections more quickly, it said.
The five current questions asked of NHS and social care services (safe, effective, caring, responsive and well-led) will be kept, but 34 separate quality statements will be looked at to “ensure clarity and remove duplication”.
The CQC also promised to improve the way it deals with the NHS and social care sector, and will pause assessment of integrated care systems (ICS) for six months.
The CQC has previously asked Professor Sir Mike Richards to carry out an internal review, which will also be published on Tuesday.
Ian Dilks, chairman of the CQC, said it accepted the Dash findings and “we will address the recommendations with urgency”.
He said both the Dash review and that from Sir Mike “have reaffirmed the support for a robust health and care regulator and recognised the dedication and experience of CQC staff”.
“We are committed to rebuilding trust in CQC’s regulation and are taking action to make sure we have the right structure, processes, and technology in place to help us fulfil our vital role of helping people get good care and supporting providers to improve,” he said.