The realities of care delivery

High-quality regulation depends not only on what the CQC finds, but on how well it understands the context in which those findings arise. This includes the pressures facing individual providers, differences between services and sectors, and the increasingly integrated arrangements through which care is delivered.

Without strong contextual understanding, the CQC risks repeating diagnoses of known problems, misinterpreting their causes, and imposing additional requirements without helping address the underlying barriers to improvement.

Understanding local pressures

Trusts continue to face significant financial and operational pressures alongside demands to improve productivity, performance and quality. Our findings suggest trust leaders remain divided over how well they think the CQC understands the environment in which they operate. While 38 per cent rated its understanding as good, a third (33 per cent) rated it as poor. Positive responses are down marginally from 41 per cent in 2024 but remain well below 2018 (62 per cent) and 2019 (52 per cent) levels.

Free-text responses suggest the concern is not simply whether the CQC understands these pressures, but whether it recognises their impact when describing its findings.

Crucially, trust leaders are not asking the CQC to lower its standards or excuse poor or unsafe care because the wider environment is difficult. The value of independent regulation lies in assessing care against an objective standard, regardless of how other providers are performing.

However, they do feel the CQC should better reflect the context in which care is being delivered when explaining its findings, including wider system pressures and any improvement activity already underway. This would help provide a fuller picture of performance and help the CQC distinguish between risks already being managed and areas where independent scrutiny can uncover new risks or accelerate improvement.

One acute trust leader described a specific example of regulatory action that undermined existing improvement work underway with its ICB and NHSE. Another described the CQC omitting important details about existing improvement activity in its inspection findings:

Continuity of regulatory relationships locally appears important to building this knowledge. Many respondents still report high levels of personnel change and instability. Promisingly, some leaders described greater continuity and have benefited from increased informal engagement. It just appears not to be widespread yet.

As the CQC rebuilds its regulatory model, continuity of local relationships should be a priority. Stable points of contact can help inspectors develop the contextual knowledge needed for more informed and proportionate regulation.

Understanding sector needs

Concerns about context also extend to whether the CQC’s current approach reflects the different sectors it regulates. Just 27 per cent of leaders agreed that it meets the needs of their sector, compared with 41 per cent who disagreed.

These findings reinforce the case for moving away from a one-size-fits-all approach. The NHS Alliance has previously welcomed the CQC’s return to sector-specific frameworks in our response to its consultation. However, we continue to believe that primary care and community care should have separate frameworks to reflect their distinct characteristics.

This is one of the clearer green shoots in the CQC’s recovery. But new frameworks alone will not rebuild sector credibility. They need to be administered by inspectors with the expertise to apply them consistently and confidently.

Greater sector specificity is not without its limitations, though. In particular, patients do not experience care in sectoral siloes and risks often emerge at the boundaries between services and organisations. As the CQC rightly takes steps to rebuild its sectoral credibility, it must also set out how it will assess cross-sector and system-wide issues under its new model. As will be discussed in the next section, mitigations will be needed to ensure the problem is solved rather than moved.

Understanding integrated models of care

Integrating care requires models of delivery and governance that cross sectoral, organisational and professional boundaries. The CQC’s regulatory model must reflect this and be ready to adapt to increasingly joined-up ways of working in local areas. Our findings suggest the CQC currently has some way to go. Nearly half of trust leaders (44 per cent) rated the CQC’s understanding of integrated models of care as poor, including 20 per cent who rated it as very poor. Leaders identified place-based working, provider collaboratives, integrated teams and group models as areas requiring more thought:

Traditional units of assessment can also create unnecessary duplication where governance and leadership are shared:

More broadly, just 4 per cent agreed that the CQC currently encourages providers to collaborate and integrate care, compared with 59 per cent who disagreed. These findings underline the importance of ensuring regulation supports rather than cuts across increasingly collaborative models of care. As one trust leader put it:

The challenge is therefore to rebuild sector expertise without inadvertently rebuilding regulatory siloes. The CQC’s new approach must recognise both the distinct features of individual services and the increasingly integrated systems and pathways through which patients receive care.