Evaluating the effect of external inspections of the Care Quality Commission of acute NHS hospitals in England

Background: External oversight institutions were introduced to the English National Health Service (NHS) in an attempt to encourage quality improvements and avoid failures of care. Despite the breadth of literature exploring the theoretical relationship between improvement of quality of care and external oversight, robust empirical evidence does not yet exist to support this premise. In this thesis, the effect and costs of the Care Quality Commission (CQC) external inspections of acute hospitals on quality of care are explored. The aim is to determine to what extent inspections are associated with changes in care quality, and if inspections are cost-effective. Methods: Three pieces of empirical research are presented. First, existing literature on the effect of external oversight on hospital organisational performance and clinical outcomes was surveyed through an overview of reviews. Second, the effect of CQC inspections and their announcement on seven measures of care quality was estimated in three scenarios using an interrupted time-series design. Finally, the opportunity costs of CQC inspections were explored in a purposive sample of English acute NHS trusts. Results: The overview of reviews showed that external oversight has mixed effects on organisational performance and clinical outcomes. However, the quality of the evidence was low to moderate. The interrupted time-series studies suggest CQC inspections were not associated with changes in the measures of care quality. Although some statistically significant changes were present, the size of the effect is unlikely to be clinically relevant. The opportunity cost for acute trusts of a CQC inspection was estimated to lie between £169,691 and £418,136. Conclusions: CQC inspections are not associated with improvements in the quality of care provided in acute NHS hospitals.