Title: Provider ratings: the effects of the Care Quality Commission's new inspection and rating system on provider performance
Funder: Department of Health and Social Care

Abstract: Background The introduction of provider performance ratings in health and social care in England is one part of a wider set of changes in the regulatory model and inspection regime, and of the Department of Health s policy response to the Francis report. Their key purpose is to drive improvements in the quality of care. We know from research that rating systems are complex to design and implement, and can have both positive and negative effects. Aims This study sets out to examine the development and impact of provider performance ratings in health and social care in England. We will examine how systems of ratings have been developed and are used in practice, what impact they have on provider performance, and how they could be improved. Our four main research questions (articulated in more detail in the aims and objectives section) are: How is the system of provider ratings intended or expected to drive improvements in the quality of care? How is the system of provider ratings implemented in practice? What impact does the system of provider ratings have on quality of care and other attributes of provider performance? How could the system of provider ratings be further developed and improved? Research plan The project consists of four main workpackages: WP1 &ndash; Provider rating design and development: evidence synthesis and theory building. We will examine the theories in use and expected mechanisms in the new system of provider ratings through interviews with key informants and documentary review alongside a rapid realist review of the research literature on ratings/indicators and mechanisms for change/improvement. This workpackage will provide the theoretical framework (and set of programme theories) which will guide WP2 and WP3. . WP2 &ndash; The system of ratings: geographic case studies of provider rating in practice. We will select six health and social care &ldquo;systems of care&rdquo; (geographic areas likely to be concordant with CCG and/or council boundaries) as case studies in which to examine the process of and response to ratings in four sectors (acute care, primary care, mental health and adult residential social care) through providers, the public and other stakeholders in that system of care primarily through interviews, meeting observations and documentary review. WP3 &ndash; The costs and impact of ratings: a quantitative assessment using existing data sources. We will undertake a quantitative analysis of the costs and impact of ratings by using the ratings data itself alongside data from CQC s post-inspection provider survey and a number of routine performance data sets. We will use advanced statistical methods to explore associations between ratings and changes in performance . WP4 &ndash; Improving provider performance rating. We will engage in proactive dissemination and knowledge mobilisation both to test emerging and interim findings and to seek to articulate research outputs in ways that key audiences are able to bring them to bear on future policy and practice. We will manage the project actively to ensure key milestones are met and deliverables achieved. Research team The research will be undertaken by a team from the University of Manchester and the Kings Fund in London, who have already been researching the development and implementation of CQC s new inspection model in acute care, and its underlying regulatory model. We have a strong track record in research and working with policymakers and practitioners to make our research findings and recommendations useful to key audiences. Impact and influence This research is explicitly intended to examine how the system of ratings could be improved (RQ4) and to engage in proactive dissemination and knowledge mobilisation with policymakers and practitioners to that end (WP4).

Lay abstract: In response to the Francis report and other concerns, the Department of Health and the Care Quality Commission introduced changes designed to prevent, detect and deal with problems with the quality of care more quickly and effectively. CQC has completely overhauled its regulatory model and inspection regime to make it more detailed, with the increased use of expert knowledge, data and views from a range of stakeholders. It has introduced provider performance ratings in five domains (safe, effective, responsive, caring and well-led) using a four point scale (outstanding, good, requires improvement, or inadequate). These ratings are published alongside a narrative report following each inspection. This new approach has been introduced first in NHS acute care, but is being developed in other areas of health and social care. Our research sets out to examine how providers, the public and other stakeholders respond to provider ratings, and what impacts inspection and ratings have on the quality of care and on improving performance. These are important but complex questions to answer. Understanding how ratings work, as part of the wider inspection process, is essential if we are to increase the potential benefits for the quality of healthcare, and reduce the costs and any adverse or unintended consequences. We have four main questions in our research: How is the system of ratings meant to work, and bring about improvements in the quality of care? How does it work in practice, and what do providers, the public and others do in response to ratings? What impact does the system of ratings have on measures of the quality of care and provider performance? How could the system of ratings be improved? We plan to use a combination of qualitative and quantitative research methods, and to make good use of the large amounts of data which CQC collects about inspections and ratings. Our findings will be shared with CQC and the Department of Health, as well as with health and social care providers themselves, to help improve the effectiveness and efficiency of the system of provider ratings.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE