Can NHS regulation really drive improvement?

Matthew Taylor

Hello and welcome to the latest edition of Health on the Line produced by Health Comms Plus on behalf of the NHS Confederation. 

Before we get into the content for this episode, many of you will know that NHS Providers and NHS Confederation announced our decision to merge the end of last year. And indeed, that merger has taken place. 

Now following a highly competitive and rigorous process, Sir Ciarán Devane will be the first chief executive of our new joint membership body. Sir Ciarán will join us from Ireland's Health Service Executive and we'll confirm his start date soon. 

It just gives me an opportunity, however, to pay tribute to my counterpart Daniel, the last chief executive of NHS Providers. Without Daniel, we absolutely would not have got to where we've got to. It really is very much his achievement, and I'm sure Daniel will go on to do great things for the National Health Service. 

Our new merger organisation will have a new name. Oh, I know you are intrigued, but I can't quite tell you yet. We'll have a new name and brand and that's going to be revealed in the coming weeks with details about our new, shiny new, amazing membership offer, which will be going to members next month. 

But now to today's episode of Health on the Line, and I'm pleased to bring to you a very special guest in the shape of Professor Sir Mike Richards.

Mike is the chair of the Care Quality Commission, the health and social care regulator, as if I needed to tell you. Sir Mike has been one of the most influential figures in shaping modern healthcare in England, from his pioneering work as the first national cancer director, which transformed outcomes, to his leadership as chief inspector of hospitals at the CQC.

Mike's consistently driven improvements in quality, safety and patient experience. And more recently, his landmark reviews on screening and diagnostics have set the blueprint for expanding capacity and improving early diagnosis across the ages. I know this because I'm 65 and it feels like every two weeks I get invited for some kind of diagnostic test, and of course, I enthusiastically respond.

So Mike's many insights continue to guide policy and practice at the highest level. He is high up on the list of people that ministers and senior officials phone when they've got a problem and they want some sage advice. 

Mike, welcome to Health on the Line. 

Professor Sir Mike Richards

Thank you very much Matthew, and thank you for that wonderfully kind introduction.

Matthew Taylor

So, Mike, I've given a bit of your recent bio, but why don't you tell us a bit more about yourself. Tell us why you took on, you know, you don't need to do more work, but you took on this role and you obviously took it on with a sense that you could make a difference. So tell us about the first ten months and what you, from the outset, set your key priorities. 

Sorry, that's a very complex question, but anyway, about why you took the role and what your priorities are. 

Professor Sir Mike Richards

Well, I describe myself as having an unplanned career and also being a failed retiree. 

But I never really meant to go into medicine. It was only after I'd been at university for a year that I realised I didn't want to be a physicist, and I looked back down the prospectus. I can't think why I'd never thought of it, I came from a medical family. And then I had an extremely happy career in medicine. 

I got lured into management and leadership. I thoroughly enjoy being national cancer director. Incidentally, working very closely with the new chief executive of your unnamed organisation, Ciarán Devane, who I know well from those days.

But more recently since retiring, I technically retired eight years ago, people have given me interesting things to do, including diagnostics and screening. And then towards the end of 2024, I was invited to do a review of the CQC. This was in the wake of Penny Dash's review. She had said, what has gone wrong? I think my task was to say why has it gone wrong. And to look at the assessment framework, to look at other aspects of how we went about our inspections and assessments, and clearly things had gone wrong in a fairly major way.

I think that's well known, I'm not saying anything new there, but then after that I was encouraged to apply to be chair, and I've really felt, yes, this is something that matters. Regulation in my view, and I've said this over many years, the  CQC is not an improvement agency, but we are an agent for improvement.

So we're there to protect the public and patients and then through, if we do good inspections and assessments, we are there to help drive improvement. And so that was an opportunity I couldn't turn down. 

Matthew Taylor

And you are in this interesting position of going into an organisation that you've undertaken a kind of diagnostic of in terms of the kind of problems that it's got. What did that mean in terms of your immediate sense of priorities? 

Professor Sir Mike Richards

Well, of course Julian Hartley, to whom I would like to pay tribute, he moved in before me. He started in December 2024, and I started in April ‘25, and Julian had set out four immediate priorities and five foundational improvements.

Those were based on Penny Dash's report and on my report, and so they remain our key things that we need to do for the next stage. We will then need to move into the wider question that the ten-year plan actually says that we have got to become the best health and care regulator in the world, but we need to get the basics right first.

So we, for example, we need and have got back into our sector based team. So there are specialist teams for hospitals, for mental health, for primary and community care, and for adult social care. We, as you know, have been consulting on the assessment framework and no doubt we'll come onto that, and all of those things.

Plus, of course, behind it all is the fact that we have an IT system that was meant to do great things for us, but frankly, which hasn't delivered. So we are now working on trying to get that IT system to deliver. 

Matthew Taylor

And on top of that, of course, there are other changes in terms of what's happening with the legislation. Obviously our abolition of NHS England and Healthwatch, your taking over the health services safety investigations body. 

So on top of those challenges, and I have, by the way, I kind of recognise this from a Confed point of view. You know, we are incredibly ambitious for the way we can evolve as an organisation, but you know, we are merging with Providers. We've brought into Confed the Q Network, which is a fantastic thing. So the world never stands, still does it while you're trying to improve things? 

Professor Sir Mike Richards

No, it absolutely doesn't stand still. I am confident that we can, if and when the legislation comes through, that we can take on board HSSIB, making clear that there are specific functions that HSSIB needs to keep.

We're working on that with them as we speak. So I think all of that is fine. But we have got to get on with getting our provider assessments right. Yes, the context is changing all the time. There's a huge focus on maternity care. We need to respond to that too and actually make sure that CQC is doing as good a job as it possibly can on assessing maternity services.

We'll come on to other things, but yes, we will need to respond. Of course we do. 

Matthew Taylor

So, I'm going to get into the question of the assessment framework in a second. 

But I just ask a kind of broader question, Mike, which is, it does sometimes feel, in the public sector as a whole actually, but particularly in health, as though we're caught in this kind of vice, which is on the one hand, rising public expectations, an intolerance, absolutely justified intolerance of the public, of us getting things wrong. The importance of us learning lessons constantly do matter, which tends to drive more regulation. 

On the other hand, a sense that the really big issues for the health service around kind of transforming productivity, around a different model of care, around maybe a different kind of relationship with the public, that this big stuff, it's hard to do because in a sense, so much of what we do is driven by responding to the kind of broad regulatory environment. 

So it's like we're trying to give what the public want, but in trying to do so, it makes it harder to do the really big changes that they want do. 

That’s probably not very well articulated, but do you see what I mean here? I kind of pick this up quite a lot when I talk to people.

Professor Sir Mike Richards

Somehow we need to do both. We still need to be able to regulate individual providers and make sure that they are doing the job that they should be doing. And one of the things that came out, when I was doing my review back in the end of 2024, actually particularly from an event with NHS provider chief execs, where they were saying, please redefine what good looks like because then we will know what we are aspiring to, and that is something I'm absolutely committed to doing.

CQC shouldn't do that on its own. CQC should do that in partnership with providers, with NHSE/DHSC, we should do it together. But defining what good looks like, I think will help people to know what we will be looking for. And I think it's very important to say we could and we should be looking for what is good as well as what is not good. And so that is absolutely something that I am working on with people in CQC to make sure that that is the case. 

And we need to train our inspectors to be able to do that. We need to get them knowing what good looks like. And remember that what good looks like does not stay static over time. To give a sort of specific example there, when I started as chief inspector of hospitals, critical care outreach teams were relatively speaking novel, and so we would give very good marks to people that had got them up and running.

Now, if there wasn't a critical care outreach team or the equivalent, I think we would mark them down as requiring improvement. But equally then something like Martha’s Law comes along and we need to be able to incorporate that saying, are you doing that? And again, that will become absolutely standard very quickly.

So one of the things that we will be asking people as we look at what good looks like is what has changed over the last ten years and where is it we need to focus our attention? 

Matthew Taylor: Well that brings me neatly to the consultation you've undertaken on your assessment framework. One of your colleagues told us the other day, maybe they say this to everyone, but they said that the submission that we had made jointly with NHS Providers, when we were two organisations – now we’re one – was one of the best submissions that you got.

So tell me what you're learning from the consultation around your assessment framework. What has that taught you and what is that leading you to conclude? 

Professor Sir Mike Richards

First off, can I endorse the comment about it being a very good and very helpful response? In fact, just to show that I have seen it, I'm waving it in front of the camera this minute, all eight pages of it is very good indeed. And very helpful. 

So, helpful partly because for the large majority of the questions we asked, we are getting a very positive response from the two organisations together, and so that suggests that we are in the right direction. A lot of those were the same direction as I was hearing when I did the review, so we will be implementing those.

There are areas that are going to go on being contentious – single word ratings being one of them, but equally how with very large trust groups, how do we assess them? My own view on that, and this is something that we are still working through, is that actually we do need to be able to assess locations because from a patient point of view, they matter.

If I give the example of a very large trust, like Bart’s – it's Whipps Cross Hospital, it's Newham Hospital, it's the Royal London, it's Bart’s – an individual patient may want to know, well, what does Whipps Cross look like? And so we need to be able to tell them that. 

But then do you just merge all of those together to give an overall rating? Or do we specifically look at a leadership of the trust group to say how good do we think that trust leadership is? And those are things we are still working through. And I'd be delighted to have further conversations with you and your successors about that. 

Matthew Taylor

Yes, absolutely. Let's have that conversation. And I think it's important that it's a continuing conversation. There are kind of particular moments when new frameworks are agreed and laid down but we need to be in a mode, I think, of continuously talking and evolving and avoiding some of the brittleness that can sometimes emerge in the relationship.

I want to come to a couple of the other kind of challenges around about getting this right, but one way into it is just to talk to you about ICBs. We did quite a lot of work with Julian around trying to kind of co-create an ICB assessment framework with CQC and then of course the responsibility for that was taken away.

I'm interested in your view of CQC’s role when it comes to the future of ICBs as strategic commissioning. Is that something you've been able to give some headspace to? 

Professor Sir Mike Richards

Not a lot, is the answer. I mean, it's very definitely on the agenda, but there are certain aspects that we do need to move forward on quite fast.

Neighbourhood health is clearly something that is coming and therefore we will need to assess neighbourhood health. Well again, I can't tell you exactly what that's going to look like now, but it is on our priority list to try and to find that. And one of the reasons that we have moved to a slightly different model, which is that community services are now alongside primary care, primary community services under Bola Owolabi. But one of her priorities is to try and work out how best to assess neighbourhoods, which are clearly a major part of ICBs. 

Matthew Taylor

Yeah, and that takes me to this broader question, I think, which is, and you'll recognise it so I don't need to kind of labour the point. 

In the end, it is much easier to regulate things that happen within organisations for which the leaders of those organisations can be held wholly responsible, than it is to regulate things that take place in the spaces between organisations, for which it's much harder to attribute direct responsibility and accountability. 

But yet, if you look at the literature around public service reform over the last 20 years or so since the kind of retreat of new public management as the kind of hegemonic framework for public service reform, a lot of that literature has emphasised the incredible importance of interagency collaboration to deal with on the one hand complex problems, and on the other hand people with complex needs. 

Now I had really interesting conversation with a chair of a hospital trust. You know, a really, really impressive person. Talking all, well, I would say almost entirely, about what he was trying to achieve in his hospital. Absolutely no mention of anything beyond his hospital, even though I believe very strongly that unless we are able to take things like the left shift, a preventative move, different kinds of…, unless we're able to do that radical change, we're not on a sustainable pathway.

So, given that it is easier to regulate and hold accountable within organisations, but we need the action to take place between organisations, how does CQC think through that conundrum? 

Professor Sir Mike Richards

So we are at the thinking stage, but do I recognise the importance? Absolutely, yes, I do.

I think there are a number of different ways that we can tackle it. Firstly, when we do a well-led inspection of a provider: have they got a vision and a strategy? Have they got the right leadership? Have they got the right governance, et cetera, et cetera. But how are they working with their partner organisations is part of that framework and should become, I think, an even bigger part of the framework. 

The very best trusts that I inspected back in the day, they were the ones who were working very closely with partners and so that will be an element. 

I think we also need to have more of a focus on specific pathways, pathways of care. Now, you know I have a background in cancer care and diagnostics for that matter, and that is just an example, and it shouldn't be the only one, but how is the patient getting from GPs, because they mostly come through GPs, through the diagnostic phase into the hospital and out again at the other side.

But equally the same applies to urgent and emergency care. To what extent do we blame an A&E department for having corridor care? Or do we blame the whole system for delayed discharges, and how well is an A&E department working with its ambulance service, you know? And are we conveying the right patients in the ambulances in the first place? 

For example, are patients in care homes being properly assessed for what their wishes are and whether it would be appropriate always for them to be transferred? But that requires conversations with relatives and with the patient themselves. And so some of those patients, it would be better for them if they were not being conveyed to a hospital and they're not potentially dying in a corridor in an A&E department. 

Matthew Taylor

Yes. Well, I'm really glad you're thinking about this, Mike. Because it's not, this is not a problem with CQC, this is an inherent challenge with regulation and accountability. 

You know, I've been a chief executive for 24 of the last 27 years, and in any organisation there's always this kind of conversation, which is, well, do we hold you to account for the things you control? Which are mainly about kind of outputs. Or do we hold you to account for things which you don't completely control, but matter more, which is outcomes? And there's a tendency to end up shrugging your shoulders and saying, no, well, we're going to focus on the former because it's just much easier to do and much more direct.

But it's just is a kind of conundrum we have to carry on working on, isn't it? 

Professor Sir Mike Richards

And Penny Dash's review very clearly stated, and I totally agree with her, that we didn't have a sufficient focus on outcomes and we are absolutely committed with Penny to getting shared data. And as you may know, I co-chair the National Quality Board with Penny Dash, and one of the top things on our list is to get a shared data set that we will all use, which will focus on outcomes. 

Matthew Taylor

So Mike, I'm going to move on to a bug bear and a bit of gossip. So the bug bear is, you expect me to raise this with you, my members wouldn't be happy if I didn't. The timeliness of CQC inspection reports. Some, as you know, being held up by over a year.

I know you are on it, Mike, but can you give us some hope? Can you give us some hope? 

Professor Sir Mike Richards

I can give you hope, but I can't say it's going to be done overnight. It is getting better. And in fact, the fact that we have moved back into having sector-specific teams, that means that we have inspectors who can focus on particular areas.

They can become more expert in those areas, and that actually makes the inspection – if you've inspected a number of A&E departments, or a number of maternity services or whatever, you get good at that and you get good at knowing what we should be looking for. So that in itself will accelerate the process.

We are having to do workarounds with our IT system. We've got a major programme of how to get the IT working properly, but this is going to take longer. If I promise you this will be done by the summer, I'm not being honest with you, so it is going to take time, but we will do everything we can in the meantime to speed that through and we are monitoring that very well.

Matthew Taylor

That's great to hear. And then following Julian Hartley's decision to step down, Arun Chopra has been acting as your interim CEO, can you give us a bit of insight information about when you are hoping to appoint a permanent CEO and also tell us a bit about what you'd be looking for in the ideal candidate. You never know if some of our listeners might be interested in the challenge. 

Professor Sir Mike Richards

Well, if any of your listeners are interested, do please get in touch with me. That's my first statement. And I would be genuinely interested to have conversations with any of your old listeners on that. 

We have now engaged an external recruitment partner, AKA, a head hunter, and the soft launch is underway. We're still a week or two away, I think, from actually going to advertisement, but people don't need to wait for that. I am as keen as anyone to get that resolved as quickly as possible. 

So, what am I looking for? Ideally somebody with who is an experienced leader, who's demonstrated that they can lead a significant organisation. Somebody with a passion for both protecting the public and driving improvement. Somebody with a lot of human skills, culture. 

Culture is really important both within CQC, where the culture hasn't been what it should be. It's hugely important within provider organisations. I have said this many times, but if there is one data set on a hospital that I would look at all times, it is the staff survey. It gives me the best information about the culture in that organisation. 

So I want somebody who is going to a focus on culture and how we can help to drive improvement in culture, both within and externally. 

So those are things that are off the top of my head. They could come from an NHS background, they could come from local government, they could come from another regulator. All of those things I've got an open mind on, but anybody that's interested, yes, do please get in touch. 

Matthew Taylor

Well, brilliant. You heard it here, folks. 

Now, Mike, lastly, reflecting on your other role chair of the UK National Screening Committee. I know you have had numerous conversations with Wes Streeting, there's something he talks about a lot when it comes particularly to cancer. What single policy change would you say would have the greatest impact in terms of improving early diagnosis? 

Professor Sir Mike Richards

Right. Well, at the moment, well over 90 per cent of all cancer patients present via their GP. Only about 6 or 7 per cent actually are diagnosed through screening. I would love to see that number double or even triple, and I don't think that's impossible.

There are things coming down the track. I don't know which ones of those are going to be effective. I'll be surprised if over the period of the ten-year plan we don't have a multi-cancer early detection test that that really makes a difference, that can pick up numerous different cancers. That's one real area of hope.

People will know that we are currently out to consultation on a draft recommendation about prostate screening. Our view at the National Screening Committee is that isn't quite there yet, but we believe that with further work that could be done. I mean, we've already identified that people with BRCA mutations are good candidates because the disease not only strikes younger, but it is more aggressive. So we're keen on that. 

But there are modifications to breast screening and modifications to cervical screening, to bowel screening. All of those are areas that we, the National Screening Committee, will be looking at. And all of those are areas where I believe the genuinely will be improvements over the next few years. 

Matthew Taylor

I agree, Mike, and I think this is something we should feel optimism about it, but that doesn't mean we should feel complacency about it because we want to accelerate this, you know? I said earlier, didn't I, that you know, you get to my age, 65, you get lots of invitations into forms of screening. I'm one of those, that’s got an irony, really me running the NHS Confederation. But I'm a health anxious person. I'm a hypochondriac, and so I always find these kind of diagnostic things quite nerve wracking. But that's I think my age. This is new stuff for me. 

The exciting future I think is one where, young people get to assume that regular health checks, very reliable, very customer friendly, easy to do, are just kind of part of how you manage your life. And also, you know, as the statistics improve, people become less and less fearful of something being discovered because they are more and more hopeful that even if something is discovered, it's likely to be solved.

So, one of those areas, Mike, where I look 20, 30 years ahead and I just think, my goodness, the world is going to be so much better. 

Mike, thank you so much for sharing your thoughts with us today. And listeners, if you have an exciting or innovative programme of work that you'd like to tell us about, please do. You might end up on Health on the Line. 

Contact us at Healthcommsplus@nhsconfed.org 

Mike, again, thank you and thank you for listening.