Recommendation 17

Enhanced quality standards

Accepted in principle
The NHS Commissioning Board together with Clinical Commissioning Groups should devise enhanced quality standards designed to drive improvement in the health service.  Failure to comply with such standards should be a matter for performance management by commissioners rather than the regulator, although the latter should be charged with enforcing the provision by providers of accurate information about compliance to the public.

NHS England and clinical commissioning groups will have regard to enhanced quality standards in the way they commission services, and the Care Quality Commission will use them to inform their ratings of providers.

NHS England will work with clinical commissioning groups to use enhanced quality standards to drive improvements in the health service.  NHS England has agreed with the National Institute for Health and Care Excellence that the concept of enhanced standards is represented by the existing quality standards, developed by National Institute for Health and Care Excellence and endorsed by NHS England.  Compliance with these standards should indeed be a matter for commissioners rather than the regulator. NHS England is currently required in legislation to have regard to quality standards, and clinical commissioning groups are required to do the same through NHS England’s planning guidance.

The Care Quality Commission will use enhanced quality standards to inform its quality ratings of providers.  In line with recommendation 13, where there are emergent evidence-based technologies with the potential to drive widespread improvements, the National Institute for Health and Care Excellence will also include developmental standards within quality standards.

As outlined in the response to recommendation 249, providers are required to publish a Quality Account each year, providing accurate information on their performance in relation to quality standards. NHS England will review Quality Accounts before the 2014/15 cycle to ensure that they give patients appropriate information on the services they use, and that they add value to the quality assurance infrastructure used by trusts, local and national organisations.


The National Institute for Health and Care Excellence has introduced developmental statements in its quality standards where appropriate. Between June and September 2014 it published the National Institute for Health and Care Excellence quality standards – the process guide, a consultation on its updated quality standards process guide which made detailed proposals for how developmental statements would be identified and produced.

The Care Quality Commission and Monitor work together to assess the capability of a Foundation Trust and/or its leadership to ensure safe and quality care. Monitor makes this assessment from the Board down, the Care Quality Commission from the ward up. The Care Quality Commission and Monitor have a new single, overarching framework for judging whether or not an organisation and/or service are well-led. The Care Quality Commission and Monitor use the framework to help inform their assessments and inspections.

The framework is used during the routine inspection of Foundation Trusts where the Care Quality Commission requests information from Monitor in preparation for an inspection. The Care Quality Commission’s inspection provides a judgement on the quality of services and Monitor will then take action where necessary to support improvement. The Chief Inspector of Hospitals can also recommend that a Foundation Trust be put in special measures. As part of this, Monitor provides intensive support, including appointing an Improvement Director. The Care Quality Commission will then re-inspect and recommend whether the Foundation Trust should be kept in, or taken out of, special measures.

For example in July 2013, after the Care Quality Commission inspection identified significant concerns about the quality of care, the Chief Inspector of Hospitals recommended that North Lincolnshire & Goole NHS Foundation Trust be placed in special measures. Monitor initially used its powers to agree a programme of work with the Foundation Trust to address issues in governance, clinical effectiveness, patient safety and experience. Monitor subsequently oversaw the Foundation Trust’s delivery of this programme, resulting in the quality issues being addressed. Following a recommendation from the Chief Inspector, the Foundation Trust was removed from special measures in July 2014.

The Care Quality Commission, Monitor and the NHS Trust Development Authority have jointly developed and published guidance on how the special measures programme worked for NHS trusts and Foundation Trusts. The Care Quality Commission and Monitor have also published a joint working agreement document setting out how they will work together.

A review of Quality Accounts has taken place in 2013/14 and engaged 180 stakeholders, including patients, carers, service providers, Healthwatch, NHS England, NHS Trust Development Authority, Care Quality Comission and Monitor.  As a result of this review, there is now an area on NHS Choices providing presentational guidance and as part of the review, it was recommended this should be further developed to include guidance about publishing data in a more patient friendly way. This will be further developed in 2014/15. The Quality Accounts review also identified the need to provide local Healthwatch organisations with guidance on how to effectively challenge local Quality Accounts. This is being taken forward by NHS England and Healthwatch with a view that this will help to inform the approach Healthwatch take to commenting on Quality Accounts in 2014/15.