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Letters Inspection of hospitals

Small, not large, teams assess hospitals internationally

BMJ 2013; 347 doi: (Published 06 November 2013) Cite this as: BMJ 2013;347:f6620
  1. Charles D Shaw, independent adviser quality in healthcare1
  1. 1Arundel, UK
  1. cdshaw{at}

In his letter, Auger argues that the new Care Quality Commission inspection regime is under-resourced.1 Apart from their demands on clinical specialist time, and competing with peer review by the royal colleges and associations, inspection teams of 20-25 may be unsustainable. They may have worked better for the pinpoint investigation of the Keogh reviews of 14 hospitals than they would for programmed review of every acute and mental health trust in England.

Large teams were a criticised feature of the Health Advisory Service, which inspected mental health and long term care services before the creation of the Commission for Healthcare Improvement. Ever larger assessment teams never meet the infinite demand for more expertise, but they do multiply the complexity of internal communications, coordination, and costs of site visits out of proportion to their added value. They are also unduly disruptive to the organisation being assessed.

Data submitted by 44 healthcare accreditation organisations to an international survey in 2010 show that larger hospitals and academic medical centres are assessed typically by small teams that provide 15-30 “surveyor days.”2 Examples include Accreditation Canada (24-33 surveyor days among six surveyors) and the Joint Commission in the US (20 surveyor days among five surveyors). The largest teams are deployed by the French Haute Autorité de Santé, which is the regulatory counterpart of the Care Quality Commission (5-6 “expert visitors” between five and 15 days on site).

Given the history of healthcare regulation in England, the rationale for returning to swarms of assessors is unclear. Successive inspectorates have suffered from standards, assessment methods, and solutions that have been prescribed by politicians rather than by technical experts, evidence, and experience in the NHS and in other healthcare systems. Sustainable programmes for improvement of quality and safety require consistency of policy, effective interaction between mandatory and voluntary schemes, and realistic business planning. The work and the workforce must be shared.


Cite this as: BMJ 2013;347:f6620


  • Competing interests: None declared.


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