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Rating health and social care providers for quality

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The Secretary of State was interested in investigating if ‘Ofsted’ style ratings could be introduced for health and social care providers. This initiative had a challenging history, a mixed evidence base, and it was subject to strong stakeholder opinions. Taking this into account, the Secretary of State agreed to bring in an outside organisation with relevant expertise to analyse the evidence, learn lessons from the past and engage stakeholders. The Nuffield Trust was contracted to carry out the work and provide recommendations to Ministers. Their involvement facilitated discussions with stakeholders that the team believe may not have taken place had the work been conducted in-house.

Find out the lessons learnt

A complex and contested issue

The challenging history and the complexity of introducing ratings, in particular in the health service, compelled the Department of Health to take a new approach. The Department commissioned the Trust on a single tender to carry out a detailed literature review of the evidence and a broad stakeholder engagement exercise. The terms of reference for the Review allowed the Nuffield Trust to identify both the advantages and disadvantages of provider ratings and the contract made it clear that the final report would be published independently of the Department of Health.

The value of independence

The approach of the Nuffield Trust was to combine an engagement exercise with a literature review, looking specifically at learning from the past and international comparators. Instead of carrying out a traditional paper consultation, the Trust brought the different parties together in a series of meetings. These sessions were iterative: the discussion developed over time as new findings emerged and were discussed at each meeting.

Managing the process

For both the Department and the Nuffield Trust, it was important to have clear contractual agreements. A major part of this was clarifying communication lines between the Department and the Trust. The Department seconded a team member over to Nuffield for the duration of the project. This ensured the lines of communications were kept open and enabled better knowledge transfer. It was particularly helpful towards the end of the project when the Mid-Staffordshire Public Inquiry report was published, a month before the Ratings Review. The policy landscape was changing quickly as a result The Nuffield Trust had to keep up to date with the new policy developments to ensure that their work on the Ratings Review remained relevant.

A different way of working

The independence and fixed timetable for the Review meant that the team had less flexibility with the project than would have been the case if the work had been conducted internally. However, there was real value in opening up the policy making process. Some external stakeholders who were crucial to the development of the policy were sceptical of the direction that the work had taken so far. Having a trusted, independent body to lead the engagement helped to facilitate a constructive discussion on key issues. Stakeholders felt that they had a safe forum in which to air their views. In addition, the opportunity to discuss and debate with policy developers rather than simply respond to a consultation document allowed for a richer report and a much stronger base from which to move to implementation.


The review was published, concluding that “ratings for care homes and other providers of adult social care services, and potentially for GP practices could be useful for the public… A single summary score of a hospital’s performance risks masking examples of good and poor care across different departments and wards. Therefore, the review recommends that any attempts to rate quality in hospitals should focus most closely on individual departments and clinical services rather than indicators based on management performance, such as finances…. [and] combined with other approaches, such as robust surveillance, inspection and special investigations [to identify lapses in care]”.

The Secretary of State was impressed with the quality and thoroughness of the advice received, and the recommendations were broadly accepted. The work also received a warm response from stakeholders who offered to support the implementation phase. The policy is more likely to be successfully implemented as a result of the evidence based approach and stakeholder engagement. The process that was followed to develop the policy is also particularly transparent given that the advice was published. In turn, this strengthens the Department and delivery bodies’ accountability in relation to this policy.

Lessons learned

If you are thinking of following a similar approach, the team recommend that you:

  • Decide what’s important for the work when seeking an external organisation to carry it out. In this work, the team valued the communications and public affairs capability of the organisation as well as its academic reputation and deep sector knowledge.
  • Weigh up the costs and benefits of seeking external advice compared with conducting work in-house. In this case, commissioning external advice helped facilitate discussions that may otherwise not have taken place and conclude the work sooner than if it had been conducted in-house. This outweighed the time spent contracting the work and informing the Nuffield Trust of changes to the policy landscape.
  • Don’t have a pre-determined answer. The external body needs the space to develop conclusions and recommendations.
  • Respect the independence of the organisation – even if this means agreeing to disagree!
  • Make sure everyone, including external stakeholders, understand that the policy decision will be made by Ministers who will be informed but not instructed by the advice.
  • Establish a clear contract and identify an influential contract manager.

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