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The competing demands of compliance

Dennis Bacon explores the impact that non-CQC related compliance initiatives have on providers.

The Institute of Public Care’s Market Shaping Toolkit takes a significant leap forward in attempting to understand the pressures facing health and social care and the relationship between local authorities and care providers. It supports both smaller care providers and local authorities to engage in market shaping and develop innovative practice to meet local needs together. It has been designed to highlight good practice around the country in the way that local authorities and smaller care and support providers collaborate and provide innovative services.

As part of this, the report attempts to break the key myth around private providers being out for personal gain. It says:

Myth: Private providers are only interested in making a profit for personal gain. Any additional cash will go on that rather than improved services or conditions for staff.

Reality: The majority of providers, regardless of sector, will use profit to reinvest in the business. Private providers will need to use some of their profits to pay back their financial backers, charities will invest surplus to meet their charitable aims. Banks and other lenders take a risk when lending and need a minimum level of return if they are to take that risk. Any type of organisation (private or voluntary) may have to declare significant profit in order to stay cash neutral. A provider that does not invest in its business or fails to reward its staff adequately is unlikely to survive. Quality will fall through the lack of investment and staff will leave because of uncompetitive wage rates. Not generating a return on investment, or taking all the profit for personal gain, are both unsustainable business strategies.

Financial pressures

Health and social care budgets are under increasing pressure. This is resulting in a reduction to the fees that providers can charge under revised care contracts with commissioners. At the same time as constraints on fees, providers are being compelled to react to increasing demands from improvement programmes, staff training and compliance reporting activities. All of these demands redirect resources from delivering care. They also have a financial impact, whether direct or indirect, which increases costs beyond the income generated from local authority contracts. Understandably, this has led to independent and not-for-profit providers questioning the future sustainability of their services.

Compliance pressures

Looking at compliance specifically, all providers are required to comply with Care Quality Commission (CQC) standards. These are designed to ensure both a consistent standard of practice and an acceptable level of safe care. In most cases, providers are capable of managing the quality processes between the regulator (auditing) and organisational performance (governance) requirements with approaches in place to address non-compliance.

However, as well as complying with CQC standards, providers have to consider other agencies and initiatives developed to ensure the delivery of safe and quality practice. These include public health’s infection control audits, and clinical commissioning groups’ quality audits as part of contract monitoring. It would be reasonable to suggest that many of these duplicate the intended outcomes of the CQC.

In the recently released Commissioning for Better Outcomes: A Route Map, commissioners have accountability to ensure that they:

  • Work in partnership with a wide range of local authority services, housing, health, the third sector and care and support providers to develop shared outcome frameworks.
  • Have a collaborative relationship with the CQC; sharing information between the organisations to avoid duplication of effort, ensuring a shared focus on services requiring improvement.

This needs to happen. Providers feel under pressure to participate in the ever growing number of compliance (and often duplicating) quality assurance initiatives – even if they fall outside of, or compete directly with, the requirements of the CQC.

Costs of compliance

This pressure to participate also has an associated cost for providers. Money and time represent potential opportunity for providers. However, organisations can only realise this opportunity when they have both access to, and the targeted use of, these resources. Those aspects of operations that aren’t a constructive use of time or money reduce productivity and divert resources from delivering effective, quality services.

It’s difficult to quantify how much work this is and what the associated costs are, but the impact is being felt across the sector and is affecting the sustainability of services. Providers’ sustainability is based on their ability to manage their costs. Adhering to any of a number of different compliance considerations that fall outside the CQC’s remit costs time and money and could impact on the service in a variety of ways. It could lead to stagnation, continuous improvement or innovation but providers don’t always know which. This means it is important that we identify the level at which compliance with non-CQC initiatives impacts on the ability to deliver services.

It is reasonable to assume that complying with initiatives may be adversely impacting the provision of services. It reduces the time available to spend on caring and increases non-productive demands. When given the option, and surplus resources and revenue to dedicate to something, providers should consider prioritising those initiatives that translate to higher levels of care against the CQC’s standards. While this is the ideal, the issue remains that to be able to decide which initiatives to undertake and to quantify the costs, we need to understand their impact on both resources and finances. Also, the impact of not being involved in the activities, whether reputational or otherwise, must be considered.


In the absence of quantitative data on the cost of compliance, providers will continue to struggle with targeting their resources towards growing the business in capacity and quality of services. Research needs to be undertaken into the cost of compliance to identify where duplication is evident. This will enable the CQC, commissioners, market shapers and providers to collectively manage the essential element of quality and safety, while ensuring resources remain available for innovation and continuous improvement.

Dennis Bacon is Chair of Norfolk Independent Care Association. Email: Twitter: @NorfolkICare

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