City Research Online

Rapid evaluation of the Special Measures for Quality and challenged provider regimes: a mixed-methods study

Fulop, N. J., Capelas Barbosa, E. ORCID: 0000-0002-7621-7957, Hill, M. , Ledger, J., Li Ng, P., Sherlaw-Johnson, C., Rolewicz, L., Schlepper, L., Spencer, J., Tomini, S. M., Vindrola-Padros, C. & Morris, S. (2023). Rapid evaluation of the Special Measures for Quality and challenged provider regimes: a mixed-methods study. Health and Social Care Delivery Research, 11(19), pp. 1-139. doi: 10.3310/gqqv3512


Background: Health-care organisations in England that are rated as inadequate for leadership and one other domain enter the Special Measures for Quality regime to receive support and oversight. A ‘watch list’ of challenged providers that are at risk of entering Special Measures for Quality also receive support. Knowledge is limited about whether or not the support interventions drive improvements in quality, the costs of the support interventions and whether or not the support interventions strike the right balance between support and scrutiny.

Objective: To analyse the responses of trusts to the implementation of (1) interventions for Special Measures for Quality trusts and (2) interventions for challenged provider trusts to determine their impact on these organisations’ capacity to achieve and sustain quality improvements. Design: This was rapid research comprising five interrelated workstreams: (1) a literature review using systematic methods; (2) an analysis of policy documents and interviews at the national level; (3) eight multisite, mixed-methods trust case studies; (4) an analysis of national performance and workforce indicators; and (5) an economic analysis.

Results: The Special Measures for Quality/challenged provider regimes were intended to be ‘support’ programmes. Special Measures for Quality/challenged provider regimes had an emotional impact on staff. Perceptions of NHS Improvement interventions were mixed overall. Senior leadership teams were a key driver of change, with strong clinical input being vital. Local systems have a role in improvement. Trusts focus efforts to improve across multiple domains. Internal and external factors contribute to positive performance trajectories. Nationally, only 15.8% of Special Measures for Quality trusts exited the regime in 24 months. Entry into Special Measures for Quality/challenged provider regimes resulted in changes in quality indicators (such the number of patients waiting in emergency departments for more than 4 hours, mortality and the number of delayed transfers of care) that were more positive than national trends. The trends in staff sickness and absence improved after trusts left Special Measures for Quality/challenged provider regimes. There was some evidence that staff survey results improved. No association was found between Special Measures for Quality/challenged provider regimes and referral to treatment times or cancer treatment waiting times. NHS Improvement spending in case study trusts was mostly directed at interventions addressing ‘training on cultural change’ (33.6%), ‘workforce quality and safety’ (21.7%) and ‘governance and assurance’ (18.4%). The impact of Special Measures for Quality on financial stability was equivocal; most trusts exiting Special Measures for Quality experienced the same financial stability before and after exiting.

Limitations: The rapid research design and 1-year time frame precludes longitudinal observations of trusts and local systems. The small number of indicators limited the quantitative analysis of impact. Measurement of workforce effects was limited by data availability.

Conclusions: Empirical evidence of positive impacts of Special Measures for Quality/challenged provider regimes were identified; however, perceptions were mixed. Key lessons were that (1) time is needed to implement and embed changes; (2) ways to mitigate emotional costs and stigma are needed; (3) support strategies should be more trust specific; (4) poor organisational performance needs to be addressed within local systems; (5) senior leadership teams with stability, strong clinical input and previous Special Measures for Quality experience helped to enact change; (6) organisation-wide quality improvement strategies and capabilities are needed; (7) staff engagement and an open-listening culture promote continuous learning and a quality improvement ‘mindset’, which is critical for sustainable improvement; and (8) consideration of the level of sustainable funds required to improve patients’ outcomes is needed.

Future work: Future work could include evaluating recent changes to the regimes, the role of local systems and longitudinal approaches.

Study registration: The review protocol is registered with PROSPERO (CRD42019131024).

Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 19. See the NIHR Journals Library website for further project information.

Publication Type: Article
Additional Information: Copyright © 2023 Fulop et al. This work was produced by Fulop et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This is an Open Access publication distributed under the terms of the Creative Commons Attribution CC BY 4.0 licence, which permits unrestricted use, distribution, reproduction and adaptation in any medium and for any purpose provided that it is properly attributed. See: For attribution the title, original author(s), the publication source – NIHR Journals Library, and the DOI of the publication must be cited
Publisher Keywords: Humans, Health Services Research, England, Surveys and Questionnaires, Humans, England, Health Services Research, Surveys and Questionnaires
Subjects: H Social Sciences > HM Sociology
H Social Sciences > HN Social history and conditions. Social problems. Social reform
R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine
Departments: School of Policy & Global Affairs
School of Policy & Global Affairs > Violence and Society Centre
SWORD Depositor:
[thumbnail of 3044230.pdf]
Text - Published Version
Available under License Creative Commons: Attribution International Public License 4.0.

Download (3MB) | Preview


Add to AnyAdd to TwitterAdd to FacebookAdd to LinkedinAdd to PinterestAdd to Email


Downloads per month over past year

View more statistics

Actions (login required)

Admin Login Admin Login