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The CQC in the future in terms of assessing organisations also need to take account of the external as well as the internal factors also driving the agenda of the organisation's leadership for example the impact of commissioning intentions and contracting and such things as demand managemen leading to organisations having to implement significant savings programmes whilst seeking to maintain and improve the quality of services.

Peer review when conducted well - works well - and can really help to influence change and drive improvements and importantly gets the buy in of the clinical and management teams.

Finally, the post commented above about the quality of senior leaders is rather depresssing - however, if people behave in that way - it is important to understand what is driving that behaviour -and tackle it.