There has been so much focus on the future role of Monitor that almost no attention has been paid to how the NHS’s other regulator, the Care Quality Commission, is coping with the challenges of reform and tighter budgets.

HSJ’s exclusive revelation of the concerns presented to the last CQC board meeting should therefore act as a wake-up call.

The regulator highlights not one, but three, major areas of risk, all of which are considered “likely” to happen. These risks are that the CQC:

  • “fails effectively to identify or deal with non-compliance leading to persistent poor quality care for users”;
  • “lacks the volume and/or type of resource required to meet the demands placed upon it, leading to unacceptable levels of performance”;
  • “fails to operate in line with required standards of probity and value for money”.

In short, the CQC is – potentially – in very big trouble indeed.

Chief executive Cynthia Bower is prioritising action to mitigate these risks, but it is a mighty big to-do list at a time of such changes and mounting pressure. The CQC needs certainty to get a grip on these risks – but certainty is rarer than a Liberal Democrat on the health secretary’s Christmas card list.

The fate of the Health Bill is one of obvious and growing uncertainty, but another significant source of pressure is provided by the inquiry at Mid Staffordshire Foundation Trust. Delays have already been caused by the failure to release government documents, meaning that senior Department of Health figures have still not been interviewed. Sources close to the inquiry suggest their testimony will lead to the need to re-examine many witnesses. These same sources predict the inquiry will not report until early 2012.

That report, which the government will find impossible not to endorse, will almost certainly have profound implications for the CQC – but planning for these implications is next to impossible.

The inquiry is also sucking up weeks of CQC management time. Most significantly Ms Bower has been interviewed as both CQC chief executive and as the boss of NHS West Midlands during 2006-08. A return to the witness stand is likely.

The CQC is closely involved in the national quality board’s attempts to ensure quality, safety, effectiveness and patient experience are not undermined by the transition to whatever new system emerges from the policy turmoil.

Ms Bower’s latest board report reveals the CQC must determine “what its relationship needs to be at national and local level with other parts of the system”. A difficult job to do if those national and local levels are not determined.

Ms Bower adds: “given the attention of other players will be focused elsewhere during the transition period, what are the particular areas of risk for CQC and how we should mitigate against these?”

The risks identified above aside, the opportunity cost for the CQC created by the continuing uncertainty is also enormous.

Registration of new providers remains a struggle and there is little sign of the promised “live” rating system to inform patients about the quality of care at organisations treating NHS patients. Issues such as the CQC’s role in the any qualified provider policy and the assessment of commissioning consortia remain unresolved even as these policies begin to make themselves felt on NHS services.

Then there is the CQC’s relationship with Monitor. If Monitor is going to be given a more balanced role in ensuring that the system does the right thing through competition, collaboration and integration; if resources remain tight; and if the Mid Staffs inquiry follows the heartfelt recommendation of its witness, former Healthcare Commission chair Sir Ian Kennedy, then what chances of a single, merged NHS regulator?