Inspection in action - an evaluation of hospital inspections in Wales

  • Anne Christine Hanser

Student thesis: Doctoral ThesisDoctor of Health (DHealth)


This thesis investigated healthcare regulation practice in Wales with the aim to evaluate the strengths and weaknesses of hospital inspection regimes implemented by the Healthcare Inspectorate Wales (HIW). Applying Pawson and Tilley’s (1997) realist theory-driven programme evaluation, the study interviewed 46 representatives from eight NHS organisations, five independent sector organisations and HIW. HIW draws on various mechanisms to direct, detect and enforce compliance with standards. The research found that, while some elements of HIW’s inspection regimes such as self-assessments seemingly eroded over time, others have contributed to regulatory effectiveness. Engaging healthcare managers in the standard development process has created common understanding and ownership. Professional independence and clinically-competent reviewers, who scrutinise healthcare provision, validate findings and give informed feedback, have added credibility to hospital inspections. Hospital managers generally appreciated external reviews as a ‘reality check’ or lever for change. Commitment to quality and the fear of exposure have motivated compliant behaviour amongst hospital managers. Differences exist in the regulation between NHS and independent hospitals in Wales. Managers seem to find it easier to comply with or exceed healthcare standards in small, specialised hospitals than in large NHS bodies with many hierarchical levels. Further, HIW inspections have effected positive change in both NHS and independent hospitals. However, there were examples of repeated negative inspection results in some NHS hospitals. This suggests that HIW’s impact on improvements in the NHS has been limited.The findings suggest that HIW’s inspection regimes can be improved by regularly reviewing inspection methods and tools, systematically monitoring improvement actions and carefully selecting reviewers with matching clinical skills. The study did not find a standard prescription for an ideal inspection regime. Conversely, regulatory effectiveness requires the inspectorate to strike the right balance between different options and for inspectors to use their professional judgement in the specific context.
Date of Award3 May 2018
Original languageEnglish
Awarding Institution
  • University of Bath
SupervisorJane Millar (Supervisor), Charles Shaw (Advisor) & Chris Potter (Advisor)


  • regulation
  • inspection
  • healthcare
  • effectiveness
  • hospital
  • Wales
  • realist evaluation
  • evaluation
  • quality

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