Imagine you are given a set of eight index cards.   Each card shows a picture of a child eating one of two types of food – a gooey chocolate cake or a light carrot cake.  Each card also shows the child’s reaction after eating it – either smiling or looking ill.  You are asked if the cards suggest either kind of food makes the child unwell.

If you are like the subjects of an experiment conducted by Deanna Kuhn, you would suspect that chocolate cake was unhealthier and would say that the evidence supported you.  In her experiment, that was the case even when the cards showed a greater correlation between the carrot cake and sickness.  Kuhn concluded that if people were able to find some evidence in support of their hypothesis, they were able to reach a conclusion that the evidence supported their view.

This is one of many studies relating to confirmation bias – the practice of seeking, interpreting and ignoring evidence to support views one already holds.

The phenomenon of confirmation bias affects CQC and providers as well as other stakeholders.  For CQC, inspectors likely form views very quickly.  According to the social psychologist Jonathan Haidt, the mechanism of decision-making is that intuition leads the way, and the head follows.  When it comes to inspections, confirmation bias means that inspectors would naturally seek evidence to support their intuition, and ignore or fail to gather other evidence.

Health and social care services are incredibly complex institutions and in every setting there is ample opportunity to find evidence – favourable or not – to support one’s intuition about the quality of the service.

It is no wonder that the day after Panorama was broadcast Sir Stephen Bubb said on Radio 4 that CQC was not fit for purpose.  The reality is that CQC is not currently able to reliably and consistently tell the difference between good and unsafe services.   Its inspectors are probably collecting evidence and drafting reports to support views they subconsciously formed before reasoning kicked in.

As to providers, it is natural for them to want to feel a sense of pride about their services.  They may be more willing to seek out and accept evidence that supports that view, particularly if it is in agreement with the view of other stakeholders.  The closer the relationships between those auditing services and the location in question, the more likely it is that they will intuitively have a positive feeling towards the service, and the less likely they will be to find fault.  In some cases, providers may also reward managers according to internal quality KPIs, adding a further incentive for seeking favourable evidence.

When it came to Whorlton Hall, it seems that the confirmation bias of CQC and the providers was working against them identifying the poor standards.  In the case of CQC, that reportedly included supressing the views of one of its inspectors.

What are the solutions?


  1. Recognise the power of confirmation bias and test how it is affecting its inspection function.
  2. Explore the origins of inspectors’ intuition. This may involve an uncomfortable exploration of unconscious bias.
  3. Studies seem to show that working with others can mitigate the risk of confirmation bias. Consider abandoning the ‘lead inspector’ model and using a genuinely collaborative approach.
  4. Greater standardisation about how and what evidence is collated, and how it is interpreted.
  5. Test the objectivity of inspection methodologies by having different inspectors interpret the same evidence.
  6. Train inspectors to seek evidence that disproves their intuition, rather than only seeking evidence that supports it. That is the only way of testing whether a hypothesis is truly sound.


  1. Use robust quality assurance systems to audit quality and compliance. Test the effectiveness of those systems in identifying areas for improvement.  If they are not spotting problems, they are not working.
  2. Use external consultants to provide an additional check.  Vary the consultants to avoid personal relationships between the consultant and managers that can hinder the objectivity.
  3. Incentivise people to identify areas for improvement.
  4. Test whether incentives for positive internal audit results hinders identifying development areas.
  5. Listen carefully to the views of people using services. What is their daily life really like?
  6. Consider mystery shopping or other innovative methods of testing how services are experienced, rather than how they are recorded.


Please get in touch if you have any thoughts on this, or need any help on regulatory matters.


Jonathan Landau, Barrister

5 Chancery Lane
London, WC2A 1LG
DX: 182

Telephone: 0207 406 7532

Mobile: 07980 897 429



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