Abstract
The Special Measures and Challenged Provider (SMCP) Regime introduced for struggling healthcare organisations in England represents a subtle shift to the scope of external regulation from performance oversight to include supporting internal service improvement. External regulation alone has a had a mixed impact on the quality of care and Vindrola-Padros and colleagues' study highlights that externally driven improvement initiatives may also struggle to succeed in turning around performance. Principally, this is due to a failure in acknowledgment that poor performance results from a myriad of external and internal factors which coalesce to impede organisational performance. A struggling organisation may be indicative of wider issues in the local health and care system. Whole systems approaches to improvement with collaboration across providers and the effective use of data may support struggling organisations but their role maybe tempered with the increased centralisation of the delivery of improvement regimes such as SMCP.