Regulation of health and adult social care: the case for improvement

Regulation of health and adult social care: the case for improvement

Dr Nick Bishop 26 October 2011

Senior Medical Advisor

Care Quality Commission

CQC’s RoleWe make sure that the care people receive meets essential standards of quality and safety.

We encourage ongoing improvements by those who provide or commission care

Compliance with Essential Standards of Quality and Safety based on Health & Social Care Act (2008)

Providers not professions

Currently > 20,000 registered providers in England only

NHS Trusts, Adult Social Care, Independent Healthcare providers, Ambulance services, Dentists

Out of Hours providers April 2012

Over 30,000 after Primary care in 2013

Each will have a database of information relating to Compliance (Quality & Risk Profile)

All will be subject to annual inspection visit

“Annual Regulator”

Why bother?

NHS Budget ca £100 billion

Adult Social Care Budget ca £17 billion

What does this look like?

£50 notes

£1 million

2.26 metres

Mt Everest 8848m 29029’

26 x Mt Everest

NHS Budget

•230 km

•26 x Mt Everest

•144 miles

Questions for successive governments

How can we ensure that this expenditure is managed?

How do we ensure we get value?

How can we justify this expenditure by showing improved outcomes?

Questions for successive governments

How can we ensure that this expenditure is managed?

Griffiths report 1993 on Management

How do we ensure we get value?

Audit Commission

How can we justify this expenditure by showing improved outcomes?CHIHealthcare CommissionCSCICQC

} Regulation

The size of the NHS task….

•Every day……

•a million people will visit their General Practice•over two million prescriptions will be filled •40,000 diagnostic tests•30,000 operations •50,000 visits to A&E •20,000 ambulance call-outs•2000 babies are born

“If I had to reduce my message for management to just a few words, I’d say it all had to do with reducing variation.” – W Edwards Deming

Admissions and Discharges by day of week

Trust A

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Num

ber

Admissions Discharges

Bed Occupancy (England)

Monday Tuesday Wed Thursday Friday Saturday Sunday

103 102 100 99 96 98 102

Poor outcomes over time – CUSUM

Plot goes up when there is a death

Down when a patient survives

Plot can never fall below zero

Alert signalled

16

Uses of intelligence

Outlier assessment

Hospital Episode Statistics

Clinical audits

Quality Risk Profiles

CQC engagements

Local knowledge

Other soft intelligence

17

The case of Mid Staffs

7 mortality alerts in 5 months.

Wider concerns about mortality among patients admitted as emergencies.

Poor responses from the trust with no assurance that they recognised any cause for concern.

Clinical evidence submitted by the trust that suggested otherwise

18

Actions that have resulted

Redesigning patient pathways

Minimise delays for surgery

Changes to antibiotic prescribing practice

Reviews of care home admissions

Management of ICU

Better identification of early warning signs

Formal mortality reviews

Improved governance systems

Regulation cycle

STANDARDS

ASSESS

ENCOURAGE

OR

ENFORCE

MONITOR & REASSESS

STANDARDS

Regulation and competition:tools for improvement

Versus

Or

With?

Regulation and competition:tools for improvement?

Versus

Or

With?

ENFORCE

ENCOURAGE

Two types of competition…(1)

The Prima Donna Foundation Trust:

•All acute specialties including heart surgery and paediatrics•Emergency department and Intensive Care•Elective surgery•Undergraduate and Postgraduate medical teaching•Nursing and Physiotherapy Teaching•Other AHP teaching•Heavy research commitment linked to University•Offers 24/7 access for emergencies and consultant presence12/7

Paid according to tariff

Two types of competition…(1)

“Day-Cases-R-Us”

•Two operating theatres•Day case ‘posh trolleys’•Specialises in hernia repair and cataract surgery•Staffed by surgeons who are not eligible for specialist registration in UK•No teaching•No research•No overnight beds

Paid according to tariff….(or higher!)

Two types of competition…(2)

“Ivan Imens-Proffet Residential Care Home”

•Ten bedded care home with nursing•Some compliance concerns from CQC•No development programme for staff•Poor induction•Heavy use of agency staff•No attempt to link with primary care doctors•No regular review of medications•Poor record keeping•No involvement by residents in End-of-Life decisions•Ambulance called when patients deteriorate

Two types of competition…(2)

“Utopia Nursing Care Home”

•Ten bedded care home with nursing•Staffed by local carers and qualified nurses•Manageable staff turnover with good stability•Independence facilitated•Each resident’s care record reviewed regularly•Residents encouraged to voice views on End-of-Life care•Family of residents consulted about them and their views•Links with local general practitioners who visit regularly for ‘rounds’•Links with local palliative care team•No inappropriate admissions to hospital

Questions…

How do we create incentives for improvement in a false market?

How valuable is choice of provider without information about quality?

How do we stimulate innovation in a standards-driven system?

How do we raise the level of standards without introducing targets?

Has regulation led to improvement?

“One never notices what has been done; one can only see what remains to be done”

Marie Curie

With acknowledgements to Wellcome Trust

Thank you

nick.bishop@cqc.org.uk