How can regulation drive improvement?

Gwyn Bevan

ippr Policy Seminar 16th November 2005

Change agent or watchdog? Should regulation drive

improvement?

How can regulation drive improvement? Agenda? Objective

quality assurance / improvement? outcomes / systems & processes?

Mode inspections: all / targeted & proportionate? regulatory distance: peer review /

professional inspectors? Scope

NHS / foundation trusts / pluralism? quality / quality & finance

How can regulation drive improvement? Looking back: regulating NHS

Looking forward: regulating pluralist market

How can regulation drive improvement? Looking back: regulating NHS

Regulatory failure in 1990s Clinical Governance Reviews (CGRs) by Commission for Health Improvement (CHI)

Market failure in 1990s star ratings Looking forward: regulating

pluralist market

1990s: Regulatory failure CHI’s CGRs

the killing fields the fastest gynaecologist in the south of England Britain’s worst serial killer

Scandalous failure to actAbsence of system to require action

Did CHI’s CGRs drive improvement?

NHS inspections Systems &

processes All trusts

Targeted & proportionate?

Peer review Quality assurance

Benefits? Feasible Know inspected for

sure Preparation for visit Aware CGRs star

ratings CHI found little new

but action followed

1990s: Market failure targets & star ratings

NHS logic Ministerial

accountability for local failures

Collegial decision making by doctors

The caucas race: everybody has won, and all must have prizes.

Did targets & star ratings drive improvement?

35

45

55

65

75

2001 2002 2003 2004 2005

% category A calls within 8 minutes: target 75%

Star ratings

35

45

55

65

75

2001 2002 2003 2004 2005

Wales

Did targets & star ratings drive improvement?

Star ratings (England only)

% category A calls within 8 minutes: target 75%

Did targets & star ratings drive improvement?

Gaming?

75% < 8 minutes

Source: http://www.chi.nhs.uk/eng/cgr/ambulance/index.shtml

Gaming common (one in three) but marginal impact (2% - 6%)

75% < 8 minutes

How can regulation drive improvement? Looking back: regulating NHS Looking forward: regulating

pluralist market Targeted & proportionate inspections:

synecdoche? Quality assurance? Quality improvement? Quality & finance?

The problem of synecdoche

3-star trust? Omitted from targets

CHI’s CGRs? Data analysis Visits?

T&P inspections? Regulator without

hindsight Regulatee with

foreknowledge False positives &

negatives

Quality assurance? Redesign CGRs

All providers Redefine clinical governance Peer review: staffing a requirement Regular & random visits

Investigations of perceived problems Systematic audit of targets Roman code for whistleblowers?

Quality improvement: all providers? National clinical audits 50 common conditions /

procedures Require participation & funding

data collection

Quality & finance? Regulation of finance governance of

failure Core services? Destabilisation?

Matter for ministers Regulator of quality

must know about financial problems Develop & publish information to inform

threat of patient choice

How can regulation drive improvement? Agenda? Objective

quality assurance / improvement? outcomes / systems & processes?

Mode inspections: all / targeted & proportionate? regulatory distance: peer review /

professional inspectors? Scope

NHS / foundation trusts / pluralism? quality / quality & finance