European Partnership for Supervisory Organisations in Health Services and Social Care (EPSO), Sofia, 12th October 2018 How does regulation impact on the quality of care? Research to identify CQC’s contribution Alan Boyd Research Fellow in Healthcare and Public Sector Management University of Manchester, UK Email: alan.boyd@manchester.ac.uk Web: https://www.research.manchester.ac.uk/portal/alan.boyd.html

Researching healthcare regulation Topic Dates Impact of clinical governance reviews on NHS trust performance 2003-04 Regulatory approaches in seven sectors/industries 2004-06 CQC’s new acute care regulatory model 2013-14 Impact of inspection and ratings in health and social care 2015-18 Supportive and streamlined approach to improving care 2017 CQC’s contribution to the quality of care 2018-19

Impact of inspection and ratings in health and social care  

How do we think about the impact of regulation? Tend to focus on regulatory interventions (mostly inspections, rating or enforcement actions) Ask about “before and after” changes – measure compliance with “directions” But – research suggests this is a very narrow view of impact Look at the whole regulatory regime, not just individual interventions like inspection Look at the whole system – regulator, providers and many other stakeholders Consider multiple pathways or mechanisms to impact Think about both intended and unintended (or positive and negative) impacts

Pathways to impact – Bilateral

Pathways to impact - Multilateral

CQC’s contribution to the quality of care Pathway Investigation Stakeholder Annual stakeholder survey Systemic Theory of change for local system reviews Relational Theory of change for on-going provider relationships

Stakeholder impact pathway Prospects and problems Stakeholders can amplify/extend regulator intelligence, influence and impact Can be problematic – capacity/capability, extent of shared interests/agenda, diffusion of responsibility, information sharing Happens when care is poor? Challenge to organise it to support general improvement

Systemic impact pathway Prospects and problems Increasingly integrated health/care system needs regulation focused on systems or commissioners as well as individual providers Provider-focused regulation has unintentional systemic impacts Regulator lacks formal powers over new forms of organisation Systemic issues such as access and resourcing raise sensitive policy issues Structural barriers to necessary organisational cooperation E.g. funding streams, governance, culture etc.

Local system reviews – what works? Power of the personal Engaging communication – service user experiences Respected reviewers – experience, empathy Sustainable over the long-term? Power of facts Independent investigation Objective data and thorough analysis inform evaluation Is routine data available? Power of ‘can do’ We / they have done it! Evidenced Capacity? Improvement support New insights? No one conducted system reviews recently Power of us Facilitative/learning/non-blaming Open process; involve organisations Burden?

Relational impact pathway Prospects and problems Regulation is a social interaction Informal, ‘below the line’ regulatory interaction is important But risk that this may be at odds with the formal regulatory regime

On-going provider relationships – what works? Across multiple contact points and at different levels Interpersonal skills and training Assessment gets in the way? History? Credibility In-house and external consultants? Clash of interests Regulatory power Insights in between inspections Keeps improvement on the agenda Build trust and greater openness? Capture and collusion? Resource pressures? Time for interaction Transactional behaviours

Some ideas for the future Focus more on impact in regulatory design and development – setting out intended impacts and pathways to improvement and seeking to test them prospectively and build in evaluation Seek to understand and build improvement capability, both internal and external to organisations Inspection and rating consume most regulatory resources and may crowd out other more impactful activities – seek ways to have regulatory interactions short of/other than inspection, use regulatory intelligence and judgement, and be cautious about the value of ratings Recognise that regulation is a social process, and invest in the quality and development of the people who are the regulator Seek ways to co-opt other stakeholders – patients, service users, commissioners, professional associations, etc – to the purposes and processes of regulatory regime

Questions for discussion How are you addressing stakeholder, systemic and relational impact? What issues are coming up? What research do we need to resolve key uncertainties and gaps in knowledge?