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 Role We 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? CHI Healthcare Commission CSCI CQC } 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

Bed Occupancy (England) MondayTuesdayWedThursdayFridaySaturdaySunday

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