The relationship between those that supervise and those supervised Neil Prime – Head of Analytics, Board member EPSO

2 Background and rationale Survey and discussion builds on London discussion Research within EPSO showed that the majority of EPSO members felt that the organisations they supervise: ‘generally share supervisory goals and co-operate with supervision’ (the ‘compliance’ model of regulation) This session attempts to explore this finding and to explore with EPSO members what they think influences this relationship A number of inherent factors are suggested that might influence this relationship e.g. the types of services supervised The output from this session will be a policy document/statement from EPSO setting out what it believes to be the key drivers that influence relationships between supervisors and those supervised

Survey results from 2010 EPSO London EPSO memberShare goals or are reluctant EstoniaReluctant FinlandShare SwedenShare Northern IrelandReluctant DenmarkShare LithuaniaShare SloveniaShare FranceShare NetherlandsShare NorwayShare WalesShare BulgariaNot included in last survey GermanyNot included in last survey HungaryNot included in last survey

Compliance versus Deterrence ComplianceDeterrence amoral calculators (Kagan (1984)) good hearted compliers (Walshe (2003)) EPSO majority

Autonomy and flexibility of supervision (Preker and Harding 2003) CharacteristicDefinition Extent of delegationWhat powers are delegated to the regulatory institution by the state? Scope of delegationOver what areas does the regulator have discretion? Governance and accountabilityHow are the governance arrangements organised? Who is accountable? Participation rightsWhat decision making powers do regulators have? Institutional designHow and when does the state intervene in the work of the regulator?

6 The original question Which of the following most closely matches your organisation’s view of those you supervise? 1. The organisations we supervise share the same goals and cooperate 2. The organisations we supervise do not share the same goals and cooperate 3. The organisations we supervise are reluctant to share the same goals

Type and extent of services supervised The Care Quality Commission has responsibility for supervising: The National Health Service Independent healthcare provision and some cosmetic treatments Adult Social Care People detained under the mental health act Ionising radiation The Care Quality Commission has a supervisory role in England only and does not cover children 7

8 Type and extent of services supervised Do you think that the type of services supervised by the supervisory body influence the ‘supervisory relationship’? (For example: highly complex organisations such as large hospitals could require a more quantified and detached approach than institutions for care for the elderly, this could lead to a different relation) Do you think that not having responsibility for supervising services that affect the whole population of a state or country influences the ‘supervisory relationship’? (Certain groups of people such as children not covered by your supervisory powers or certain aspects of care such as responsibility for ICT or medical devices or food safety or social aspects of nursing for example)

Market control and economic factors The Care Quality Commission ‘registers’ providers of care for which they pay a fee The Care Quality Commission therefore (theoretically) controls entry and exit from the market The Care Quality Commission is seen as the ‘quality regulator’ and is working with Monitor who is the economic regulator The Care Quality Commission is working towards a model of full cost recovery that is to be ‘cost neutral’ 9

Market control and economic factors Do you think that having supervisory powers that permit you to stop organisations from providing care influences the ‘supervisory relationship’? (Are any of us controlling the market?) Do you think that economic factors, such as payment of fees to the supervisory body, influences the ‘supervisory relationship’? (Do any of us levy a charge or look for cost recovery?) 10

Market size and size of regulator The Care Quality Commission supervises approximately 40,000 providers of care The Care Quality Commission has approximately 2500 staff and a ratio of one inspector to providers This ‘portfolio’ is a mixture of adult social care and healthcare providers 11

Market size and size of regulator Do you think that the size of the market supervised influences the ‘supervisory relationship’? (Do factors such as number of providers of care you can visit or supervise or monitor per year influence the relationship?) Do you think that the ratio of staff within the supervisory organisation to the number of staff at the organisations that are supervised Influences the ‘supervisory relationship’? (Do factors such as the number of staff in the supervisory body and the number of staff / management at the supervised organisation in relation to the volume and complexity of data and information being requested influence the relationship?) 12

Fitness to practice and the supervisory relationship The Care Quality Commission has no responsibility to directly supervise clinicians in their fitness to practice This is the responsibility of the General Medical Council, the Nursing and Midwifery Council and others The Care Quality Commission uses an information lead approach to supervision that relies on risk assessment and targeting inspections 13

Fitness to practice and the supervisory relationship Do you think that in cases where supervisory bodies have direct responsibility for assessing clinician’s fitness to practice, this influences the ‘supervisory relationship’? (This includes specific responsibility for allowing clinicians to administer care to a patient) (Do any of us assess the competence of clinicians as part of our work?) Do you think the type of supervisory model used influences the ‘supervisory relationship’? (How would you describe your supervisory model such as ‘inspection focused’, ‘risk based and targeted’, ‘peer review’ or a ‘mixed approach’?) 14

Government and society The last year, with a change in Government has seen a ‘bonfire of the quangos in the UK and the cessation of major parts of the regulatory system The relationship between the supervisor who seeks to remain independent from Government and to undertake its duties is sometimes tense Some aspects of the role of the supervisor in England require sign off by the Department of Health and the Secretary of State There is currently a very high profile Inquiry (the Francis Inquiry) underway in England which is investigating the efficacy of regulation 15

Government and society How does the dialogue between Government and supervisory body influence the way supervisory activity is undertaken? (Do we think that how much power Government has in setting the agenda for the supervisory body influences the relationship?) Is there a culture of political blaming and shaming after medical misconduct ? (How much influence is exerted on the supervisory relationship by the press, public, Government and the supervisor when clinicians behave badly and are found out?) 16

Mergers and future influences The regulatory system for health and adult social care has undergone major changes over the last ten years Policy analysis indicates that changing regulatory practice and structures before the relationship with those regulated matures, produces instability with regulatory practices 17

Mergers and future influences What impact do mergers or organisational changes (e.g. reorganisation) to supervisory bodies have on the ‘supervisory relationship’? (Have any of us been through a recent change or re-organisation and if so, how did it influence the relationship?) What do EPSO members think will provide the biggest challenges to the supervisory relationship over the next few years? (For example – changes to the health market within the European area) 18

Next steps Write up the session Form working group/theme Publish joint statement Very many thanks! 19