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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 Role. We make sure that the care people receive meets essential standards of quality and safety.

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

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  1. Regulation of health and adult social care: the case for improvement Dr Nick Bishop 26 October 2011 Senior Medical Advisor Care Quality Commission

  2. 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

  3. 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

  4. “Annual Regulator”

  5. Why bother? • NHS Budget ca £100 billion • Adult Social Care Budget ca £17 billion • What does this look like?

  6. £50 notes 2.26 metres £1 million

  7. Mt Everest 8848m 29029’ 26 x Mt Everest

  8. NHS Budget • 230 km • 144 miles • 26 x Mt Everest

  9. 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?

  10. 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

  11. 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

  12. “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

  13. Admissions and Discharges by day of week

  14. Bed Occupancy (England)

  15. Alert signalled Down when a patient survives Plot goes up when there is a death Plot can never fall below zero Poor outcomes over time – CUSUM

  16. Uses of intelligence Hospital Episode Statistics Clinical audits Outlier assessment Quality Risk Profiles Local knowledge Other soft intelligence CQC engagements 16

  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 17

  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 18

  19. Regulation cycle STANDARDS STANDARDS MONITOR & REASSESS ASSESS ENCOURAGE OR ENFORCE

  20. Regulation and competition:tools for improvement • Versus • Or • With?

  21. Regulation and competition:tools for improvement? • Versus • Or • With? ENFORCE ENCOURAGE

  22. 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

  23. 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!)

  24. 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

  25. 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

  26. 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?

  27. 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

  28. Thank you • nick.bishop@cqc.org.uk

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