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

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

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

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

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

23. 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

24. 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!)

25. 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

26. 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

27. 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?

28. 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

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