How can regulation drive improvement? Gwyn Bevan
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Transcript of How can regulation drive improvement? Gwyn Bevan
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How can regulation drive improvement?
Gwyn Bevan
ippr Policy Seminar 16th November 2005
Change agent or watchdog? Should regulation drive
improvement?
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How can regulation drive improvement? Agenda? Objective
quality assurance / improvement? outcomes / systems & processes?
Mode inspections: all / targeted & proportionate? regulatory distance: peer review /
professional inspectors? Scope
NHS / foundation trusts / pluralism? quality / quality & finance
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How can regulation drive improvement? Looking back: regulating NHS
Looking forward: regulating pluralist market
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How can regulation drive improvement? Looking back: regulating NHS
Regulatory failure in 1990s Clinical Governance Reviews (CGRs) by Commission for Health Improvement (CHI)
Market failure in 1990s star ratings Looking forward: regulating
pluralist market
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1990s: Regulatory failure CHI’s CGRs
the killing fields the fastest gynaecologist in the south of England Britain’s worst serial killer
Scandalous failure to actAbsence of system to require action
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Did CHI’s CGRs drive improvement?
NHS inspections Systems &
processes All trusts
Targeted & proportionate?
Peer review Quality assurance
Benefits? Feasible Know inspected for
sure Preparation for visit Aware CGRs star
ratings CHI found little new
but action followed
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1990s: Market failure targets & star ratings
NHS logic Ministerial
accountability for local failures
Collegial decision making by doctors
The caucas race: everybody has won, and all must have prizes.
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Did targets & star ratings drive improvement?
35
45
55
65
75
2001 2002 2003 2004 2005
% category A calls within 8 minutes: target 75%
Star ratings
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35
45
55
65
75
2001 2002 2003 2004 2005
Wales
Did targets & star ratings drive improvement?
Star ratings (England only)
% category A calls within 8 minutes: target 75%
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Did targets & star ratings drive improvement?
Gaming?
75% < 8 minutes
Source: http://www.chi.nhs.uk/eng/cgr/ambulance/index.shtml
Gaming common (one in three) but marginal impact (2% - 6%)
75% < 8 minutes
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How can regulation drive improvement? Looking back: regulating NHS Looking forward: regulating
pluralist market Targeted & proportionate inspections:
synecdoche? Quality assurance? Quality improvement? Quality & finance?
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The problem of synecdoche
3-star trust? Omitted from targets
CHI’s CGRs? Data analysis Visits?
T&P inspections? Regulator without
hindsight Regulatee with
foreknowledge False positives &
negatives
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Quality assurance? Redesign CGRs
All providers Redefine clinical governance Peer review: staffing a requirement Regular & random visits
Investigations of perceived problems Systematic audit of targets Roman code for whistleblowers?
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Quality improvement: all providers? National clinical audits 50 common conditions /
procedures Require participation & funding
data collection
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Quality & finance? Regulation of finance governance of
failure Core services? Destabilisation?
Matter for ministers Regulator of quality
must know about financial problems Develop & publish information to inform
threat of patient choice
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How can regulation drive improvement? Agenda? Objective
quality assurance / improvement? outcomes / systems & processes?
Mode inspections: all / targeted & proportionate? regulatory distance: peer review /
professional inspectors? Scope
NHS / foundation trusts / pluralism? quality / quality & finance