Transcript Cass debate - City University London

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
2.26 metres
£1 million
Mt Everest 8848m 29029’
26 x Mt Everest
NHS Budget
•230 km
•144 miles
•26 x Mt Everest
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
Regulation
CQC
}
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
Trust A
7,000
6,000
4,000
3,000
2,000
1,000
Admissions
Discharges
y
da
Su
n
da
y
ur
Sa
t
y
Fr
id
a
y
sd
a
Th
ur
ay
W
ed
ne
sd
y
da
Tu
es
on
da
y
0
M
Number
5,000
Bed Occupancy (England)
Monday
Tuesday
103
102
Wed
100
Thursday Friday
99
96
Saturday Sunday
98
102
Poor outcomes over time – CUSUM
Down when
a patient
survives
Plot goes up
when there is
a death
Plot can never
fall below zero
Alert signalled
Uses of intelligence
Clinical
audits
Hospital
Episode
Statistics
Quality Risk
Profiles
Other soft
intelligence
Outlier
assessment
Local
knowledge
CQC
engagements
16
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
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
Regulation cycle
STANDARDS
STANDARDS
MONITOR &
REASSESS
ASSESS
ENCOURAGE
OR
ENFORCE
Regulation and competition:
tools for improvement
Versus
Or
With?
Regulation and competition:
tools for improvement?
Versus
ENFORCE
Or
With?
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
[email protected]