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How can regulation drive improvement? Gwyn Bevan. ippr Policy Seminar 16 th November 2005 Change agent or watchdog? Should regulation drive improvement?. How can regulation drive improvement? Agenda?. Objective quality assurance / improvement? outcomes / systems & processes? Mode - PowerPoint PPT Presentation
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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?
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
How can regulation drive improvement? Looking back: regulating NHS
Looking forward: regulating pluralist market
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
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
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
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.
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
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%
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
How can regulation drive improvement? Looking back: regulating NHS Looking forward: regulating
pluralist market Targeted & proportionate inspections:
synecdoche? Quality assurance? Quality improvement? Quality & finance?
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
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?
Quality improvement: all providers? National clinical audits 50 common conditions /
procedures Require participation & funding
data collection
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
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