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How can regulation drive improvement? Gwyn Bevan

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

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How can regulation drive improvement? Gwyn Bevan

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  1. How can regulation drive improvement?Gwyn Bevan ippr Policy Seminar 16th November 2005 Change agent or watchdog?Should regulation drive improvement?

  2. 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

  3. How can regulation drive improvement? • Looking back: regulating NHS • Looking forward: regulating pluralist market

  4. 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

  5. 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 act Absence of system to require action

  6. 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 Did CHI’s CGRs drive improvement?

  7. 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.

  8. Did targets & star ratingsdrive improvement? % category A calls within 8 minutes: target 75% Star ratings

  9. Did targets & star ratingsdrive improvement? % category A calls within 8 minutes: target 75% Wales Star ratings (England only)

  10. Did targets & star ratings drive improvement?Gaming? Gaming common (one in three) but marginal impact (2% - 6%) 75% < 8 minutes 75% < 8 minutes Source: http://www.chi.nhs.uk/eng/cgr/ambulance/index.shtml

  11. How can regulation drive improvement? • Looking back: regulating NHS • Looking forward: regulating pluralist market • Targeted & proportionate inspections: synecdoche? • Quality assurance? • Quality improvement? • Quality & finance?

  12. 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

  13. 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?

  14. Quality improvement: all providers? • National clinical audits • 50 common conditions / procedures • Require participation & funding data collection

  15. 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

  16. 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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