Healthcare Commission Legacy Report 2010

Inspecting Informing Improving
Involvingclinicians Buildinglocalrelationships Safeguarding childrenandvulnerableadults ThirdpartyfeedbackOutcomes for patients Informationled regulation A rangeof regulatory tools Patients experience of healthcare Riskbased approachProtecting patients safety Encouragingimprovement Annualhealthcheck Accessibleinformation about healthcareInvestigating serious servicefailures Promotingequal citizenship Reviewingpatientscomplaints Measuringwhat matters Independent assuranceabout qualityof care Helpingpatientsmakeinformed decisions Action toreduceinequalities Robust and proportionate enforcement Protecting humanrights Reducingburdenofregulation Wholesystemapproach Surveillance
TheHealthcare Commission 20042009

Regulatinghealthcare experienceandlessons
March2009CommissionforHealthcareAuditandInspection Thisdocumentmaybereproducedinwholeorinpartinany formatormediumfornoncommercialpurposes,providedthat itisreproducedaccuratelyandnotusedinaderogatorymanner orinamisleadingcontext.Thesourceshouldbeacknowledged, byshowingthedocumenttitleandCommissionforHealthcare AuditandInspection2009. ISBN:9781845622268 Concordatgatewaynumber:172
Contents
AbouttheHealthcareCommission Introductionandbackground Whatcontributionhastheregulationofhealthcaremade
tobetteroutcomesandqualityofcareforpeople? Whatlessonshavebeenlearnedabouttheapproach
toregulatinghealthandhealthcare? Whatare thelessonsfromregulationforthehealthcare
systemasawhole? Conclusion AppendixA: AnalysisofthehealthcaresectorinEngland AppendixB: SummaryoftheHealthcareCommissions
progress against itsstrategicgoals AppendixC: Comparativecostsofregulationbysector
for2007/08 AppendixD: Implementingourregulatorymodel:key activities AppendixE: AssessmentoftheperformanceoftheNHS
inmeetingcorestandards AppendixF: Realtimesurveillancefollowingupoutliers AppendixG: ConclusionsfromSpotlightonComplaints 2009 AppendixH: Indepthreviewsandstudies References 2
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TheHealthcareCommission20042009:Regulatinghealthcareexperienceandlessons
AbouttheHealthcareCommission
TheHealthcareCommissionworkstopromoteimprovementsinthe qualityofhealthcareandpublichealthinEnglandandWales. InEngland,weassessandreportontheperformanceofhealthcare organisationsintheNHSandindependentsector,toensurethatthey areprovidingahighstandardofcare.Wealsoencourageprovidersto continuallyimprovetheirservicesandthewayinwhichtheywork. InWales,theHealthcareCommissionsroleismorelimited.Itrelates mainlytonationalreviewsthatincludeWalesandtoouryearlyreport onthestate ofhealthcareinEnglandandWales. Whatwedo Inspecting Toinspectthequalityandvalueformoneyofhealthcareand publichealth Informing Toequippatientswiththebestpossibleinformationaboutthe provisionofhealthcare Improving To promoteimprovementsinhealthcareandpublichealth How we work Weworkcloselywithpatients,carersandthepublictomaintain ourfocusonimprovingtheirexperiencesofhealthcare. Wepromotetherightsofeveryonetohaveopportunitiestoimprove theirhealthandto receivegoodhealthcare. Ourapproachtoassessinghealthcareisbasedonthebest availableevidenceandaimstoencourageimprovement. Weworkinpartnershiptoensureatargetedandproportionate approachto auditandinspection. Weworklocallytobuildrelationshipsandintelligenceaboutthe qualityofservicesthroughoutEngland. Weareindependentandfairinourdecisionmakingandreporton whatwe findfairly andimpartially. Weareaccountableforouractionsandforwhatweachievein relationtoourcosts.
2 TheHealthcareCommission20042009:Regulatinghealthcareexperienceandlessons
On1April2009,theCareQualityCommission,thenewindependent regulatorofhealth,mentalhealthandadultsocialcare,takesover theHealthcareCommissionsworkinEngland.
HealthcareCommissionandExecutiveTeam
Commissionersinoffice at31.3.09 ProfessorSirIanKennedy,
Chair
SirNickPartridge,
JointDeputyChair
PaulStreetsOBE,
JointDeputyChair
KhurshidAlam
DrSarahBlackburn
PatrickBoyle
DrFionaCampbell
DrJenniferDixon
ClareDodgson
CharlesGoody
MichaelHake
ProfessorDeirdre Kelly
CliffPriorCBE
JohnScampionCBE
ProfessorIqbalSingh
Commissionerswhoheldoffice before1.4.08 DrSharonHopkins ProfessorSirBruceKeoghKBE MelindaLetts LordPatelofBradfordOBE ProfessorShirleyPearce StephenThorntonCBE Executiveteam2008/09 AnnaWalker,ChiefExecutive IanBiggs,HeadofOperations
(fromOctober2008)
LorraineFoley,
HeadofInformatics
MarciaFry,Headof
OperationalDevelopment
SteveHeminsley,
HeadofCorporate Services
MirandaKavanagh,
HeadofCommunications
andEngagement
KateLobley,HeadofOperations
(to October2008)
GaryNeedle,Headof
AssessmentandMethods
JamieRentoul,HeadofStrategy
Introductionand background
TheHealthcareCommissionceasestoexistattheendofMarch2009. A new,integratedregulatorofhealth,mentalhealthandadultsocial caretheCareQualityCommissiontakesoveron1April2009.In thisreport,welookatthelessonsthathavebeenlearnedfromthe workoftheHealthcareCommissionoverthelastfiveyears.Our objectiveistoinformthecontinuingdebateabouttheplaceandrole ofregulationasitrelatestohealthandhealthcareinEngland. Thechangingarrangementsforregulatinghealthandadultsocial carecomeatatimewhentheroleofregulationindifferentsectorsis comingunderclosescrutiny.Infinancialservices,whereglobalisation andcomplexapproachestothepackagingandsellingonofdebthave fundamentally changedthenature oftransactionsandthe assessmentofrisk,regulatorsintheUK,EUandUSarebeing askedquestionsabouttheirrole.Inhealthandsocialcare,thecaseof BabyPhasraisedquestionsabouttheroleandeffectivenessof regulators insafeguardingchildren. Thesedevelopmentsfollowaperiodwhentherehasbeenahighlevel ofconsensusintermsofpolicywithingovernmentontheapproachto regulationindifferentsectorsofpublicandprivateactivities.The dominantviewhasbeentopromoteanapproachtoregulationwhere theattentionthatanorganisation,serviceortransactionreceives fromtheregulatorisbasedonanassessmentoftheriskofpoor outcomes(riskbasedregulation). Thisis,therefore,agoodopportunitytotakestockofwhathasbeen achievedthroughregulationaspartofthedesignofthehealthcare system,drawingontheexperienceofregulationasconceivedbythe Healthcare Commission.Indoingso,lessonscanbeidentifiedwhich canassistinmakingregulationaseffectiveaspossiblein safeguardingthepublic,protectingtheirrights,promotingbetter outcomesforpeople,andsupportingthosewhocare forthem. Inthisreportwe have: Setoutthebackgroundtotheestablishmentofthe HealthcareCommission. Summarisedtheapproachtoinformationled,riskbased regulationtakenbytheCommission. Consideredthecontributionthatregulationofhealthcarehasmade tobetteroutcomesandqualityofcareforpeople.
TheHealthcareCommission20042009:Regulatinghealthcareexperienceandlessons 5
Introduction
Reviewedthelessonsthathavebeenlearnedabouttheapproachto regulation,andtheimplicationsforfutureregulatorymodels. Highlightedthelessonsfromregulationforthehealthcaresystem asawhole.
Background
TheHealthcareCommissionwasestablishedon1April2004. ItreplacedtheCommissionforHealthImprovementwhichexisted from2000to2004andtookovertheregulationoftheindependent healthcaresectorfromtheNationalCareStandardsCommission. Italsotookontheresponsibilitytocarryoutnationalstudiesofthe valueformoneyofhealthcareservicesfromtheAuditCommission. Thedevelopmentofregulationshouldbeseeninthecontextofthe Governmentsoverallapproachtopolicyonhealthcare.The CommissionforHealthImprovementwasestablishedatatimewhen theGovernmentsstatedobjectivewastoprovidesignificant investmentinbuildingthecapacityoftheNHStomeetthedemands placedonit,coupledwithstrongperformancemanagementtodeliver a setofnationaltargetsthatfocusedheavilyonimprovingpatients accesstocare.TherolegiventotheCommissionforHealth Improvementfocusedlargely onimprovingclinicalgovernance(the systemthroughwhichNHSorganisationsseekto improve thequality ofthecaretheyprovidebycreatinganenvironmentinwhichclinical excellencecanflourish,andinwhichtheyareaccountableformeeting thatobjective). TheHealthandSocialCareAct2003 1, whichestablishedthe HealthcareCommission,satalongsideashiftintheGovernments statedapproachtotheNHStowardsamoredevolvedselfimproving systemwithastrongerfocusonthecommissioningofservices, greaterchoiceforpatients,agreaterfocusonpublichealthand tacklinghealthinequalities.*Clearerincentivesfororganisations providingcarethroughchangedfinancialarrangements,better informationonperformance,more provisionofNHSfundedcareby theindependentsector,andgreaterindependenceforwellmanaged NHStrusts.The2003ActalsoestablishedNHSfoundationtrusts, withMonitorastheirindependentregulator. TheestablishmentoftheHealthcareCommissionastheindependent regulatorwasanimportantcomponentofthisoverallapproachtoa moredevolvedsystemwiththenotionthattheregulatorwouldplay
* Atermwhichembracesinequalityinhealthstatus,inequalityinaccesstohealthcare,and inequalityinthecareprovided.
animportantpartinholdingmoreautonomousbodiestoaccount fortheirperformance.Therearesomeparallelsinthelocal accountabilityoflocalauthoritiesandtheroleoftheAudit Commissioninassessingandreportingontheirperformance. Theinquiryintothemanagementofthecareofchildrenundergoing complexcardiacsurgeryatBristolRoyalInfirmarywasaparticular contributingfactorbehindthelegislationandcreationoftheHealthcare Commission.Theinquiryaddressedarangeofissues,concernedwith puttingpatientsatthecentreofhealthcare,involvingpatientsandtheir families,leadershipinthemanagementandprovisionofcare,a strongerfocusonsafety,bettertrainingofstaff,betterinformationand monitoring,agreednationalstandardsandregulation. TheHealthcare Commissionwasalsoestablishedatatimewhenthe Governmentwasseekingto reduce significantly thedirectcostsof regulation(withacommitmentintheBudgetof2005toreducethe costsofpublicsectorregulationbyonethird)andtheindirectcosts ofregulationbornebyregulatedbodies.Aspartofthisapproach,the Hamptonreport 2 wascommissionedbyHMTreasury.Itconcluded thatregulationshouldberiskbasedtomakeitmoreeffectiveandto reduceunnecessaryburdensonbusiness.Thiswasrelevanttothe HealthcareCommissionasitsremitspansboththeNHSandthe independentsector. Theframeworkoflegislationandpolicyaroundthe HealthcareCommission Underthe2003Act,theHealthcareCommissionwasestablishedas anindependentbodywiththegeneralresponsibilityofencouraging improvementintheprovisionofhealthcarebyandforNHSbodiesin EnglandandWales. Inexercisingitsfunctionofencouragingimprovement,the Commissionmustconsidersuchmattersasaccesstohealthcare,its qualityandeffectiveness,andtheavailabilityofinformationprovided tothepublic.Inaddition,andasaconsequenceoftheReportofthe BristolInquiry,theCommissionisspecificallyrequiredtobe concernedwiththeneedtosafeguardandpromotetherightsand welfareofchildrenintheexerciseofitsfunctions. TheCommissionsmainstatutoryfunctionsinEnglandareto: ReviewtheperformanceofeachNHSorganisationandawardan annualrating. Regulatehealthcareprovidedbytheindependentsector. InvestigateseriousservicefailuresintheNHS.
Introduction
CarryoutreviewsoftheprovisionofhealthcareintheNHS (includingreviewsoftheeconomyandefficiencyoftheprovisionof healthcare). ConsidercomplaintsaboutNHSbodiesthathavenotbeen resolvedlocally. ReportannuallytoParliamentonthestateofhealthcarein EnglandandWales. Promotetheeffectivecoordinationofreviewsorassessmentsof theprovisionofhealthcare. The2003Act 1 alsostatedthatpublichealthwastobeincludedaspart ofhealthcare.This,coupledwiththefactthatoneoftheseven domainsintheGovernmentsStandardsforBetterHealth 3 whichthe Commissionwasrequiredtotakeaccountofwaspublichealthand thatthenewnationaltargetslargelyfocusedonpopulationhealth, gave theHealthcare Commissionaclearremittocoverthemain aspectsofpublichealth:protectionandimprovementofhealth, tacklinghealthinequalities,preparednessforemergenciesandthe extenttowhichagenciesatlocallevelworksuccessfullyin partnershipwitheachother. Thisisauniqueroleincomparisonwith regulatorsofhealthandhealthcareinothercountries. ToprovidethecontextinwhichtheHealthcareCommissionoperates, a briefsummaryofthehealthcare sectorinEngland,includinglevels ofactivity,expenditure,workforceandnumbersoforganisations,is setoutinAppendixA. The regulationoforganisationsisoneelementoftheoverallapproach developedbytheGovernmenttobringaboutimprovementsinhealth andhealthcareinEngland.Othermechanisms,whichlargelyfocuson theNHSandthehealthofthepopulation,include: Regulationofprofessionals,forexamplethroughtheGeneral MedicalCouncilandtheNursingandMidwiferyCouncil,and improvementofprofessionalstandardstobemetbyprofessionals, through,amongothers,theRoyalColleges. Developmentoftheworkforceandofleadership. Developmentofnationalstandardsofcareinformed,forexample, bytheNationalInstitute forHealthandClinicalExcellence. Developmentanddisseminationofgoodpractice,forexample, throughtheInstituteforImprovementandInnovationandthrough theNationalPatientSafetyAgency. Strongerfocusonthecommissioningofservicesbyprimarycare trustsandpracticebasedcommissioners.
Performancemanagementbystrategichealthauthorities,oraction byMonitorinthecaseofNHSfoundationtrusts. Greaterchoiceforpatients. Financialincentives,forexample,throughtariffs. Increasedcompetitionfromawiderrangeofprovidersofcare, forexample,throughtheprogrammeofIndependentSector TreatmentCentres. Auditingoffinancialmanagementandlocalvalueformoney, largelythroughtheAuditCommission. Improvedinformationforpatientsandthepublic,forexample, throughConnectingforHealthandmorerecentlytheNHS Choiceswebsite. Actiontoreducetherisksoflitigation,throughtheNHS LitigationAuthority. TheGovernmentsgoalsforthehealthcaresystem,asitdevelopedits policies,focusedlargelyontheNHS.Theyfallintotwocategories: Progressinmeetingspecificmeasuresofperformancesetoutin successivePublicServiceAgreementsandtheninmoredetailinthe OperatingFrameworkfortheNHS.Thesehavenowevolvedintoaset ofexistingcommitmentsthatmustcontinuetobemet(forexample, a maximumof4hours waitingtimeinA&E)andnew nationaltargets (forexample,ratesofmortalityinthecaseofcancer). AchievementoftheStandardsforBetterHealth 3 fortheNHSsetout bytheDepartmentofHealthin2004.Theseprovidemore general objectivesastothestandardsofcarewhichtheGovernment expectedallprovidersofNHScaretomeet(forexample,inthe provisionofcarewhichenhancesthesafetyofpatients;orwhich ensuresthatpatients,theircarersandrelativesaretreatedwith dignityandrespect).Thiswasthefirsttimesuchgeneralstandards hadbeenestablished.TheHealthcareCommissionwasgiventhe role oftakingaccountofcompliancewiththesestandardsin assessingtheperformanceofNHStrusts. Fortheindependentsector,theNationalMinimumStandards establishedundertheCareStandardsAct20004, reflectedthe Governments objective asessentiallyoneofconsumerprotection withtheregulatorprovidingassurancethatindependentproviders couldberegisteredonlyiftheymettheNationalMinimumStandards setoutinregulations. InconsideringtheHealthcare Commissionsstatutoryremit,androle withintheoverallGovernmentpolicyframework,itisworth
Introduction
highlightingtheissuesofindependenceandtheresponsibilityto encourageimprovement. Takingindependencefirst,itisclearthatiftheDepartmentofHealth wastostepbackfromitsformerapproachofhandson management,devolvingresponsibilityandcreatingfoundationtrusts outsidethejurisdictionofStrategicHealthAuthorities,some mechanismwasneeded,independentofallothers,toholdthesystem toaccountonbehalfofthetaxpayer.Thisneedremains,indeedit growsincreasinglyimportant,asthepublicseekinformationabout theNHSandindependenthealthcarethattheyfeeltheycantrustand relyon. Thestatutoryreferencetoencouragingimprovementisofthefirst importance.Itexplicitly identifiestheplace ofregulationintheoverall architecture forthesystemofhealthcarebeingdevelopedby government.ItwastheGovernmentsBetterRegulationTaskForce (asitthenwas)thatstatedthattheonlypurposeofregulationinthe publicsectorwasto promoteimprovement.Thesignificanceofthis roleliesnotleastinthewaythattheHealthcareCommission conceivedanddesigneditsapproach,whichisconsideredbelow. TheHealthcare Commissionsvisionformodernregulation WhentheHealthcareCommissionwasestablished,therewasonlya briefhistoryofregulationinhealthcareattheleveloftheorganisation (amatteroffouryears),thoughregulationofthevariousprofessions waswellestablished.Thewordregulationwasnotcommonlyused inhealthcaretheCommissionforHealthImprovementandthe NationalCareStandardsCommissionwereseenasinspectorates ratherthanregulatorsandtheirprogrammeofworkwaslargely seenasbeingconcernedwithvisitingorganisationsproviding healthcareonaroutine,periodicbasis. Bornperhapsfromexperienceoftheregulationofprofessionals, regulationwasthoughtofintermsofpolicingtopdown,potentially oppressive,astickwithoutanycarrot,andburdensome. ThiswasnottheCommissionsview.Instead,theaimwastoworkwith thegrainofgoodpracticeandtorecruitpatientsandprofessionalsin identifyingwhatwasgood,rootingoutwhatwaspoor,andseekingto bringaboutthechangeswhichwouldmeanthatthegoodwouldbethe norm.To adoptthisroleofencouragingimprovementcreatestension, however,notleastwiththosewhosejobitistomanagethesystem.Of course,healthytensionisanecessaryfeatureofindependent regulation.So,clearlinesofaccountabilityandresponsibilitywere
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needed,sothattheCommissionsstatutoryroleinencouraging improvementcouldbecoordinatedwiththeroleofothersindelivering whateverproducedthatimprovement.But,whateverthetension,itis fundamentalthattheregulatorhasarole,with,ofcourse,others,in improvement.Otherwise,thenecessarystimulusforchangeonbehalf ofpatients,fromapositionofindependence,islost. Insettingoutitsvision,theHealthcareCommissiondeliberately soughttotakeanewanddifferentapproachtoitsregulatorytaskin tenkeyways: Reinforcingtheaccountabilityoforganisationstoassurethemselves of thestandardsofcaretheyarecommissioningorproviding. Workingwithpatientsindefiningwhatisimportantinimproving healthandhealthcareandreportingbacktothem. Workingwithcliniciansandclinicalbodiestodefinebenchmarksof goodperformance,andtodeterminewhichmeasureswouldbeof mostassistanceintheircareandtreatmentofpatients. Givingparticularemphasistotherightsandentitlementsof peoplewhofindthemselvesvulnerable,soastopromote equalcitizenship. Focusingonwhatthewealthofinformationinhealthcaresaid aboutperformanceandtheriskofpooroutcomesforpeople. Makinginformationaboutthequalityofcareavailableinrelevant andaccessibleways,soastosupportbetterinformeddecisions andtoreinforceotherwaysofpromotingimprovement. Ensuringrobustinterventionintacklingpoorperformance. Takingawholesystemsviewlookingatcommissionersand providersofcare,andhealthaswellashealthcare. Workinginpartnershipwithotherbodiestoobtainamore comprehensiveviewofthequalityofservices,tostimulate improvementandto eliminate duplicationofeffortandreducethe costsofregulation. Establishingalocalpresencetoactastheeyesandearsofthe Commissionandtobuildlocalrelationships. Theoverallapproachwasin2004seenasradical.Itrequired differentwaysofworkingtobeestablishedanddeveloped.Thevision, andlessonslearnedinseekingtoimplementit,areconsidered furtherbelow.
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Introduction
TheHealthcareCommissionsstrategicgoals Takingintoaccountitsstatutoryobjectives,itsvisionformodern regulation,andthecrowdedfieldoforganisationsconcernedwiththe improvementofhealthandhealthcare,theHealthcareCommission setitselfsixgoalsinitsstrategicplanin2004,asameansofdefining whatitwouldregardassuccessinitsregulatoryrole.Theywereto: Promoteabetterexperienceofhealthandhealthcareforpatients andthepublic. Safeguardthepublic. Provideauthoritative,independent,relevant,accessibleand fairinformation. Takealeadincoordinatingandimprovingtheimpactandvaluefor moneyofassessmentandregulation. Promoteactiontoreduceinequalitiesinpeopleshealthand increaserespectforhumandignity. Createanorganisationdeliveringworldclassassessment andregulation. AppendixBprovidesasummaryofourprogressinmeetingthesegoals. Regulatorymethodsandapproaches Intranslatingthevisioninto a regulatorymodelthatbroughttogether therangeofstatutoryfunctionsinanintegratedandcoherent approach,theHealthcareCommissiondevelopedarangeof regulatorymethodsandapproachesassummarisedbelow.This combinedthebroadassessmentoforganisationsinmeeting standards,deeperdivesinreviewingparticularservicesand pathwaysofcareasthesehavemostrelevancetopatients,and targetedintervention,investigationsandenforcement.Animportant partofeachmethodisreportingtothepublictheCommissions findingsinanaccessibleandrelevantform. Providingindependentassurance andinformationtopatientsandthe publicaboutthequalityofcareinasectorwithover100billionof expenditureperyearisanenormoustask.Bytakinganinformation led,riskbasedapproachto regulationandpursuingaregulatory approachwhichwasasmuchabouttheanalysisofinformationto identifyriskasaboutinspectionontheground,theCommissionwas able tobealeanorganisationathirdofthesizeofothercomparable regulatorybodieswhileregulatingamuchlargersectorwitha budgetwhichwaslessthan0.1%ofexpenditureonthesector AppendixCprovidesinformationonthecostsofregulationindifferent sectorsinrelationtothesizeofthesectors,recognisingthatdifferent
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Rangeofregulatorymethodsandapproaches Focusofregulation and assessment Organisations Sector Method
Independent healthcare NHS
Broadassessmentofcompliancewith NationalMinimumStandards Broadassessmentofcompliancewithcore standardsandnationaltargets(indicators fromgovernmentofpriorities)throughthe annualhealthcheck Indepthnationalreviewsandstudiesof services;forexample,ofmentalhealth servicesandservicesforpeople with learningdisabilities Inspectionandenforcement
Servicesor pathwaysofcare
NHS
Specificareasof concernin individual organisations
Independent healthcare NHS
Interventionandinvestigation
regulators havedifferentfunctionsinrelationtotherisksandother matters intheirsectors.AppendixDprovidesabriefsummaryof someofthekeyactivitiescarriedoutbasedontheoverall regulatoryapproach. TheapproachtotheassessmentoftheperformanceoftheNHSin meetingthecorestandardssetoutintheGovernmentsStandardsfor BetterHealth 3 wasakey partoftheregulatorymodel.Thisapproach reflectedthevisionformodernregulationdescribedaboveandis illustratedinAppendixE.Inconsideringanylessonstobegained fromtheHealthcareCommissionsexperience,itisworthhighlighting themainfeaturesofthisapproach,whichwereakeypartofthe annualhealthcheck,oneofourcentralactivities.Theyare: A formalselfdeclarationbytheboardofeveryNHStrustofthe extenttowhich,intheirview,theycomplywiththecorestandards, takingaccountoftheguidanceprovidedbytheCommission a crucialstartingpointsinceboardsareresponsibleforthe servicesprovided.
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Introduction
A commentarybythirdpartiesinparticular,PatientandPublic Forums(untiltheywerereplacedbyLocalInvolvementNetworks), otherpatientsgroups,andtheOversightandScrutinyCommittees oflocalgovernment.Thecommentarymustbeincludedinthe trustsselfdeclarationandmadepublicatthetimeofsubmission. AnanalysisbytheCommissionofthedatasubmittedbytrustsin theirselfdeclarations,byreferencetothedatasetsandthousands ofitemsofdata,bothquantitativeandqualitative,thatwehold. A visit(inspection)onthebasisofrisk,asidentifiedbythetrustor bytheCommission;wealsovisitacertainpercentageoftrustson a randombasistoprovidefurtherevidencethatoursystem isworking. A qualificationofthetrustsdeclarationwherethereissignificant discrepancybetweenwhatthetrustdeclaredandwhatthe Commissions evidence orvisitsdemonstrate. A ratingofperformanceforeachtrust.
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Whatcontributionhas theregulation of healthcaremadetobetteroutcomes andqualityof careforpeople?
Assetoutinour2008StateofHealthcare report5, significantprogress hasbeenmadeinthelastfiveyearsandindeedthelastdecadein improvinghealth,reducingprematuredeaths,protectingpatients rightsandimprovingtheoverallqualityofcare.However,thereare alsoimportantareaswhereprogresshasnotbeensoimpressive forexample,intacklinghealthinequalities,improvingthesafetyof patients,meetingtheneedsofpeoplewhoareoraremade vulnerable,andtheprioritygiventosafeguardingchildren. Clearly,hugeadditionalresourcesfortheNHShaveplayedamajorpart intheimprovementsinhealthandhealthcare.Therehavealsobeen extensivereformsofgovernmentpolicywhichhavesoughttoimprove theperformanceofthesystemofhealthcare.And,ofcourse,theactual deliveryofimprovementisaboutlocalpeoplerespondingtothehealth needsofcommunitiesandtheinteractionbetweenindividualsand clinicalteams. Disentanglingthecontributionofregulationamidsttherangeof influencesonpatientsandthepublic,clinicians,commissionersof careandmanagersis,therefore,extremelychallenging.Inparticular, in theNHSitisclearthatindependentassessmentbytheregulatoris closely connectedtoincreasedlocalpublicaccountability,andto performance managementbytheleadershipoftheNHSandoversight offoundationtrustsbyMonitor. Nevertheless,thereisarangeofrobustevidencefromevaluation workthatsupportstheviewthatregulationhasmadeanimportant contributionaspartoftheoverallsystemforimprovingthequalityof care.TheHealthcareCommissionhascommissionedanextensive rangeofexternalresearchinto,andevaluationoftheimpactof, differentaspectsofitswork.ThereportMakingadifference? 6 summarisesthefindingsofthisresearchupto 2008.Thisreport drawsonitandsubsequentmaterialwhichisavailableonthe Commissionswebsite.Inparticular: NHSperformanceonstandardsandindicatorsofnationalpriority TheproportionofNHStrustsratedexcellentorgoodhas increasedfrom46%in2005/06to60%in2007/08.Someofthismay bedueto trustsgettingbetteratsatisfyingtheregulator.However, foranumberofstandardsandtargetstheassessmenthasgot tougheroverthisperiodandinspectionswhicharetriggeredbyour
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Whatcontribution hasregulation ofhealthcare madetobetter outcomesand qualityofcare forpeople?
identificationofriskscontinuetobemorelikelytoidentifynon compliancewithstandards.Thissuggeststhattrustsarenotableto gamethesystemagainstthewealthofintelligenceandinformation thattheCommissionisabletoanalyse. PerformanceinmeetingarangeofGovernmenttargetshasimproved significantlysinceweincludedthesemeasuresinperformance assessment;forexample,waitingtimesfortreatmentforcancer, admissiontohospitalfortreatment(18weekstarget),andcarein AccidentandEmergencyDepartments. EvaluationshowsthatourassessmentsoftheNHSarefairand contributetodemonstrableimprovementandthatthebenefits outweighthecosts. 70%ofNHStrustsagreedthattheannualhealthcheckself declarationprocesswasagooduseofstaffstime.* 93%ofNHStruststhoughtthattheannualhealthcheckhada positiveimpactonpatientcare. 81%ofNHStruststhoughtthatitfocusedattentiononthesafety ofpatients. 25%reportedanincreaseinbenefitsinthesecondyear;57%that thebenefitswerethesamesotheimpacthadbeensustained. Independenthealthcareprovidersperformance CompliancewithNationalMinimumStandardsintheindependent sectorhasalsoimproved93%oforganisationsmetoralmost met allofthestandardsin2007/08comparedto50%in2005/06(thougha directcomparisonisnotstraightforwardastheCommissionchanged itsmethodologyforinspectionoverthisperiod). Evaluationofourregistrationandassessmentsofindependenthealth providersshowsthat:** 99%ofproviderssawtheassessmentsandinspectionasimportant inpromotingandimprovingthequalityofcare. 97%thoughtthatitimprovedtheirreputationwiththepublic. 80%thoughtthattheprocessfocusedonthesafetyofpatients.
* Evaluationofthesecondyearoftheannualhealthcheck(performancein2006/07), interviewswith220NHStrusts. ** Evaluationofindependenthealthproviders,surveyof100providers2007.
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NHStrustsperformanceinreviewsofservices Reviewsofparticularservices(suchasmaternity,inpatientmental health,careofolderpeople,diabetes)havestimulatedimprovement. Thesereviewshavefocusedespeciallyongroupswhofindthemselves morevulnerable,andhavealsoprovidedausefulfocusonpathways ofcareandintegrationofhealthandsocialcare(forexamplein communitymentalhealthandlearningdisabilities). Evaluationofourreviewsshowedthat: 99%oforganisationssurveyedsaidthatthereviewsfocusedonthe righttopics. Overtwothirdsthoughtthattheinformationgeneratedwasuseful andworthwhile. 70%reportedthatthereviewshadpositiveimpactsforpatients. 82%reportedthatthereviewscoreswerefair. Investigationsintosignificantfailings Investigationsintoseriousservicefailureshavebroughtabout improvementsinindividualorganisations,andhavealsohada positive impactacross theNHSinimprovingpatients safetyandthe qualityofcare,forexample,followinginvestigationsintomaternity services,learningdisabilitiesandinfectioncontrol. Evaluationoftheimpactofinvestigationsshowedthat:6 35%oftrustsreportedthattheyhadsignificantimpacton improvingstandardsintheirowntrust;55%reporteda smallerimpact. 89%thoughtthatinvestigationsimprovedpatientssafetyand85% thatthey improvedthequalityofcare. Lessthanhalfthoughtthatinvestigationshadimprovedpatients confidence,while 15%thoughtithadworsened. Workingwithpatients Thepatientsvoicehasbeenbroughtintothesystemofassessingrisks andperformanceasamatterofcoursewithlocalgroupsproviding commentariesontrustsdeclarations;localinformation,intelligence fromthecomplaintssystemandquantitativedatafromsurveysbeing centraltotheanalysisofrisk;andpeopleusingservicesbeinginvolved inreviewssuchastheauditoflearningdisabilityservices.Thishas encouragedtruststo give moreattentiontotheviewsofpatientsand thepublic.Afterthefirstyearofassessingcompliancewithcore standards,anindependentsurveyofNHStrustsfoundthat:
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Whatcontribution hasregulation ofhealthcare madetobetter outcomesand qualityofcare forpeople?
30%oftrustsagreedthatafterthefinaldeclarationtheyhada betterrelationshipwiththeirthirdparties. 37%oftruststhoughtthattheynowplacedmorepriorityon involvingpatients,communitygroupsandthepublicasaresultof theassessment. Commentsbytrustswithnoopinionorthatdisagreedweresplit intotwodistinctgroups:thosewhothoughtthattheirpatientand publicinvolvement(PPI)forumshadlittlegraspofthe task/capacitytocommentatthattimeandthosewhothoughttheir relationshipswerealreadyexcellent. Aspartofanevaluationofourwiderprogrammeofassessmentin 2007/08,webroughttogether22representativesfromarangeof voluntaryorganisationsandtheCommissions NationalPatientForum Reference Group.Themajorityofparticipantsagreedthatthe Commissionsprocessofassessmenthashadsomepositiveimpact, asanyprocesswhichinvolvesexternalscrutinyislikelytohelpto drive upstandardsandleadtoimprovement.Severalfeltthatthe impactwasmostapparentinacutetrustswherestandardsand targetshavehelpedfocusattentiononimprovingwaitingtimesand cleanliness.Manyfeltthatoneofthemainbenefitsoftheprocess wasthattherehadbeenanincreasedcommitmentfromtruststo involvepatientsandthepublicindecisionmaking.Several participantswere able to recountexampleswherecommentson trustsselfdeclarationsfromPPIforumshaddirectlyorindirectlyled toimprovementsinthequalityofcareatalocallevel. Providingaccessibleandrelevantinformation TheCommissionhasalsobecomeareliablesourceofinformation ontheperformanceofhealthcareorganisationsandservices. TheCommissionpublishestheresultsofitsassessmentsandallof itsreportsonitswebsite,whichreceivesaround140,000visitors eachmonth.In2007,IPSOSMoriconductedasurveywith40 commentators fromvariousbackgrounds,includingjournalists, MPs,healthcareproviders,cliniciansandregulatorypartners.The resultsrevealedthattheCommission'sinformationisviewedasits majorstrength. Therearealsoareaswherethesystemasawhole,including regulation,doesnotseemtohavebeenaseffectiveinachievingbetter outcomesforpeople.Thesearepickedupinthenextsection.
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Whatlessonshavebeenlearned abouttheapproachtoregulating healthandhealthcare?
ThissectionsetsoutthemainlessonsfromtheHealthcare Commissionsapproachtotheimplementationofitsvisionfor modernregulationofhealthandhealthcare. Themainthemes,linkingbacktotheelementsofthevisionreferred toearlier,are: Theuseofarangeofregulatorytoolsandapproachesflexiblyin relationtotherisksinthevarioussectorsprovidingand commissioninghealthandhealthcare. Holdingorganisationsto accountforthequalityofcaretheyprovide andtheoutcomesforpeople usingservices. Workingwithpatientsandthepublic. Involvingcliniciansandclinicalbodiesinmeasuringwhatmatters. Promotingequalcitizenshipandgivingparticularemphasisto therightsandentitlementsofthosewhofindthemselves morevulnerable. Makingeffective useofexistinginformation. Improvingtheinformationavailableontheoutcomesofcareand theexperience ofpatients. Providingaccessibleandrelevantinformationonthequalityofcare. Ensuringrobustinterventionandinvestigationintackling poorperformance. Takingawholesystemview. Workinginpartnershipandaligningregulationwithother mechanismsforachievingtheGovernmentswidergoalsin thesystem. Buildingthecapabilityoftheregulatortodoitsjobandrespondto requeststotakefurtherfunctions,andestablishingalocalpresence.
Usingarangeofregulatorytoolsandapproachesflexiblyin relationto risks

Itistoosimplistictocharacterisetheregulationofhealthcareorof otherpublicsectorsasbeingeitheraboutarollingprogrammeofin depthinspectionsortheanalysisofpredeterminedquantitativedata to highlightrisks.Rathermodernregulationneedstobemultifaceted,
TheHealthcareCommission20042009:Regulatinghealthcareexperienceandlessons 23
Whatlessons havebeen learnedabout theapproach toregulating healthand healthcare?
usingarangeoftoolsandmethodstobesteffectinensuringthat organisationsareaccountablefortheachievementofstandardsofcare andthepursuitofimprovement.Effectiveregulationcombines: Listeningcarefullytousersofservicesandstaffandtakingtheir concernsseriously. Engagingwithothers(suchaslocalpatientsgroups)toshare intelligenceandperspectives. Selfassurancebythoseaccountable(suchasboardsofNHS trusts)byreferencetoclearstandards. Measurementandbenchmarkingbyreferencetointelligent outcomefocusedindicators. Regularsurveillanceofperformancethroughtheconstructionof alertsindicatorsofvariationfromexpectedoutcomes determinedinconsultationwithcliniciansandpatientsandearly warningofpotentialconcerns. Undertakingvisitseffectivelyinariskbasedandtargetedway. Robustandproportionateenforcement. Overall,thedevelopmentofarangeofappropriatemethodologieshas beeneffectiveinoptimisingtheimpactoftheCommission.The combinationofbroadassessmentsofcompliancewithstandards, deeperdives inthecaseofparticularservicesandpathwaysofcare, targetedinterventionsandinvestigations,andpublicreportingof findingshaveallowedtheCommissiontoflexitsregulatoryapproach inrelationtotherisksofpooroutcomesforpeople.Theoverall impactofeachactivityhasbeenenhancedbybeingpartofawider integratedapproach. Holdingorganisationstoaccountthroughregulationforthequality ofcaretheyprovideandtheoutcomesforpeopleusingservices TheHealthcareCommissionhasreinforcedtheresponsibilityof organisationsprovidingservicestoassurethemselvesofhowwell theirorganisationsareperforming.Theboardsoforganisationsare legallyresponsiblefortheperformanceoftheirorganisationsand shouldthereforerenderanaccountofperformanceandbeheld accountable.TheapproachthattheCommissiontooktoinformation ledregulation(seebelow)followedonfromthis.Organisationsshould havesufficientinformationtoknowwhattheyaredoingandtobe heldaccountable. Thenotionofusingselfassurancebyboardsasthestartingpointfor theassessmentofcompliance withcorestandardswasviewedwith concernbysomecommentators.Somefearedthatitwouldbelike
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mostformsofselfregulationselfservingandunreliable.Others suggesteditwasonlybeingdonetosavemoney.However,itwasnot decidedonlightlyanditwasnotdrivenbyfinancialpressures.Rather, itwastherightthingfortheregulatortodo,toreinforcethe fundamentalpointthathealthcareorganisationsare,andshouldbe, accountabletothepeoplewhousetheirservicesandneedtobeable todescribeandexplainwhattheyaredoing. MostNHStrustsunderstoodthethinkingbehindtheapproachand builtthenecessaryselfassuranceintotheirexistingsystemsof governance(orhadalreadydoneso).Thisreinforcesthenotionthat theinformationthattheregulatorisaskingforisnomorethanthat whichaboardwouldwantforitselfanyway. Somefailedto grasptheapproach,orperhapsthoughtthattheycould gamethesystem.But,thebreadthoftheexistingdata heldand analysedbytheCommission,andtheimportanceofthecommentaries frompatientsgroupsandlocalauthorities,havesteadilycauseda changeinsuchattitudes.Submittinganaccuratepicture,wartsand all,hascometobeseenbyboardsasthebestwayforward,notleast sothathelpcouldbeofferedwhereneeded.Theupshotisthatthe systemisbroadlyseentobeworking.Independentevaluationofthe annualhealthcheckin2007/08foundthattheoverwhelmingmajority ofNHStrustssurveyedbelievedthattheCommissionsprocessof assessmenthadbeenanimportantfactorindrivingimprovementin theirownorganisation. Oneofthekey aspectsofthesystemisthesettingofthestandards (whetherStandardsforBetterHealthintheNHSorNational MinimumStandardsintheindependentsector)andensuringthat thereisasharedunderstandingofthelevelsofperformance necessarytomeetthestandards.Standardsareonlyofanyvalueif they leadtobetteroutcomesforpeople.Toomanyofthecurrent standardsarenotactuallyambitiousenoughintheoutcomesthat theyareseeking.Andtoomuchoftheattentionofthesystemhas beenonwhethersystemsandpoliciesareinplace,ratherthan whetherpeoples rightsare beingconsistentlysafeguarded,better careisbeingdelivered,andcrucially,asaconsequence,better outcomesforpatientsarebeingachieved,asaresultofthe implementationofthosesystemsandpolicies.Ourview is ofcourse thatthedeliveryofhighqualityhealthcareneedssystemsand policies,butthatthefocusofthosewhoprovideandcommissioncare andthatoftheregulatorshouldincreasinglybeontheoutcomesfor patientsandtheirexperienceofcare.
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Workingwithpatientsandthepublic TheHealthcareCommission,whiletakingaccountofthe GovernmentsStandardsforBetterHealth 3 (asrequiredbystatute), soughttobuildregulationfromthebottomup,buildingaconsensus withthepublicandprofessionals,sothatthestandardsand measuresofperformanceitfocusedonwouldreflectandbeowned bywhatpatientsandthosecaringforthemthinkisimportantin improvinghealthandhealthcare.Thenotionwasoneofcoproduction ratherthantopdownimpositionindeterminingwhatgoodlooks likeand,thereby,ofregulatingwiththeengagementandconsentof theregulated.Thegoalwaswhatcouldbedescribedasavirtuous circleofregulationafarcryfromthepolicingstereotypecommonly held.TheCommissionwouldaskpatients,thepublicandclinicians whatpromotedimprovedcare.Onceidentified,theCommissionwould makeitclearthatthesewerethethingsthatitwouldassesstrusts performanceby.Thosemanagingtrustswouldrespondbydelivering thesethings,andtrustswouldbethereforedoingthatwhichpatients andclinicianssaidwouldleadto improvedcarethuscompletingthe virtuouscircle. Byworkingwithpatientsandthosecaringforthem,theCommission soughtto ensure thatitsviewonwhatwasmeantbyqualityreflected whatmatteredto people.Broadly,qualitywastakentoreferto: Thesafetyofcare. Theeffectivenessandoutcomesofcare,includinghelpingpeople to leadhealthier,more independentlives. Theexperience thatpatientshave ofcare,includingfairaccess to care. TheHealthcareCommissionhasmadesignificantprogressin involvinggroupsofpatientsandthepublicinitswork,inavarietyof ways.Ithasbuiltrelationshipswithlocalpatientsgroups,including PatientandPublicInvolvementForumsandbroughtqualitative informationfrompatients,aswellasquantitative informationfrom themyriadsourcesofdata,intoregulationandassessmentina systematicway.Wehavealsosuccessfullyengagedwithothergroups representingpatientswithlocalknowledge,suchasMencapandAge Concern.Patientshavebeenpartoftheteaminsomeofourreviews ofservices.TheCommissionhasalsoconductedmajorsurveysof patients viewswhichare fedintotheannualhealthcheck. Wehavesuccessfullyarguedforthisinvolvementofpatientsandthe publicto beincludedinthestatutoryobjectivesofthenewCare QualityCommission.Itmusthaveregardtotheviewsexpressedby members ofthepublicabouthealthandsocialcare services,the
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experiencesofpeopleusinghealthandsocialcareservicesandtheir familiesandfriends,andtheviewsexpressedbylocalnetworksfor involvement.TheCareQualityCommissionmustalsopublishand consultonastatementofitsinvolvementofusersofservices. However,theHealthcareCommissionsnationalstudyonthe engagementofpatientsandthepublicengagementhasalso highlightedtheimportanceoffurtheractiontoreinforcetheneedfor commissionersandprovidersofhealthcaretoinvolvepeoplein decisionsaboutlocalprioritiesandabouttheirowncareandtotake accountoftheseviewsintheirplans.NHStrustsdeclarethemselves tobedoingwellontherelevantcorestandardrelatingtoinvolving patientsandcarersbutshiftingtoatrulypersoncentredservice willrequirethestandarditself,andthemeasurementofcompliance withit,toberathermoreexacting. Anotherimportantissueinworkingwithpatientsisthehandlingof complaintsabouttheNHS.TheHealthcareCommissionhashadthe functionofreviewingcomplaintswhichcannotberesolvedatalocal level.Carryingoutthisfunctionhasprovidedvaluableinformationto informtheoverallassessmentofrisksofpooroutcomesforpeople. TheCareQualityCommissionwillnothavetheequivalentfunction. TheDepartmentofHealthsobjectiveistoimprovethelocalhandling ofcomplaints.Aspartofthis,itisexpectedthattheschemeof registrationwhichtheCare QualityCommissionwilloperatewill requireprovidersofhealthcaretodemonstratethattheyhavean effectivesystemtohandleandrespondappropriatelytocomplaints andsystematicallylearnfromthem.Itwillbevitalforthisstandardto be setatasufficientlyhighleveltodrivesignificantimprovementin thehandlingofcomplaintslocally.AppendixGsetsoutthe conclusionsfromourlastSpotlightonComplaintsreport.7 Thereport highlightsthemattersgivingrisetothemajorityofcomplaintsand demonstrateshowtheyremainthesameandthattrusts,therefore, needtobegintorespondeffectively. Involvingcliniciansandclinicalbodiesinmeasuringwhatmatters Thevirtuouscircledescribedaboveisdependentonthepremisethat thestandardsandmeasuresofperformancearecredibleandrelevant tothepublic,topatients,andtoclinicalstaff.So,acentralpartofthe visionwasto workwithcliniciansandclinicalbodies,aswellas patientsandthepublic,todefinebenchmarksofgoodperformance: inparticular,measuresthatclinicianstelluswillbeofmost assistanceinpromotinggoodcareandtreatmentoftheirpatients. In manyareaswheretheHealthcareCommissionhasundertaken detailedwork,suchasinrelationtomaternityservices,wehave
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activelysoughttheassistanceofpatientsgroupsandclinicalbodies, suchastheRoyalColleges,inordertodefineacceptablestandardsof careandindicatorstomeasurethem.Theprojectthatthe Commissionledonbettermetrics,workingalongsidethevarious nationalclinicaldirectorsappointedbytheDepartmentofHealth, whichproducedarangeofindicatorsin13majorclinicalareas,wasa significantcontributiontotheoverallapproach.But,thesystemasa wholeneedstobedoingthisasamatterofcourse,apointrecognised bythoseRoyalCollegesthataredeveloping(and,insomecases, alreadyrunning)schemestoaccreditservices.Theseschemescan, interalia, providefurtherassurancetotheregulatoraboutthequality ofcarebeingprovidedtopatients. Itisalsoimportanttosimplifyandalignthevariousstandardsand metricswhichareusedtodefineandmeasureperformance,and ensurethattheyarerelevanttopatientsandtoclinicalstaff. Certainly,theDepartmentofHealthscorestandardswereinitially seenasconcernedwithmatterswhichweremoreformanagersto sortoutratherthantheclinicalstaff.Theintroductionofnew requirementsforregistrationunderthelegislationestablishingthe Care QualityCommissionprovidesanopportunityto involveandwork withclinicalstaffandpatientssothatregulationisseentoberelevant andeffectivebybothgroups. Promotingequalcitizenshipandgivingparticularemphasisto the rightsandentitlementsofthosewhofindthemselvesmorevulnerable TheHealthcare Commissions objective wastoassessthequalityof healthcarefromthepatientsperspective.However,itsoughttogo furtherthanthisandreflectinitsworktherightsandentitlementsof peoplewhofindthemselvesvulnerable.Whilegroupsmaydifferin theirneeds,children,olderpeople,peoplewithlearningdisabilities, people withmentalillness,andpeoplefromareasofsocial deprivation,orforwhomEnglishisnotafirstlanguage,mayallhave particulardifficultiesingainingaccess(orearlyenoughaccess)to healthservicesandhealthcareofthestandardthatallareentitledto expect.Theymayalsorequireparticularattentioninsafeguarding theirrights.Bylookingatservicesthroughtheeyesofthosewhoare oftenleastabletoasserttheirrights,theCommissionsoughtto promote equalcitizenshipandtocontributetoimprovementsinthe overallstandardsofcare. Whensettingitspriorities,theCommissionhasdrawnontheavailable evidenceonareasofconcerninhealthcare,andtheviewsofpeople respondingto consultationsonitsprogrammeofwork.The Commissionrecognisedthatgroupsthatfindthemselvesmore vulnerable maynotalwaysgetsufficientattentionintheoverviewof
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performanceatorganisationallevel,orindeedintheDepartmentof Healthsnationaltargets.TheCommissionhassoughttoimproveits guidanceoncompliancewiththeDepartmentscorestandardssothat itpromotesequality,diversityandhumanrightsmoreeffectively.We havealsoundertakenandpublishedextensiveanalysisofvariationsin theexperienceofpatientsasshownbydata drawnfromsurveysof patients,inrelationtoage,gender,ethnicity,disabilityandsocial deprivation.Thishascoveredinpatientservices,mentalhealthand maternitycare. TheCommissionhasalsogivenhighprioritytoworkwithgroupswho findthemselvesmorevulnerableinitsprogrammeofreviews, including,forexample,communityandinpatientmentalhealth,an auditoflearningdisabilityservices,dignityincareforolderpeople, servicesforchildren,andraceequality. Lookingforward,ashifttofocusregulationmoreatthelevelof servicesandpathwaysofcareshouldalsohelptoensurethat particulargroupsdonotdropthroughthenet. Makingthemosteffectiveuseofinformation TheHealthcare Commissionhasadoptedanapproachto regulation basedoninformationandwhatinformationsaidabouttheriskofpoor outcomesforpeople.Informationled,riskbasedregulationwasat thecentre oftheCommissionsvision.Ithascombineda21stcentury useofinformationtechnology,adeepanalysisofriskandthe consequentestablishmentofbenchmarksforperformance,anda leanorganisation.Wecouldadoptthisapproachbecauseofthe wealthofdatageneratedbytheNHSandotherswhoseworkbrought theminto contactwithit.Thechallengewastousethisinformationto answerquestionsaboutqualitywhichthedatahadnothithertobeen usedforinanysystematicway. InadoptingthisapproachtheCommissionsignalledtotheNHSthat, likeanylargecomplexorganisation,itoughttoknowwhatitisdoing. Itshouldbeabletoassessitsownperformanceandbeheld accountableonbehalfofthepublicastaxpayer.Thedatawasthere andwhere itwasnot,itshouldbecollected.Tothosewhocomplained ofaregulatoryburden,theanswerwassimple.Theregulatorwants fromeachorganisation,bywayofinformation,nomore thanthe organisationshoulditselfbecollectingsothatitcanknowhowitis doingandmanageitsaffairsaccordingly. Relianceoninformationdoesnotmeanthatvisitstotrusts (inspections)were nolongerundertaken.Farfromit.Inspectionhas beenacrucialpartofthesystemparticularlyinareaswherea
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rangeofadditionalsourcesofinformationwaslacking(suchasthe qualityofservicesforthosewithlearningdisabilities,orthe treatmentofolderpeopleinhospital);whereinformationsuggested thatquestionsneededtobeaskedwhichcouldonlybeansweredby visiting;andonamorerandombasis,andunannouncedonoccasions, tokeepthesystemhonest.Ouruseofinspectionwasthereforemore deliberateandtargeted,informedbyananalysisofrisksofpoor outcomesforpeople. Theintentionwasthatbypullingtogetherexistinginformation, systematicallyusingquantitativeandqualitativedatafrompeople usingservices,andworkingwithpatientsandclinicianstodefine acceptablelevelsofperformance,theregulatorwouldsteadilybuild upapictureofwhatisgoingon,whatgoodpracticeshouldamountto, andenablethegapsininformationtobefilledwheretherewasnot sufficientevidenceonthequalityandoutcomesofcare.Thecollection andanalysisofinformationinrealtimewouldalsoincreasingly allow theregulatortohighlightconcernsaboutthesafetyandquality ofcareandtakeappropriateaction,ratherthanarriveafterthefact. Inimplementingthisvision,theHealthcareCommissionembarkedon a programmeofinvestment(amountingtosome16million)tocreate itsanalyticalandtechnologicalcapability.TheCommissionhasused informationfundamentallyintwoways: Toprovideaviewofrisksinthesystemofhealthcareandto give early warningwhichrequiressomeformofaction, includingintervention. To reportpublicly ontheperformanceoforganisations,services andthosemanagingpathwaysofcare,soasto enable people to makebetterinformeddecisions. Thefirstareahasbeenveryimportant.GiventhattheCommission wasconceivedoutoftheReportontheBristolInquiry,oneofthe abidingchallengeshasbeenfortheregulatortoidentifyandheadoff dangers before they materialiseinto someawfuloccurrence,harming patientsandthosecaringforthem.Initially,giventheCommissions needtocreateaninformaticssystemfromscratch,andgiventhe statutorydutytopublishanannualratingoforganisations performance,webeganbyproducingwhatcouldbedescribedasa posthocauditofperformance.Thisapproach,theannualhealth check,involvingtheoverallanalysisofexistingdataincludingthe viewsofpatientsandthepublicto provideanassessmentofthe extenttowhichtherearerisksthataproviderofservicesmaynotbe able to delivergoodoutcomes,hasbeendevelopedovertheyears. Theanalysiswasbackedupbytargetedvisits.Thevisits,whichare triggeredonthebasisoftherisksthattheCommissionhasidentified,
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haveconsistentlyproventobemorelikelytoleadtothe selfdeclarationsmadebytrustsbeingqualifiedthanvisitscarried outonarandombasis(uptothreetimesmoreeffectiveinthesecond year).Trustsvisitedonthebasisofriskassessmentarealsomore likelytohavetheirdeclarationsqualifiedonahighernumberof standards.Sothesystemisworking.Thenextstageistogetbetter informationinareaswhichareimportanttopatients,butwherethere iscurrentlyverylimiteddata. Whiletheannualhealthcheckhasbeenasignificantdevelopment,in thatithasmovedawayfromacrudeallocationofone,twoorthree starstoanorganisationinordertoprovidearicherpictureof performance,ithasstillbeenbackwardlooking.Whatpatientswant, andtheregulatorneedstoprovide,isamoreuptodatepicture.It shouldnotmerelydescribetheperformanceofanentitycalledatrust, butseektodisaggregatetheinformationdownthroughthetrusttothe hospitalandtheunit,andacrosshospitalsandtrusts,soasto describeservices.Patientswanttoknowwhethertheirtreatmentwill bemanagedwellinthisorthatunitorthroughthisparticularpathway ofcare,andthey wanttoknowthecurrentposition. Gradually,theCommissionhasdevelopedthecapacitytoengagein realtimesurveillanceofperformance.Thisisanextremely importantstep.Itbeginstorefinetheinformationavailable,soasto tellpatientswhatthey wantto know. And,italsoprovidesanearly warningsystemwhenthingsaregoingwrongsothatactioncanbe taken.Fromtheperspectiveoftheregulator,itmeansthatless emphasisneedbeplacedonlengthyinvestigationsofthingsthathave gonebadlywrongandmoreoncollaborativeworkingbetweenthe regulatorandotherstoidentifyproblemsearlyandworktoresolve them.Somemaythinkthatthisisarolethatisproperlyfor,andcan safelybeleftto,management.Certainly,managementhasapartto play.But,inasystemofhealthcarethatattractssomuchof taxpayersmoneyandwherethingscananddogowrong,an independent,authoritative andrigorousregulator,actingonbehalfof all,isessential. AnexampleoftheprogressthattheCommissionhasmadeinthis areaofsurveillance,earlywarning,andfollowingupwhenthe analysisofdata suggestedpossible problems,canbefoundinour reportonmortalityoutliers 8. AppendixFprovidesabriefsummaryof realtimesurveillanceinfollowingupdatawhichindicatessome possibleconcerns.Todate,theCommissionhasconcentratedon mortalityoutliers.Suchoutliersraisequestions;concernsarisewhen nosatisfactoryanswerscanbefound.TheinvestigationintoMid StaffordshireNHSFoundationTrustfellintothiscategory.This systemis,ofcourse,amorepreciseregulatorytoolwherethedatais
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stronger.But,nevertheless,itisbeddingineffectivelyandneedstobe builtonby,forinstance,extendingtheapproachnexttoemergency readmissionsofpatientsintohospitals. Improvingtheinformationavailableontheoutcomesofcareandthe experienceofpatients Inseekingtoencourageimprovementinthequalityofcare,the Commissionhasbeeneffectiveinmakinggooduseofexistingdata. But,itisalsoveryclearthatthereareseriousgapsintheinformation available.Keyissuesinclude: Informationontheprovisionofsafecare.Informationonhospital associatedinfectionisnowimproving,butthereisawiderangeof otherriskstothesafetyofpatientswherethereisadearthofgood data suchasaboutfalls,managementofmedicines,surgical errors,andthepreventable deteriorationofpatientshealth. Thereportingofincidentswhensafe care hasbeencompromised remainspoorinlargepartsofthesystem.Inparticular,thereneeds tobeamuchmorerobustandconsistentapproachtothereporting ofseriousuntowardincidentsandsharingsuchreportsnationally sothatlessonscanbelearnedandimprovedpracticeimplemented. Thisisanurgentpriorityforthenewsystemofregistration. Thereislittleornodataonriskstothesafetyofpatientswhichare notincidents(andthereforenotcapturedinanysystementirely dedicatedtoreportingincidents).Thisisamajorchallengeboth philosophicallyandpractically.Therisksincludethefailureto diagnose,orthelate diagnosisof,acondition.Theyrelate particularly to primarycare andcareinthecommunity,where about90%ofcontactsbetweenpatientsandprofessionalstake place.Ifsafetyisonlyconceivedofasinvolvingsomeaction(or nearmiss),theequallyimportantcasesofinactionwillcontinueto gounanalysedandpatientswillcontinuetobeputatriskasa consequence.Thecapturingofsuchdataisnoeasytask,butinitial workhasbeencarriedoutbytheCommission.Theworkinvolved analysingalreadyavailabledataatthelevelofindividualGPs practicesto identifythereasonsforvariationinperformance.The purposewastoidentifywherebetterpreventativecarecouldhave beenprovided.Thisdatacoveredthemainlongtermconditions includingdiabetes,chronicobstructive pulmonarydisease,heart failureandhypertension,aswellasstroke.Asthesourcesofdata in primarycarecontinuetoimprove,withtheabilitytoconstruct longitudinaldataforeverypracticeinEnglandfrom2011/12,then thisgroundbreakingworkneedstobebuiltupon. Toomanyservicesstillhavelimiteddataavailableonoutcomes. Thisappliesto clinicaloutcomesandalsoto informationonthe
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extenttowhichpeopleusingservicesareabletolivehealthier, moreindependentandbetterlivesasaresultofthecarethey receive.TheagendaoutlinedbyLordDarzi,includingthephased approachtoqualitymetricsandthecomplementaryrolesofthe regulatorandNICE,placesconsiderableemphasisongreater activityatalllevelsofthesystem.Withoutbetterinformationon outcomes,thoseproviding,commissioningandreceivingservices areunlikelytoknowhowtheyareperformingandhowgoodand safecareactuallyis. Themandatoryrequirementsforinformationplacedonthe independenthealthcaresectorfallwellshortofwhatisrequired forpeopleusingservicestomakeinformeddecisionsandforthe regulatortobeabletoassessrisk.Wearesomewayfromalevel playingfieldbetweenpublicandindependentproviders. The DepartmentofHealthhasgivenhighprioritytocertain indicatorsofdesiredperformanceinitsguidancetotheNHS whatitchoosesto callthevitalsigns.Butthelackofattentionto areassuchasmentalhealth,learningdisabilities,equality,andthe integrationofhealthandsocialcareinthissetofnational priorities posessignificantrisks.Primarycare trustsareseenby theDepartmentastheengineforpromotingimprovedcare, throughtheirroleasthecommissionersofcare.Thereisadanger, however,thattheywillbecaughtbetweentheirresponsibilityto understandtheneedsoftheirlocalcommunities,commissioning care accordinglyinafairandequitablemanner,andthepolitical imperative ofrespondingto vitalsigns.Experience suggeststhat nationalprioritiesbecomethedominantissue,tothedetrimentof pursuingothergoals.Ofcoursenationalprioritiesareinevitablein a taxpayerfundedsystemforwhichgovernmentisaccountable andwhichgovernmentrightlyseekstolaydowngoals.Whatis importantis,first,thattheseprioritiesaresufficiently comprehensiveand,secondly,theyaremanagedalongside,notin competitionwith,othergoals. Providingaccessibleandrelevantinformationonthequalityofcare The regulatorshouldbringtogetherandanalyseinformationfroma widerangeofsources,bothtoidentifyareasofriskandtoreport publicly onprogressinmeetingtherelevantbenchmarksof performance,withjudgementsbeingmadeonthebasisofthe evidence.Theregulatorshouldbeareliable,independentsourceof informationonwhatisgoingoninthecommissioningandprovisionof healthandhealthcare,soastoprovideaccountabilitytothepublicfor NHSfundedcare andto enable people usingbothpublicly and privatelyfundedhealthcaretomakebetterinformeddecisionsabout theircare.TheHealthcareCommissionhasinvestedsignificanteffort
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inmakingtheinformationonitswebsiteunderstandabletopatients. Theinformationprovidedbytheregulatorshould,therefore,helpto reinforceandstrengthensomeoftheothermechanismsfor improvingcareinthesystem. ThestatutoryarrangementsunderwhichtheCommissionoperated requiredittofocusonNHSorganisations(NHStrusts).But,patients maynotknowwhatatrustis,and,inanyevent,aremoreinterested inwhathappenstothemastheynavigatetheirwaythrougha complexsetoforganisationalarrangements,capturedinthephrase thepatientsjourney.Inpart,theCommissioncouldassesshow wellpatientsarecaredforonthisjourneybyexaminingnotonlywhat happenstothemwhileinaparticularorganisation,buthowthey arrivethereandwhathappenswhentheyleave,inotherwordshow wellthejourneyismanaged.Therefore,asregulationdevelops, benchmarksofperformancespecificallyrelatedtotheperformanceof servicesandpathways,locallyandnationally,andofindividualunits, needto bedeveloped.Waysofmeasuringtheextenttowhichthe benchmarksare metarethenrequired,followedbythereportingin publicofwhatthemeasurementshows.TheCommissionhasbroken somenew groundinthisregard withitsreviewsofserviceson,for example,maternitycare,thecareofchildreninhospital,and workingwiththeCommissionforSocialCareInspectioncommunity mentalhealthservicesandcommissioningservicesforpeoplewith learningdisabilities. Ensuringrobustinterventionandinvestigationintackling poorperformance TheHealthcareCommissionhasdevelopedagraduatedand proportionateapproachtotacklingpoorperformanceinhealthcare. Thisrangesfrom: RequiringactionplansfromNHStruststhatdonotmeet corestandards. Placingspecificrequirementsonindependentsectorproviders toimprove. InvestigatingseriousservicefailureintheNHS,includingmaking recommendationstotheSecretaryofStateforHealthandMonitor to remedyfailures(specialmeasures). Takingactionbywayofenforcementwhichcanleadtode registrationofthoseprovidingcareintheindependentsector. IntheNHS,whileoverallperformanceinmeetingcorestandardshas improved,theattentiongivenbythesystemtogettingcorestandards inplace,andthen,sincetheyarecore standards,moving
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performancealongatrajectoryofimprovement,hasnotbeen adequate.TheoverallperformanceoftheNHSinrelationtothesafety ofcarehasnotchangedinthelastthreeyearsoftheannualhealth check:theproportionoftrustsdeclaringcompliancewithall standardsrelatingtosafetybeingstuckataround50%(thoughit shouldberecognisedthatforsomestandardsthereisnowmuch greaterclarityonwhatisinvolvedinmeetingthestandard,for example,ondecontamination).Thisisforasetofstandardsthatthe DepartmentofHealthsaidshouldbemeteverywherein2004.But, thisinadequatelevelofperformancedoesnotevengetamentionin theOperatingFrameworkfortheNHSfor2009/10.Itmaybethatthe politicalpressuresinthesystemaremoreconcernedwithcertain specifictargetswhicharereadilymeasuredthanwiththelesseasyto document,butfundamentallymoreimportant,generalachievement ofasetofstandardsforeveryone. AsregardstheNHS,oneofthemostsignificantactivitiescarriedout bytheCommissionhasbeenitsvariousinvestigationsintowhatthe 2003Act 1 callssignificantfailingsandwhattheCommission describesasseriousservice failures,emphasisingbothseriousness andthattheconcerniswiththeservice providedtopatients. Thepowertoinvestigatehasbeenusedwithcare.TheCommission hasdevelopedagraduatedapproach,rangingfromatelephonecallto a chiefexecutive to a fullscaleinvestigationusingexperts,taking evidenceandlastingmonths.Indeed,ofthe320requeststhatthe Commissioncarryoutaninvestigation,only17haveresultedinafull scaleinvestigation.Thedecisionwhethertodosohasbeenbasednot onlyontheapparentseriousnessofthecircumstances,butalsoon theextenttowhichlessonscouldbelearnedacrossthewholeofthe NHS(ratherthanitsbeingarelativelyparochialmatter),andwhether theinvestigationwouldallowtheCommissiontodrawattentiontoan areaofcarewhichhasbeenhistoricallyneglectedorwhich,from othersourcesofinformation,isacauseofconcern.Examplesof investigationswhichhave hadamajorimpactinpromoting improvementsincarenationallyincludethoseconcernedwiththe managementofhospitalassociatedinfections(Maidstoneand TunbridgeWellsNHSTrust)andofmaternitycare(NorthwickPark, partofNorthWestLondonHospitalsNHSTrust). TherecanbenodoubtthattheCommissionsresponsetosignificant failurehashadamajoreffectinimprovingtheperformanceof individualtrustsandinhavingawiderimpactontheoverallsystemof care.Forexample,independentevaluationshowsthat89%ofthe trustssurveyedthoughtthatinvestigationscarriedoutbythe Commissionhadimprovedthesafetyofthecareprovidedtopatients.
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TheactionstakenbytheCommissionhavecometoberegardedas thorough,authoritativeandindependent.Indeed,theCommissions reputationhasmeantthathealthcareprovidersandseniorofficials haveeven,onoccasions,chosentoseektheregulatorsintervention through,forexample,askingittocarryoutanindependentanalysisof potentialproblems(suchastheengagementovertwoweekswith PapworthHospitalaftersurgeonsreportedanabnormalincidenceof deathsafterhearttransplants). Initsinvestigations,theCommissionhasroutinelyfoundthata consistentfeatureofpoorperformanceispoorleadership.Inthis context,akeylessonfortheregulatoristheimportanceofthelocal relationshipitdevelopswithregulatedorganisations.Thisallowsthe regulatortohavearegularandcloseviewofthecapabilityofthe leadershipinanorganisationtotackleemergingproblems.Aspartof thisapproach,theCommissionhasdevelopedalocalmechanismfor recognisingandrespondingtoincreasedrisk,meetingregularlywith otherlocalagenciestopooltheirknowledgethroughmonthly risksummits. WhattheCommissioncurrentlylacks,however,isanyeffective standardsorbenchmarksbywhichtomeasurethequalityof leadership.Tosome,leadershipisentirelyamatterofmanagementfor management.Ourview,however,isthatbenchmarksofperformance canandshouldbedevelopedandthatanindependentregulatorhasa roleinmeasuringthequalityofleadershiponbehalfofpatients, cliniciansandthewiderpublic.Moreover,itisclearthattheissuesare widerthananyparticularorganisation.Thehealthcaresystemasa wholeneedstoattract,develop,andretainsufficientnumbersofhigh qualityleaders,ifperformanceistocontinuetoimprove.Givenwhatwe have saidaboutthecentralimportanceofboardsoftrusts,this imperativebeginswithboards,butthenmustbecarried forwardby themintoeverycornerofthesystem. Takingawholesystemview Inencouragingimprovementinandtheprovisionofhealthcare,the HealthcareCommissionappropriatelyhasaremittoconsiderboth thecommissioningandprovisionofcare.Itisimportanttoreview whethertheservicesthatareprovidedareoftherightstandard,but alsowhethertherightservicesare beingprovidedtoimprove outcomesfordiverselocalcommunities.Wherethereareproblemsin meetingstandardsinthecaseofaparticularprovider,the commissionersarealsoacentralpartoftheprocessofgettingtoa sustainable solution. The2003Act 1 includedthepromotionandprotectionofpublichealth
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withinthedefinitionofhealthcare.Theinclusionofpublichealth andhealthinequalitieswithinregulationandtheassessmentof performancewasthenreinforcedbythestandardsonpublichealthin theStandardsforBetterHealth 3 andthestrongfocusonoutcomesfor populationhealthinthenationaltargets.Systematicallycollected feedbackfromprimarycaretrustsandprovidertrustsshowsthatthis focushashadasignificantandpositiveimpactonperformancein relationtopublichealth.TheDepartmentofHealthsconsultation documentonthetopicsforrequirementsforregistrationplacesa muchweakeremphasisonpopulationhealththanthecorestandards onpublichealth.Asaconsequence,thereareconcernsthatinthe newregulatorysystemtheemphasisonpreventionofillhealthand ontheroleofprovidersofcareintacklinghealthinequalitieswillbe morelimited. Intakingforwarditsremitwithrespecttocommissioners,the HealthcareCommissionhasnowseparatedtheassessmentof primarycare trustsascommissionersfromtheirassessmentas providersofcare.Furtherworkisneededtoensurethatthe assessmenteffectivelyreinforcestheaccountabilityofprimarycare truststo theirlocalcommunitiesinaddressingtheirdiversehealth needs,tacklinghealthinequalitiesandsecuringgoodvaluefor societyfromtheinvestmentinhealthcare. Itisimportantto note thattheregulatoryreachoftheCommission extendsonlytoNHSorganisations.Oneconsequenceisthatthe wholeofprimarycareatthelevelofGPspracticesfallsoutsidethe Commissionsremit.Theprimarycaretrust,astherelevantNHS organisationprovidingprimarycare,istherefore,theCommissions onlyentryintotheregulationofprimarycare.Thisisashortcoming whichisnow recognised.TheGovernmentplanstoaddressitthrough theprocessofregisteringGPspractices. Workinginpartnershipandaligningregulationwithother mechanismsinthesystem TheHealthcareCommissionsoughttoworkinpartnershipwithother regulators,auditorsandoversightbodies,bothtousetheirfindingsto obtainamorecomprehensiveviewofthequalityofservicesandto eliminateduplicationofeffortandreducethecostsofregulation.The Commissionaimedto drawonandanalysedata fromawiderangeof sourcesinitswork,andtostreamlinecollectionofdatawherepossible. TheCommissionhasestablished,overtime,effectiveworking relationshipswithStrategicHealthAuthoritiesandMonitorasthe oversightbodiesforNHSorganisations.Therespectiverolesof performanceassessmentandperformancemanagementhavebeen
37
clarified.However,thenumberoftruststhatarestillstrugglingto demonstratethattheymeettheDepartmentofHealthscore standardsisunacceptable.ManagementintheNHShasfocused rathermoreontheperformanceindicatorsinnationaltargetsthanon thebroadstandardsofcareinStandardsforBetterHealth 3. The evidenceontheimprovementinperformanceovertimesuggeststhat thethingswhichareeasiertomeasurearetakenmoreseriouslythan issueswhichmatterjustasmuchormoretopatients,suchasbeing treatedwithdignityandrespect. Overall,theattentiontoimprovingtheperformanceoftheNHStrusts thathavebeenweakeronthequalityofcarehasnotbeenasvigorous oreffectiveastheturnaroundsupportgiventoNHStruststhat werestrugglingtoachievefinancialbalance.TheDepartmentof Healthsnewregimeforperformancemayhelptoaddressthisit willbeimportantthattheregulatorsassessmentofthequalityof careisakeycomponentoftheapproach. Inrelationto theHealthcareCommissionsstatutoryfunctionto coordinatetheregulationofhealthcare,thereremainsalarge numberofoversight,audit,regulatoryandassociatedbodieswith overlappingstatutoryandnonstatutoryremitsonaspectsofquality. TheHealthcareCommissionhasmadesomeprogressinreducing collectionsofdata,forexample,thenumberofspecialcollectionsof data to measure progressinmeetingGovernmentprioritieshas decreasedbyover50%since2005/06. We have alsomadeincreasinguseofothersfindingsinour assessmentofrisksandimprovedthesharingofinformationand proposedactionsamongthesebodiesparticularly througha programmeofrisksummitswithotherregulatoryandauditbodies, StrategicHealthAuthoritiesandMonitor. However,thereisaneedforamorefundamentalexaminationofthe controlsontheinformationbeingcollected,includingthatfromvisits. Thestartingpointistheinformationthatorganisationsshouldbe collectingaboutthemselves,sothattheycanknowhowtheyare doingandmanagethemselvesaccordingly. Buildingthecapabilityoftheregulatorandestablishinga localpresence Itwillbeclearfromwhathasgonebeforethatmodernregulationcalls foravarietyofskills.Historically,inspectionwasthetermused.It calledforparticularskills,notleastlongexperienceintherelevant areafromwhichgrows,insome,theabilityto identifygoodandless goodpractice.Withthemovetoinformationled,riskbasedregulation,
38
inspectorsremainimportant.Butothersareneeded.Indeed,the emphasishasshiftedtoanalysisandanalysts,andtothosewho coordinatetheregulatorslinkswithorganisationsandagenciesata regionalandlocallevel.Equallyimportantarethosewhotranslatethe Commissionsworkintoaccessibleinformation.Thislastfunctionis crucial,sincenotonlydoesitservetoholdtheCommissiontoaccount, butitalsoseekstoempowerpatientsandthepublicthrough authoritative,accessibleandfairinformationabouttheirhealthservice. TheCommissionhasestablishedeffectivelywhatwasdubbedalocal presence.Itsetupanetworkoflocalofficessothatstaffcouldliaise closelywithNHStrustsandindependentsectorproviders,local agencies,patients,andmembersofthecommunity.Theseoffices havebeentheeyesandearsoftheCommission,advisingofconcerns, feedingbackcommentandgenerallykeepingaregulatoryeyeon thingsintheirpatch.
39
What arethelessons fromregulation forthehealthcaresystemas awhole?
TheHealthcareCommissionhassoughttogiveproperemphasisto themanyexamplesofexcellentservicesintheNHSandthe independentsector.Thestaffprovidingtheseservicesrightlydeserve creditandrecognition.Thatsaid,theworkoftheregulatorin assessingperformance,highlightingconcernsaboutstandards, investigatingseriousservicefailureandprovidinginformationabout thequalityofcarehasraisedsomeimportantcommonthemesforthe healthcaresystemasawholetoaddress: Whileoveralllevelsofsatisfactionarehigh,furtherprogressis neededtoensurethatpatientsreallyareatthecentreofcare.Too manyconcernsaboutthestandardsofcarearisebecausethe cultureoftheorganisationprovidingcaredoesnotconsistently treatpeoplewithdignityandrespect,protectthemfromharmand abuse,andpromote theirrights.Patientstellusthattheywantto beabletomakemeaningfulchoices,befullyinvolvedindecisions abouttheircare,andhavetheinformationthattheyneed,when theyneedit.Furtherattentionneedstobepaidtotrainingstaff,to rewardingtherightbehaviour,toensuringthatfeedbackfrom patientsandcarers issoughtandactedon(includingthefeedback thatcomesfromcomplaints),to measuring,benchmarkingand reportingonperformance(acrossallsectorsofcare,including primaryandcommunitycare)andtoensuringthatrequirements forregistrationarepatientfocused. Manyoftheconcernsaboutpoorperformanceandinvestigations into seriousservicefailureshavehighlightedpoorleadershipand governance,particularlyinrelationtothesafetyofcare. Managementhasnotbeeneffectivefromboardtoward,and informationonoutcomesofcarehasnotbeenroutinelyreportedto theboard,analysedandactedupon. Moreattentionneedstobegiventoawiderrangeofmatters relatingtothesafetyofpatients:abetterunderstandingand descriptionofwhatconstitutesgoodcare;betteridentificationof earlyalertsandotherrelatedinformation,beforeharmoccurs; betterreportingofincidents(whichshouldhaveawidedefinitionto embrace failuretoactwhichputsapatientatrisk),more systematiclearningandimplementationoflessons;andbetter informationto compare performance. Therehavebeenrepeatedconcernsabouttheneedtoensurethat staffareappropriatelytrainedandthattheirskillsmaintained.
41
Whatarethe lessonsfrom regulationfor thehealthcare systemasa whole?
InalloftheCommissionsmajorinvestigations,theboardsofthe organisationswerenotreceivingadequateinformationaboutthe qualityofcarethattheirorganisationswereproviding.Noorganisation ofthesizeandcomplexityoftheNHS,particularlyifitexiststoprovide a service,canfunctionproperlywithoutsuchinformation. Inmanycases,therehasbeenalackofclarityonwhatgood lookslikeindeliveringcareforexampleregardingthesafecare ofpatients,safeguardingchildren,maternitycare,andservicesfor peoplewithlearningdisabilities.Toomanyofthestandardsthat aresetconcentratemoreonprocessesthanoutcomes. Therehasbeenalackofattentiontoareassuchasmentalhealth, learningdisabilities,equalitiesandtheintegrationofhealthand socialcareinthenationalprioritiessetbygovernment(thevital signs).Manyoftheconcernsaboutthequalityofcarethatthe Commissionhashadtofocusonrelatetotheseareas. Manyofthesethemesbeingpatientcentred,strongerprofessional leadership,amorerigorousapproachtoeducationandtraining, improvinginformationaboutthequalityofcare,aclearerapproachin settingstandardsarerecognisedintheDepartmentofHealthsNext StageReview.Thechallengenowistoensuresufficientlyvigorous andurgentactioninimplementingthepoliciessetoutinthatreview to make a differenceforpeople.
42
Conclusions
Regulationhasnowbeenestablishedinthehealthcaresystem. Independentevaluationhasproducedrobustandpositiveevidenceon theimpactthattheHealthcareCommissionhashad. Intakingstockofthelessonslearnedfromregulationofhealthcare,it isimportanttorecognisethattheestablishmentofanindependent regulatorwasanimportantstepforGovernment.Theindependence oftheregulatorcanbeuncomfortableforGovernmentinapartially devolvedsystem,astheregulatorwillinevitablyhighlightconcerns aboutaspectsofservicesthatMinistersarepoliticallyaccountablefor. However,itisalsoanecessarycomponentofsuchasystem.Indeed, effectiveregulationcanhelptosupportamoredevolvedsystemby providingstrongguidance topeopleusingservicesaboutthequality ofcaretheyareentitledtoreceive,andasatrustedsourceof informationtosupportdecisionmakingandaccountability. Regulationofhealthcare hasplayed animportantpartasoneleverin a broadprogrammeofreform.Clearly,thetaskofbuildingthe regulatorysystemisfarfromcomplete.Thisreporthashighlighted themainlessonsaboutwhathasworkedwellandlesswellonthe journey sofar. Assuchitisintendedtohelpthosetakingthenext stepsinthejourney. Thecreationofthenewregulatorofbothhealthandadultsocialcare providesanopportunitytobuildonwhathasbeenachieved.Itisalso anopportunitytotakesomenewdirections,byusingregistrationto providestronger guidancetothepublicaboutthestandardsofcare theyshouldexpect,ensuringbetterinformationonperformance acrossthehealthandsocialcaresectors,andpromotingamore integratedapproachtohealthandsocialcareinmeetingtheneedsof peopleusingservices.
45
Appendices
AppendixA
AnalysisofthehealthcaresectorinEngland
Characteristic People provided withcare NHS 300millionGPand communityconsultations NHSDirect4.9millioncalls,30million visitstowebsite 19millionA&Eattendances,4.5million emergencyhospitaladmissions 7 millionelective inpatients 14millionfirst outpatientattendances 308,000caseloadofcommunitymental healthservices Annual expenditure 90billionNHS2007/08(7.3%GDPin 2007/08upfrom5.4%in1997/98) 5billionselfpayand
insuredhealthcare
2.5billionNHSfunding
Numberof providers 152primarycaretrusts 169acute andspecialist acute hospitals 11ambulance trusts 59mentalhealthand/orlearning disabilitytrusts 8,300GPpractices 9,000dentalpractices 2,108establishments
ofwhich:
310acute hospitals
178mentalhealth/ learningdisability providers 180hospices 372privatedoctors 150,000inindependent healthcare Independenthealthcare 1.2millionindependent sectorhealthprocedures
Workforce
1.3millioninNHS
47
AppendixB
SummaryoftheHealthcareCommissionsprogressagainstitsstrategicgoals
Strategicgoal 1.Promote a better experienceof healthand healthcare for patientsandthe public Evidenceofachievement WhileitisnotpossibletoisolatetheHealthcareCommissions impactfromthatotherpotentialinfluences,oursurveysof patientexperienceacrossEnglandcontinuetoshowsteady overallimprovementwith92%ofhospitalinpatientsdescribing theircare asexcellent,verygoodorgoodin2007. TheCommissioniskeentoensurethattheviewsofpatientsarean integralpartofourassessmentprocess.Forexample,our programmeofsurveysofpatientsandNHSstaffisthesingle biggestsourceofdataweusefortheannualhealthcheck.The Commissionalsoencouragesdirectpatientfeedbackthroughits SpeakOutnetworkandthroughrunningfocusedengagement events.Aspartoftheannualhealthcheck,we invite council overviewandscrutinycommittees,laymembersoftheboardsof governorsofNHSfoundationtrusts,andfrom2008/09,thenew localinvolvementnetworks(LINks),tocommentonhowwelleach trust ismeetingthenationalcorestandards.Wethenpublishthese commentaries.Somepatientforummembers (thepredecessorsof LINks)have saidthisgave theirviewsaddedleveragefor improvementwithlocalhealthcareorganisations.Wealsoinvite viewsfromorganisationsrepresentingspecificgroupsofpatients forexample,MencapandAgeConcern. TherehasbeenamarkedimprovementintheproportionofNHS truststhatmeetnationalstandardsandtargetsforthequalityof theirservices.Overall,theCommissionratedonequarter(100) ofNHStrustsashavingexcellentqualityofservicesin2007/08 comparedtojust4%twoyearsearlier.Overthesameperiod,the numberoftrustsscoringweakfortheirqualityofserviceshas declinedfrom52(9%)in2005/06to20(5%)in2007/08. TheCommissionandrelevantstrategichealthauthoritieshave jointlyfollowedupthe20truststhatwerescoredasweakthis yearfortheirqualityofservicesandareactivelyencouraging improvementforpatientsintheseareas.
48
Strategicgoal
Evidenceofachievement Ourassessmentofthecomplianceofindependenthealthcare organisationswithcoreminimumstandardshassuggested overallimprovementincompliancerates.In2007/08,93%of organisationsmetoralmostmetthestandards,comparedto 50%in2005/06.However,adirectcomparisonbetweenthetwo yearsisnotstraightforwardduetochangesintheCommissions inspectionmethodologyovertime. TheCommissionhascarriedoutmorethan30nationalreviewsof individualhealthcareservicesandengagedwithpatientsand clinicianstoensurethatwemeasurewhatmattersaspartofeach review. Allourservicereviewshavegeneratedrecommendations forimprovementandtriggeredanactionplanningprocessinthose trustswhereperformancewasfoundtobecomparativelyweak. Wherewehaveundertakenfollowupreviews,wehavefoundthat healthcare organisationsaregenerallyactingonour recommendations.Ourregionalassessmentstaffalsomonitor concernsidentifiedthroughthereviewswiththetrustsand independenthealthcare providers concerned. Independentevaluationoftheannualhealthcheckin2007/08 foundthattheoverwhelmingmajorityofNHStrustsand independenthealthcareorganisationssurveyedfortheevaluation believedtheCommissionsassessmentprocesstohavebeenan importantdriverofimprovementintheirownorganisation. Inourmostrecentannualstaffsurveyin2008,86%ofourstaff believedthattheCommissionwasimprovingpatientcare.This wasanincreaseof13percentagepointssincethe2006survey.
2.Safeguard thepublic byactingswiftly oncomplaints, concernsand significant failings
TheCommissiontakesenforcementactionorinvestigationwhere thisiswarrantedtoprotectthesafetyofpatients.In2008/09,the numberofenforcementnoticesservedonindependent healthcareorganisationsdoubledoverthepreviousyear,with39 casesbeinginvestigated,thesuccessfulprosecutionofan establishmentoperatinginbreachofitsregistrationconditions andwithseveralmorecasesinpreparationforprosecution.
49
AppendixB
Strategicgoal
Evidenceofachievement TheCommissionconductsinvestigationsintosignificantfailingsin theNHS.Todatewehavereceivedhundredsofconcernsaround patientsafetyandhavecompleted17fullinvestigationsaswellas a rangeofotherinterventions.Independentevaluationshowsthat ourinvestigationshelpedtobringaboutchangebyraisingthe profileofthepoorlyperformingservicewithinthetrustasa whole,actingasacatalystforgreaterinvestmentintheservice, actingasacatalyst forthereorganisationoftheservice,and enablingindividualstodrawattentiontoissuesthatthey previouslyfeltwereignored.Inthetwotruststhathadbeen placedunderspecialmeasures,itwasfeltthatthishadhelpedto raiseprioritywithinthetrustandgalvanisesupportfrompartners. Trustshadalsofoundadditionalsupportprovidedaspartof specialmeasures,suchasexternalchangeteams,tobehelpful. Infectionratesandhygieneareissuesofparticularconcernto thepublic.RatesofMRSAbloodstreaminfectionsand Clostridiumdifficileinfectionsarecontinuingtofallacrossthe NHSasawhole. TheMRSArate fellby33%forthethird quarter of2008comparedtothecorrespondingquarterin2007,to837 reportedcasesacrossEngland.TherateforClostridiumdifficile fellby35%overthesameperiod,to 8,696reportedcases. TheCommissionsinvestigationintotheoutbreaksofClostridium difficileatMaidstoneandTunbridgeWellsNHSTrusthighlightedthe starkconsequencesforpatientsafetyofpoorinfectionprevention andcontrol.Independentevaluationshowedthatourinvestigation notonlyresultedinwholesalechangeatthetrustconcernedbut hadthebiggestimpactofallourinvestigationsnationallywith othertrustsreviewingtheirinfectioncontrolproceduresinthelight ofourrecommendations. TheCommissioninspectsallhospitaltruststoassesslocal compliancewiththehygienecodeandtodatehasservedfive improvementnoticesonNHStrustsforbreachingthehygiene code.TheCommissionactivelymonitorssuchcasesandthese trustshavenowimprovedtheirsystemsofinfectionprevention andcontrol.
50
Strategicgoal
Evidenceofachievement NHStrustsaregettingbetterathandlingcomplaintsalthough standardsremainvariable.Wereviewed8,949intheyearto31 July2008,makingrecommendationstotheprovidersonsteps theyshouldtaketoimproveservices.TheCommissionhas publishedthreeannualreportshighlightinggenerallessonsfor theNHS.Wehavealsoproducedatoolkitfortrustswhichhas beenpositivelyreceivedbyNHScomplaintsmanagers. TheCommissioninitiallystruggledwiththehighvolumeof complaintsitreceivedforreviewbuthassubsequently redesigneditsprocesses(forexample,toensurethatclinical advice issoughtearly on).Theaveragetimeittakestoclosea complainthasfallenfrom23weeksinSeptember2007tojust nineweeksbySeptember2008.
3.Provide authoritative, independent, relevantand accessible information
Onaveragewehavepublishedtworeportsamonth,aswellas makingthedetailedresultsoftheannualhealthcheckforeach NHStrust,andinspectionreportsforindependenthealthcare organisationsavailableonourwebsite. OurservicereviewsfrequentlyprovideNHSorganisationswith benchmarkedscoresonelementsofperformance.Thereisa goodbodyofresearchevidenceshowingthatpublicationofsuch dataleadstoimprovements.Cliniciansandhealthcarestaffalso tellusthatthey findituseful. In2007,wecommissionedasurveyof40keystakeholdersfrom variousfields:journalism,MPs,healthcare providers,clinicians, patientrepresentativegroupsandtheDepartmentofHealth.The Commissionsinformationisviewedbyallthesegroupsasour majorstrengthandisseenasindependentandcredible. TheCommissions website isavitaltoolinourmissiontomake informationabouthealthcareaccessibletoasmanypeopleas possibleandisvisitedby140,000visitorseachmonth.In2008we focusedbothonextendingtherangeofinformationweprovide online,andonmakingsurethatitiseasytofindandunderstand.
51
AppendixB
Strategicgoal
Evidenceofachievement In2007,weintroducedanewfacilitywherebyuserscouldtypein theirpostcodesandbetakentoGooglemapsdisplayingour ratingsofalltheirlocalNHSorganisations,withmoredetailed informationjustoneclickaway.AttheendofMarch2008,we extendedthesitetoincludesearchableinformationaboutmore than2,000independenthealthcareorganisations. TheCommissionhaspilotedanearlywarningprogramme identifyingpotentialriskstothesafetyofpatientsbymonitoring deathratesinhospitals.Wearenowexpandingthesystemto includeotherindicatorsofoutcomesforpatients,forexample, monitoringhow manypatientsare readmittedtohospitalforthe sameproblemandhow manystayinhospitalforshorteror longerperiodsthanexpected. TheCommissionandtheSocietyforCardiothoracicSurgeryin GreatBritainandIrelandhave produceddetailedinformationon cardiacsurgeryoutcomesforpatientsonadedicatedwebsite includingattheleveloftheindividualsurgeon.Feedbackfrom patientshasbeenverypositive.
4.Promote actiontoreduce inequalitiesin peopleshealth andgreater respectfor humanrights anddiversity
TheHealthcare Commissionhasaroleinseekingtoimprove healthandreduceinequalities.Aspartoftheannualhealth checkweassesshealthcareorganisationsonthepublichealth nationalstandardsandtargets,andcarryoutnationalstudies andreviewsinthisarea.TheCommissionhasundertaken surveysofpublichealthprofessionalsandproviderchief executives.TheseshowthattheCommissionsassessment methodsareperceivedbythesegroupstohavebeeninfluentialin raisinghealthinequalitiesuptheagendaofindividualNHStrusts. Itisclearfromourprogrammeofreviewsandengagementwith patients,carersandtheirrepresentatives,thatsomepatients haveneedsthattendtobemissedorpoorlymetbyhealthcare services,forexample,childrenandadolescentswithmental healthproblems.Identifyingsuchissuesisacrucialstepin ensuringthatinequitiesinprovisionaresystematically addressedinfuture.
52
Strategicgoal
Evidenceofachievement TheCommissionhasconsistentlyencouragedequality,diversity andtheprotectionofhumanrights.Forexample,ournational surveysofNHSpatientsandstaffinEngland,ourcensusof mentalhealthinpatientswiththeMentalHealthActCommission andournationalstudyofdignityhaveallhighlightedthataction isrequiredintheseareas. TogetherwithotherregulatorybodiesandtheDepartmentof Health,theCommissionhassuccessfullypursuedmore comprehensivemonitoringoftheethnicityofpatientsintheNHS. TheCommissionwillpublishanationalreviewofraceequalityin healthcareinMarch2009.ThefindingsshowthatinSeptember 2008,94%oftrustsreportedthattheyhadpublishedarace equalityschemeand96%hadproducedatleastoneofthe workforcestatisticsrequiredbylegislation.Thisrepresents markedimprovementsince theCommissionbeganlookingat howwelltrustsweremeetingtheirpublicationrequirements. Howeverthereisstillsomewaytogobeforetrustsmeetallof theminimumrequirements.
5.Take a leadin coordinatingand improvingthe impactand valueformoney ofassessment andregulation inhealthcare
TheConcordathasbeenable to reducethenumberofdata collectionswhicharenowcoordinatedbytheNHSInformation Centre.TheInformationCentrealsomanagestheROCRLite gatewayprocessforproposedregulatorydatacollections. SurveyevidenceandfeedbackfromNHSandindependent healthcare providers,however,suggeststhattheConcordatis viewedasagoodideainprinciple butwhichhasyieldedlittle in thewayofobviousimpact.In2008,theProviderAdvisoryGroup (PAG)wasestablishedto adviseonareaswheretheConcordat mightmakeadifferencefromtheproviderperspective.Arecent workshopeventtoassesstheexperienceoftheConcordatfound thatthePAGwasregardedbyConcordatmembersasahighly effectivesourceofconstructivechallenge. BetweenNovember2008andFebruary2009,theCommission hasoverseentherolloutofaseriesofcollaborativerisksummit
53
AppendixB
Strategicgoal
Evidenceofachievement meetingsoneineachstrategichealthauthorityarea.Forthe firsttime,thesemeetingsinvolvedtheprincipalhealthcare regulatorsandinspectorates,alongwithstrategyhealth authorityrepresentatives,whodiscussedconcernsaboutlocal healthcareorganisationsandagreecollective action.Morethan 250peopleattendedthem. Earlyevaluationsuggeststhatthesemeetingshavethepotential toreduceduplication,improvethereputationofregulatorswith trustsandenrichtheintelligencethatwecanusetoinform futureactivitiessuchasregistrationofNHStrusts.
6.Createan organisation delivering worldclass assessmentand regulation
TheCommissionhasaninternationalreputationforbeingatthe forefrontofmodernregulation.Delegationsfromover30 countrieshaveundertakenfactfindingvisitstolearnmoreabout ourinformationledandriskbasedapproach. TheCommissionhasbeeninnovativeandkeentolearnfrom others,by,forexample,participatingintheComprehensiveArea Assessmentpilotsitesandtrials,commissioningandpublishing evaluationofitsownwork,participatinginacademicresearchon theaccountabilityofauditandreview asacasestudy,hosting theannualconferenceoftheInternationalSocietyforQualityin Healthcare(ISQUA)in2007andpilotinginitiativeswith partnerregulators.
54
AppendixC
Comparativecostsofregulationbysectorfor2007/08
Thefollowingtablesummarisesthecostsofregulation(thecostsoftheregulator) comparedtobudgetormarketsizeasameasureforthesizeofthesectorthatisregulated. Sector Expenditure onservicesin 2007/08 98.7billionof which: NHS91 billion, Independent healthcare 7.7billion Regulator(s) annualbudget 2007/08 160.8million ofwhich: Healthcare Commission 76million, Monitor 13.5million, NPSA 30.6million, NICE 35.1million, MHAC 5.6million Costof regulator(s)% sectorspend 0.16 (0.08 Healthcare Commission) Sources
Healthcare
DHAnnualReport 2007,Healthcare Commission AnnualReport& Accounts2007/08 Gross Operating Costs,MHAC AnnualReport andOperating Accounts2006/07, MonitorBusiness Plan 2007/08,NPSA Business Plan 2007/08,NICE AnnualReport 2006/07 TheStateof SocialCare 2006/07part1 publishedJan 2008.CSCIspend fromCSCIannual report2007/08.
Socialcare
Socialcare 21.5billion
CSCI125.4 million
0.58
55
AppendixC
Sector
Expenditure onservicesin 2007/08 71.5billionof which: DfESspending 60.1billionI,

Private
childcare
spending
11.4billionII
51.8billionIV
Regulator(s) annualbudget 2007/08 Ofsted 216millionIII
Costof regulator(s)% sectorspend 0.30
Sources
Children and learners
DfES Departmental Report2008, DfESChildrens Services TheChildcare Market, Ofsted PublicExpenditure Statisticalanalysis 2007Table7.7 Departmental reportsofsix regulatorsVII.
Local services
Audit Commission 220millionV 57million bysix inspectoratesVI
0.42
Justice and community safety
HomeOffice expenditure 14.8billion
0.39
TotaleducationspendinginEnglandin2007/08,DfESdepartmentalannualreport2008,page111.
II Wehavecalculatedtheoverallspendingonchildcarebymultiplyingtheaverageweeklyfees of140(privatesector)and120(publicandthirdsector)withthenumberofweeksandthe totalnumberofOfstedregisteredplaces(1.5millionofwhichroughly20%wereinthe publicorthirdsector). III 2007/08estimatedoutturn,OfstedDepartmentalReport2007/08FinancialTablesAnnexC page57. IV Overall currentexpenditureoflocalauthoritieswas105billionin2007/08,less38billionon educationregulatedbyOfstedand15.2billiononadultsocialcarefundedbycouncils regulatedbyCSCI(14.2billioncouncilfundedsocialcarein2006/07withcostupliftof7%). V AuditCommissionAnnualReportandAccountsApril2007toMarch2008. VI CostofCJSregulatorsin2006/07wasHMIConstabulary12.3million,HMIPrisons3.4 million,HMIProbation3.6million,HMICourtAdministration(includesCAFCASSin England)2.4million,HMCrownProsecutionServiceInspectorate3.3million(in2004/05), IndependentPolice ComplaintsAuthority32millionin2007/08.Assumecost upliftbetween 2006/07and2007/08of5percent. VII DepartmentalReport2007,HMChiefInspectorofConstabularyAnnualReport200507,HM ChiefInspectorofPrisonsAnnualReport2006/07,HMInspectorateofProbationAnnual Report2006/2007,annualreportofHMChiefInspectorofCourtAdministration20062007, HMCrownProsecutionService InspectorateAnnualReport2004/05,IndependentPolice ComplaintsAuthority2007/08.
56
Sector
Expenditure onservicesin 2007/08 110billionI
Regulator(s) annualbudget 2007/08 Ofgem 35.1millionII
Costof regulator(s)% sectorspend 0.032
Sources
Energy
BERRDigestof UKEnergy statistics2007 OfcomThe Communications Market Ofwatforward programme 200708to 200910 UnitedKingdom NationalAccounts TheBlueBook 2007
Telecoms
51billion
Ofcom 126.7 millionIII Ofwat 13.2millionV
0.25
Water
9billionIV
0.14
Food
33.1billion
Food Standards Agency 144millionVI
0.43
I II
Theoverallmarketgrewby14%from2005to2006duetothestrongincreaseinprices. We haveassumedafurther10%risefrom2006to2007. OfgemCorporateStrategyandPlan20082013.
III 2007OfcomAnnualPlan2007/08. IV Baseona4%increasecomparedto2006/07whichwastheaverageofpreviousyears.11 billionindustrysizequotedinOfwatAnnualReport2007/08page1. V Ofwatannualreport2007/08pageAppendix3tableofcosts.
VI FoodStandardsAgencyAnnualReport2006/07.
57
AppendixD
Implementingourregulatorymodel:keyactivities
Involvingpatients,thepublicandstaffinourwork Theviewsofpatientsarecentraltoourassessmentof NHSperformance. OurprogrammeofsurveysofpatientsandNHSstaffisthesingle biggestsourceofdataweusefortheannualhealthcheck. Over8,000commentsfrompatientsandmembersofthepublic havebeencodedintoourscreeningsystem. Weinvitecommentonhowwelleverytrustismeetingthenational corestandardsfromcounciloverviewandscrutinycommittees,lay membersoftheboardsofgovernorsofNHSfoundationtrusts,the formerpatientandpublicinvolvementforumsandin2008/09for thefirsttime,thenewlocalinvolvementnetworks(LINks). WesupportedLINksbyrunningawarenesseventsacrossthe countryin2008/09anddevelopingawebsitesothattheycan submitpatientexperiencesthroughouttheyear. We involvepatients,carers,usersofservicesandcliniciansand theirrepresentativesinthedesignofournationalreviewsof healthcareservices,tomakesurewemeasurewhatmattersand produceinformationthatcanbeusedtoimproveservices Ourreviewvisitstolearningdisabilityserviceshaveincludedaperson withlearningdisabilitiesoracarerasamemberofeveryreview team.Evaluationofthenationalauditofspecialistlearningdisability healthservicesconductedin2007foundthatthiswasconsideredby staffintheseservicesascentraltotheintegrityofthereview. WehavecontinuedtosupportandconsultourSpeakOutnetworkof communityandvoluntarygroupsincludinggroupsrepresenting homelesspeople,travellersandminorityethnicgroups.Wehave providedthenetworkwithtrainingtohelpthemcapturepatient experiencesthatcanbefedintoourassessments. We continueto assesshealthcareorganisationsagainsttheir statutorydutytoinvolvepatientsandthepublic.In2008/09,following a reviewofwhatformsofpublicengagementworkwellandwhy,we have developedanew frameworkthatwe willberecommendingfor thefutureassessmentofpublicinvolvementinhealthcare.
58
TheCommissionhassteadilyexpandeditsworkwithawiderange of cliniciansandtheirrepresentativebodies.Wehaverecently focusedonunderstandinghowcliniciansdefinequality,througha seriesofworkshops.TheCommissionisalsoparticipatinginwork todevelopasystematicapproachtotheaccreditationofservices withtheprofessionalcollegesandbodies. TheCommissionsendsoutaregularebulletinaboutitswork to18,000subscribers.Italsoproducesaspecialistquarterly ebulletinwithitemsofparticularinteresttoclinicalstaff. Makingintelligentuseofinformationandcommunicatingthe resultsofassessmentandregulation TheHealthcareCommissionhaspioneeredtheuseofinformation fortargetingregulatoryresourcestoareasofgreatestriskto patientsandlocalcommunities. TheCommissionsscreeningandsurveillancesystemusesover 2,000itemsofnationaldataonNHSperformance. Wearedevelopingthecapacitytomonitorkeyindicatorssuchas mortalityratesinrealtime.Thismeansthatpotentialproblemscan bedetectedearly andfollowedupspeedilybytheCommissionand localtrusts.Wearelookingatextendingthisworktoencompassa rangeofindicatorsofpotentiallypooroutcomesforexample, readmissionrates. Therearesomeareasofhealthcarewhereinformationisnot readilyavailableorisofpoororvariablequality.TheCommission hasrespondedbyvisitingandinspectingsuchservicesfirsthand, forexample,conductingwardbasedobservationsforthereviewof dignityincare. Whereappropriatewehaveusedinformationtoreflectthequalityof care acrossorganisationalboundaries.Forexample,inourreview ofheartfailure,NHStrustsandprimarycaretrustswerescored collectively forthequalityoflocalservicesinover300localareas. TheHealthcareCommissionisaproducerofinformation,publishing onaveragetworeportseachmonthabouthealthcareperformance. Ourwebsiteisusedheavily,receivingaround140,000visitorseach month.Wehaveworkedwithpatientgroupsandclinicianstoimprove ourinformation.Ourwebsitewasredesignedin2007and2008after consultationwithpatientsandmembersofthepublic.
59
AppendixD
Overtime,theCommissionhasgainedsubstantialandincreased newscoverageofitsreports,reviewsandinvestigations.Amedia auditundertakeninJanuary2007showedthatcoverageinthe nationalmediahadrisenbyover30%inoneyear. TheCommissionhasworkedwiththeSocietyforCardiothoracic SurgeryinGreatBritainandIrelandandpatientstoproduce detailedinformationoncardiacsurgeryoutcomesforpatients includingattheleveloftheindividualsurgeon.Thishasbeenvery wellreceivedandisthetypeofdetailedservicelevelinformation thatpatientstellustheyfindvaluable. TheCommissionhasbeenincreasinglykeentocelebratesuccess aswellashighlightingwhereproblemsexist.Wepublishedcase studiesofgoodpracticefromtheannualhealthcheckin2007/08 andpubliclyreportonprogressfollowinginvestigationstohighlight improvementsmade. Assessingagainststandardsandnationalpriorities TheCommissionassessestheoverallperformanceofeveryNHS trusteachyearaspartofitsannualhealthcheck,publishing separate ratingsfortrustsqualityofservicesanduseofresources. OverallperformanceintheNHShasimprovedeachyearsincethe annualhealthcheckwasestablishedin2005. Anindependentevaluationofthefirstyearofthecorestandards assessmentfoundthatimprovedboardlevelaccountabilitywasthe mostwidelyreportedearlybenefitofthenewassessmentsystem (inasurveyof128trusts). TheCommissionhasastatutorydutytoprovideanannual performanceratingforallNHStrustsinEngland.Theseare intendedtoprovidepublicassuranceandarewidelyreportedin nationalandlocalmedia.Therehasbeenconcern,however,that theratingscanbemisleadingatrustthathasbeenratedas weakforexample,islikelytobeprovidingmanyinstancesof excellentcare attheindividualpatientandservice level.Greatcare isneededinthewayassessmentresultsarepresented. Somestandardsareeasiertoassessandevidencethanothers. Moreworkneedstobedone,forexample,onmethodsofassessing how wellprimarycare trustsarecommissioninghealthcare servicesonbehalfoftheirpopulations,andhowwelltrustsare workinginpartnershiptomeettheneedsoflocalpeople.The Commissionhaswelcomedthedevelopmentofthenew comprehensiveareaassessmentandhasparticipatedfullyinearly trialsofthismethodologywithotheragencies.
60
Over1,000independenthealthcareestablishmentshavebeen registeredsincetheCareStandardsAct2000 4 cameintoforce.The Commissioninspectsallestablishmentscurrentlyregisteredovera fiveyearperiod. TheCommissionisactivelyfollowingupNHStruststhatwere scoredasweakinthe2007/08annualhealthcheckwithjoint visitswithstrategichealthauthoritystaff.Wewillpublishareport in2009summarisingthelearningfromthesevisits. In2008/09theCommissionisinspectingeveryacutetrustagainstthe hygienecode.Thesevisitsareunannounced.Todatewehaveissued improvementnoticestotrustsoverbreachesofthecodeandmore widelyhavemademanyrecommendationsforimprovementasa resultoftheinspectionprogramme.Wehavecommissionedan independentevaluationoftheimpactofthisinspectionprogramme. TheCommissionhassupported thedevelopmentoftheCareQuality CommissionsmethodologyforregisteringNHSorganisationsthat arecompliantwiththehygienecodeby1April2009. Indepthreviewsandstudies TheCommissionhascarriedoutmorethan30indepthreviewsand studiesofhealthcareservices.Topicsincludeservicesforchildrenin hospital,thequalityofcommissioningoflearningdisabilityservices, dignityincare,admissionsmanagement,anauditofservicesfor peoplewithlearningdisabilities,maternityservices,olderpeoples mentalhealth,medicinesmanagementafterdischarge,raceequality inhealthcare,urgentcare,adultinpatientmentalhealth,diabetes, heartdisease,tobacco controlandsexualhealth(seeAppendixH). Inthecourseofconductingthesereviews,wehaveconductedover 100targetedfollowupvisitstotruststoencourageimprovement. TheCommissionhasprioritisedareasforindepthreviewwhere: patientsmaybemorevulnerable,forexample,children,people usingmentalhealthservicesandpeoplewithlearningdifficulties wheregoodinformationonperformanceislacking ourinvestigationsinindividualtrustsrevealissuesthatmaybe moresystemic.Ourreviewsofmaternityservicesandlearning difficultiesweretriggeredbysuchconcerns. Findingsfromthereviewsarefedbackintoourscreeningand surveillancesystemtoensurethatwehaveaholisticpictureof performance ineachtrust. Theevaluationoftheannualhealthcheckin2006/07identified substantialsupportforthetopicsselectedforreviews,with79%of
61
AppendixD
respondentsstronglyagreeingwiththeselection.Evaluationofthe impactofthreeofourearlyreviews(withasampleof100NHS servicemanagersandclinicians)foundthat70%thoughtthatthe reviewshadpositiveimpactsforpatients. Focusedevaluationoftheauditoflearningdisabilitiesin2007 foundthatthereviewwashavingamajorimpactonpractice.In thiscase,theauditresultedinawiderangeofrecommendationsto improveaspectsofcareandtheCommissionhascontinuedtowork withservices,strategichealthauthoritiesandMonitortoensure recommendationsareimplemented. Interventionandinvestigations TheCommissionhasstatutorydutiestoinvestigateserious concernsintheNHSandenforce registrationrequirementsand standardsintheindependenthealthcare sector. TheCommissionhasreceived320referralsaboutconcernsinthe NHS,completed17fullinvestigationsandpublishedarangeof interventionsandprogressreports. Anindependentevaluationoftheinspectionprogrammehasfound thatourinvestigationsarerespectedasrobustandhaveamajor impactontheindividualtrustsconcerned. Inextremecases,wheretheCommissionhaslittleconfidencethat eitheranNHStrust oritspartners havethecapacitytorectify problems,ithasrecommendedthattheSecretaryofStatefor Healthputinplacespecialmeasures.Whilethisisrare, evaluationsuggeststhatitishighlyeffectiveinpromotingchange inthesecases. TheCommissionhasincreasedthenumberofenforcement actionspursuedagainstindependenthealthcareorganisationsin thelastyear. Evaluationandmediaanalysisshowsthatourinvestigationswork hasastrongimpactnotonlyonthetrustunderthespotlightbut alsonationally.Themorecrosscuttingtheissueunder investigation(forexample,infectioncontrol)thegreatertheimpact hastendedto beacrosstheNHS.Servicespecificinvestigations, forexample,intomaternityservices,havesimilarlyhada demonstrable impactacross thespecialty. TheCommissionhasrespondedtoconcernsaboutthelengthof timetakentoconductfullinvestigationsbysuccessfullyconducting morerapidinterventionswithtrustswherethisiswarranted.
62
PatientsunresolvedcomplaintsabouttheNHS EachyeartheNHSdelivers380milliontreatmentsandreceives around135,000complaints.TheCommissionreviewscaseswhere thepatientisunhappywiththeresponsefromthetrust.The Commissionreviewed8,949complaintsintheyearto31July2008. TheCommissionupheld30%ofthecasesreviewedduringthis period,upfromalmost20%lastyear.Inafurther17%ofcases (downfrom26%in2006/07),theCommissionfoundthatthetrusts responsetothecomplainantwasnotsufficientanditwassent backtothetrustforfurtherwork.Thismeansalmosthalfof complaintsreviewedrequiredfurtherworkbythetrust. TwentysevenpercentwereoutoftheCommissionsjurisdiction, mostlybecausethecomplainanthadnotraisedtheirconcerns locallyfirst.Thissuggeststhatsometrustsarenotmakingthe complaintsprocedure clearenoughforpatientsandthepublic orthatpeopledonothavefaithintheindependenceofthe localprocedure. Eighteenpercentofcaseswerefoundinfavourofthetrust becausetheNHShadhandledthemappropriately. Wehaveannuallypublishedareporthighlightingthelessonsfor trustsemergingfromourreviews. Wehavebroughtdownthetimetakentoclosecomplaintstoan averageofjustnineweeks.Thisisamajorimprovementonour earlierperformance. Workingwithothers TheCommissionhasaroleincoordinatingregulationand inspectionacrosshealthcaretoreduceunnecessaryadministrative costsandduplication.IthassetuptheConcordat avoluntary agreementbetweenorganisationsthatregulate,audit,inspector reviewelementsofhealthandhealthcareinEngland.The ConcordatwaslaunchedinJune2004by10organisations,ledby theHealthcareCommission.Therearenow20signatoriesworking togethertocoordinatetheiractivitiessuchasaudits,reviewsand inspections.Bystreamliningtheiractivities,thesesignatoriesare supportingtheimprovementofhealthservicesforthepublic. TheConcordathasbeenresponsibleforvariousinitiativessuchas, a dedicatedwebsiteandwebbasedschedulingtoolforregulators andinspectorates. Concordatmembershavemappedtheinformationtheyholdto identifyareasofduplication.
63
AppendixD
Wehavedesignedaregulatoryimpactassessmentthatisused acrosstheconcordatgrouptoassessthecostsandbenefitof regulatoryactionsinadvanceofimplementationinlinewithgood regulatorypractice. TheNHSInformationCentrenowapprovesandmonitorsnewdata collectionsfromregulatorsandoperatesaformalgatewayprocess. Twodatacollectionshavebeenentirelydiscontinuedasaresult. TheHealthcareCommissionitselfhasconductedjointreviewsof serviceswiththeAuditCommission,NationalAuditOffice,CSCI, theMentalHealthActCommission,Ofstedandothers. TheCommissionhasreducedthenumberofcriteriaitusesto assesscorestandardsintheNHSandsince2006/07usesthe judgementsofotherbodiesassufficientevidenceofcompliancefor relevantcore standards.Wehaveintroducedtargetedinspectionof theindependenthealthcaresectorsinspectingallorganisations overafiveyearcycleratherthanannually. FromNovember2008,theCommissionledtherolloutofanew wayofworkingtogetheratlocallevelthecollaborativerisk summitmeetings.Localregulatorystaffmeettoshareintelligence andinformationaboutrisksinlocalhealthcareorganisationswith strategichealthauthoritycolleagues.Theaimofthemeetingsisto agreecollectivelyonappropriateaction.Earlyevaluationsuggests thisapproachhasrealpotentialtoreduceunnecessaryduplication.
64
AppendixE
AssessmentoftheperformanceoftheNHSinmeeting corestandards
Corestandards
Selfassessment Patientand publicviews Declaration
Crosschecking
Targeted inspection
Nofurtheraction
Random inspection
Rating
65
AppendixF
Realtimesurveillancefollowingupoutliers
Anoutlierarisesfromtheanalysisofinformationthatisroutinely available.Itidentifieswhere,withinanorganisation,thenumbersof patientswhohavesufferedanadverseoutcome(notably,butnot always,death)issignificantlyhigherthanwewouldexpect.Thereare manyreasonswhythismightbe,andwecannotanddonotassume thatthereisaprobleminthequalityofcare.However,theseoutliers cannotbeignoredandwehavedevelopedaprocessforrigorously followingthemup. Thebasictechniqueusedto identifyoutliersiscalledCUSUM(cumulative sum)whichdetectssignificantdeviationsfromexpectedoutcomes, derivedeitherfromstandardisedmortalityratesortheunderlyingrisk associatedwitheachpatient.Iftheplottingofdatacrossesafixed controllimit,thenasignificantrunofpooroutcomesisdetectedandan alertissignalled.Figure1givesanexampleofaCUSUMchart. Figure1:CUSUMofinhospitalmortalityforpatientsadmitted asemergencieswithnontransientstrokeorcerebrovascular accident,age> 69orwithcomplicationsorcomorbiditiesat MidStaffordshireHospitalsNHSTrust
10 9 8 7 6 5 4 3 2 1 0 2005/06 Quarter 1 2005/06 Quarter 2 2005/06 Quarter 3 2005/06 Quarter 4 2006/07 Quarter 1 2006/07 Quarter 2 2006/07 Quarter 3 2006/07 Quarter 4 2007/08 Quarter 1 2007/08 Quarter 2 2007/08 Quarter 3 2007/08 Quarter 4 Controllimit
66
Whileitisimportanttofollowupoutliersbroughttoourattentionby otherbodies(forexample,RoyalColleges,andtheDrFosterUnitat ImperialCollegeLondon).Wealsothinkitessentialfortheregulator activelytoidentifyoutliers,onthebasisthatanymayrepresentarisk tothesafetyofpatients.We,therefore,createdaprogrammeofwork touseourexperienceandthewealthofdataavailabletousactivelyto searchforandfollowupstatisticaloutlierswiththeaimofidentifying potentialfailuresincareattheearliestpossiblestage.Thisrequiresa particularlythoughtfulandsensitiveapproach,asdataaloneis unlikelytoprovideacompleteinsightintothecomplexities ofhealthcare. Theprocess offollowingupoutliers,thereforeiscrucial. Ourprocessincludes: Preliminaryanalysisto identifyinaccuracyorartefactinthedata. Advice frominternalandexternalclinicalandotherexperts. A multidisciplinarypanelfordecisions. Communicationwiththeorganisationsinvolvedtoestablishthe accuracyofthedatausedinouranalysisandtounderstand whetherthere maybeknownproblemswiththequalityofdata in theorganisation. Interventionwhere noclearandwellevidencedexplanationforan outlierisavailable.
67
AppendixG
ConclusionsfromSpotlightonComplaints 2009(the HealthcareCommissionsthirdannualreportonreviewing secondstagecomplaintsabouttheNHS)
SinceweassumedresponsibilityforthesecondstageoftheNHS processforhandlingcomplaintsinJuly2004,wehavereviewed 30,268complaintsabouttheNHSmadebypatientsandtheir relatives,andmade16,500recommendationstoresolvecomplaints andimproveservices. Overthisperiod,wehaveseensomeimprovementsinthewaythatthe NHSrespondstocomplaintsbut,astheoutcomesofourreviewsfrom thisyearshow,there issomewayto gobefore theNHScanconfidently saythattherearerobustarrangementsforhandlingcomplaintsacross England.Thiswillbeabigchallengefortrustsunderthenew arrangements,whichare duetocomeintoforceinAprilthisyear. Thetypesofcomplaintsthatwe have seenhave notchanged substantiallyoverthelastfourandahalfyears.Theyhavemostly relatedtothefundamentalsofgoodhealthcare:communication,the attitudeofstaff,recordkeeping,andprivacyanddignity. Manycomplaintshavealsobeenaboutapoorstandardofhandling complaintsbytheorganisationconcernedthiswastheissuethat complainantswere mostconcernedaboutthisyear.Forexample: Letterswhichdonotseektounderstandthecircumstancesofthe complaint,orarefullofclinicalorothertechnicalterminology. Concernsraisedbythecomplainantnotaddressedintheresponse. A failure tointerviewortakestatementsfrommembersofstaff involvedinthecomplaint. A lackofflexibilityinthetrustsapproach,forinstance,notoffering thecomplainanttheopportunitytomeetrepresentativesofthe trusttodiscusstheirconcerns. Wehavealsoseencasesthisyearwheretrustshaveapologisedfor thingsthathavegonewrong,buthaveexpressedthisinequivocal terms.Forexample,chiefexecutiveswhosaytocomplainants:Iam sorryifyoufeelthatway.Westronglyrecommendthattrustsprovide a fullandunequivocalapologywhenshortcomingsincareand treatmenthavebeenidentified.
68 TheHealthcareCommission20042009:Regulatinghealthcareexperienceandlessons
Asweemphasisedinlastyearsreport,itiscrucialthatNHS organisationsgettheaspectsofacomplaintwhichinvolveproviding appropriateservicetothecomplainantrightatthefirsttimeof asking.Complaintsandfeedbackfrompatientsarelikelytoplayan increasinglyimportantroleasamechanismtoimprovepatientscare intheNHS.TheframeworksetoutinthefinalreportoftheNHSNext StageReview,HighQualityCareforAll 9, seesfargreaterchoicefor patientsandmorepersonalisedservices.Advancesintechnology meanthattherearenowmorewaysforthepublictoprovidefeedback toNHSorganisations.Inthiscontext,itwillbeevenmoreimportant forNHSorganisationstolistentoandlearnfromcomplaintsto ensurethatthequalityofservicesmeetstheincreasingexpectations ofpatientsandthepublic. Wehavealwaysbelieved,andthisisreflectedinourpreviousreports onNHScomplaints,thatcomplaintsarebestresolvedbythelocal providerwithouttheneedforinvolvementofanoutsideagency. Improvingthewaythatcomplaintsarerespondedtolocallyhasalways beenthefocusofourwork.WecallonNHSorganisationstouseall theguidanceongoodpracticeavailabletoimprovetheirhandlingof complaints,includingourSpotlightreports,ourComplaintsToolkit andtheOmbudsmans Principlesof GoodAdministration 10, Principlesfor Remedy 11 andPrinciplesof GoodComplaintsHandling.12 Weknowthatpatientsandtheirrepresentativesmakecomplaintsto healthcareorganisationsforthreemajorreasons: Theywantanexplanationoftheeventsleadingtotheircomplaint. Theywantanapology. Theywantanassurancethatthesamemistakeswillnotbemade inthefuture.13 We urgeNHSorganisationsto ensure thattheygiveactiveconsideration tothesethreecrucialcomponentswhenrespondingtoacomplaint. Thekey findingofthisreportisthatthere isstillmuchthattheNHS candotoimprovethewaythatitdealswithcomplaints.Itisessential thatthere isachangeofthinkingthroughouthealthcare organisations thattheyviewcomplaintspositivelyasalearningexperience,rather thanadoptingadefensiveapproach.Thisisevenmoreimportantwith theincreasedemphasisonprovidersgettingtheirresponsesto
69
AppendixG
complaintsrightfirsttimeunderthenewarrangements.Wehave doneagreatdealofgoodworkoncomplaintsandweareproudofour achievementsastheindependentreviewer.WecallonNHS organisationstobuildonourlegacyoflearningtocontinuouslydrive improvementsincomplaintshandling.
Nextsteps
Wehaveprovidedasuccessfulindependentservice,whichhas identifiedkeythemesincomplaintsandhasdisseminatedtheseto theNHS.Asaresultofanumberofreports,includingprevious publicationsofSpotlightonComplaints,theNHSsystemforhandling complaintsisbeingreformed,togetherwiththesystemforhandling complaintsaboutsocialcare.From1April2009,asingle,simpler processwillbeintroducedforallhealthandsocialcareservicesin England.Underthisnewsystem,complaintsshouldbemadefirstto theproviderofNHSorsocialcareand,ifthecomplainantremains unhappywiththeoutcome,totheParliamentaryHealthService Ombudsman(orLocalGovernmentOmbudsmanwherethatis appropriate).TheHealthService andLocalGovernmentOmbudsmen willworktogetherinacoordinatedwayoncomplaintsthatcrossthe boundariesbetweenhealthandsocialcare.Ourfocushasalways beenonimprovinglocalresolutionofcomplaintssowewelcome thesereforms,whichputmuchgreateremphasisonresolving complaintslocally. WetrustthatNHSorganisationswilldrawonthelessonsthatwehave learnedfromcomplaintsastheymoveintothenewsystem.Asthis reportshows,thereareconsiderablechallengesfacingtheNHStobring thestandardsoflocalresponsesforcomplaintsuptoonewherepatients are muchlesslikelytoseekasecond,independentviewontheir concerns.Itisvitalthattrustsboardsshowclearleadershipon complaintsandchallengesomeoftheareasofpoorpracticethatwe have highlighted.Poorhandlingofcomplaintscancausedamagetothe reputationofNHSproviderssoitisessential,inamorecommercially competitive environmentofhealthcare,thatboardslistentoandlearn from,complaints.Thosecommissioningservicesalsoneedtomakeclear thattheywillfollowupanyfailingsinhandlingcomplaintswithvigour. Thisreportshowsthat,althoughmuchprogresshasbeenmadeon NHScomplaints,thereismuchworktobedonetoachievetheseaims andthattherearemanychallengesindoingsoforNHSorganisations andtheOmbudsman.However,wetrustthatthenewarrangements willmeettheseaims.AnNHSthatislocallyresponsivetopatient concernsandthatcontinuouslyimprovesasaresultofcomplaintsis somethingthatwouldbeuniversallywelcomed.
70
AppendixH
Indepthreviewsandstudies
Publishedreports Commissioningservicesandsupportforpeoplewithlearning disabilitiesandcomplexneeds, March2009 A reviewoftheclinicalgovernanceoftheDefenceMedicalServicesin theUKandoverseas, March2009 Actionsspeaklouder:Asecondreviewofhealthcareinthecommunity foryoungpeoplewhooffend, February2009 Spotlightoncomplaints2009:Areportonsecondstagecomplaints abouttheNHSinEngland, February2009 Commissioninghealthcareinprisons, February2009 Not justamatterof time:Areviewofurgentandemergencycare servicesinEngland, February2009 Improvingservicesforsubstancemisuse2007/08, January2009 Thesafermanagement of controlleddrugs:Annualreport2007, September2008 Auditof servicesforpeople withlearningdifficulties:Servicesfor youngpeopleandadolescents, August2008 Towardsbetterbirths:AreviewofmaternityservicesinEngland, July 2008 Thepathwaytorecovery:AreviewofNHSacuteinpatientmental healthservices, July 2008 Safeguardingchildren:Thethirdjointchiefinspectorsreporton arrangementsto safeguard children, July 2008 Isthetreatmentworking?ProgresswiththeNHSsystemreform programme, June2008 Improvingservicesforsubstancemisuse2006/2007:Commissioning drugtreatmentandharmreductionservices, May2008 Ionisingradiation(medicalexposure)regulations2000:Areporton regulationactivityfrom1November200631December2007, March2008
71
AppendixH
A lifelikenoother:Anationalauditofspecialistinpatienthealthcare servicesforpeoplewithlearningdifficultiesinEngland, December2007 Auditofequalitiespublications2007, November2007 Isanyonelistening?AreportoncomplaintshandlingintheNHS, October2007 Caringfordignity:Anationalreportondignityincareforolderpeople whileinhospital, September2007 Novoice,nochoice:Ajointreviewofadultspecialistcommunity mentalhealthservicesinEngland, July2007 Managingdiabetes:Improvingservicesforpeoplewithdiabetes, July2007 Healthcareassociatedinfection:WhatelsecantheNHSdo?, July2007 Pushingtheboundaries:Improvingservicesforpatientswithheart failure, July2007 Independentsectortreatmentcentres:Areviewofthequalityofcare, July2007 Performingbetter?AfocusonsexualhealthservicesinEngland, July2007 Gettingresults:Pathologyservicesinacuteandspecialisttrusts, April2007 Takingacloserlook:Endoscopyservicesinacutetrusts, March2007 Animprovingpicture:Imagingservicesinacuteandspecialisttrusts, March2007 Bettersafe thansorry:Preventingunintendedinjurytochildren, February2007 Noifs,nobuts:Improvingservicesfortobaccocontrol, January2007 Thebestmedicine:Themanagementofmedicinesinacuteand specialisttrusts, January2007 Talkingaboutmedicines:Themanagementofmedicinesintrusts providingmentalhealthservices, January2007 Spotlightoncomplaints:Areportonsecondstagecomplaintsabout theNHSinEngland, January2007
72
Improvingservicesforsubstancemisuse:Ajointreport, December2006 Managementofadmissions, October2006 Letstalkaboutit:Areviewofhealthcareinthecommunityforyoung peoplewhooffend, October2006 Raceequalityaudit, August2006 Clearingtheair:Anationalstudyofchronicobstructivepulmonary disease, June2006 Livingwellinlaterlife:AreportofprogressagainsttheNational ServiceFrameworkforOlderPeople, March2006 Tacklingchildobesityfirststeps, February2006 A snapshotofhospitalcleanlinessinEngland, December2005 Accidentandemergency, August2005 Day surgery, July 2005 Ward staffing, June2005 TheHealthcare CommissionsreviewofNHSFoundationTrusts, July 2005 ReportsforpublicationMarch/April2009 Nationalstudyofpatientandpublicengagement Race equalityreview Followupreviewofchildrensservicesinhospital Followupreviewofcommunitymentalhealthservices Olderpeoplesmentalhealthservices Healthinequalitiesreport Reviewofmanagementofmedicinesafterdischargefromhospital
73
References
1. 2. 3. 4. 5. 6. 7. 8. HMSO,HealthandSocialCare(CommunityHealthand Standards)Act2003,2003. Hampton,P,Reducingadministrativeburdens:effectiveinspection andenforcement, HMTreasury,March2005. DepartmentofHealth,StandardsforBetterHealth, 2004. HMSO,CareStandardsAct2000, 2000. HealthcareCommission,StateofHealthcare2008, 2008. HealthcareCommission,Makingadifference?:Anevaluationof theperformanceoftheHealthcareCommission20042008, 2008. HealthcareCommission,Spotlightoncomplaints:Areporton secondstagecomplaintsabouttheNHSinEngland, 2009. HealthcareCommission,Followingupmortalityoutliers:Areview of theprogrammefortakingactionwheredatasuggesttheremay be seriousconcernsaboutthesafetyofpatients, 2009 ProfessortheLordDarziofDenhamKBE,Highqualitycarefor all:NHSNextStageReview finalreport, June2008.
9.
10. ParliamentaryandHealthService Ombudsman,Principlesof GoodAdministration, March2007. 11. ParliamentaryandHealthServiceOmbudsman,Principlesfor Remedy, October2007. 12. ParliamentaryandHealthServiceOmbudsman,Principlesfor GoodComplaintHandling, November2008. 13. BMRBSocialResearch,EvaluatingtheHealthcareCommissions ComplaintsHandlingFunction, April2007.
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Inspecting Informing Improving

TheHealthcare Commission 20042009

On1April2009,theCareQualityCommission,thenewindependent regulatorofhealth,mentalhealthandadultsocialcare,takesover theHealthcareCommissionsworkinEngland.

Rangeofregulatorymethodsandapproaches Focusofregulation and assessment Organisations Sector Method

Independent healthcare NHS

Specificareasof concernin individual organisations

Independent healthcare NHS

Whatcontributionhas theregulation of healthcaremadetobetteroutcomes andqualityof careforpeople?

Whatcontribution hasregulation ofhealthcare madetobetter outcomesand qualityofcare forpeople?

* Evaluationofthesecondyearoftheannualhealthcheck(performancein2006/07), interviewswith220NHStrusts. ** Evaluationofindependenthealthproviders,surveyof100providers2007.

Whatcontribution hasregulation ofhealthcare madetobetter outcomesand qualityofcare forpeople?

Whatlessonshavebeenlearned abouttheapproachtoregulating healthandhealthcare?

Usingarangeofregulatorytoolsandapproachesflexiblyin relationto risks

Whatlessons havebeen learnedabout theapproach toregulating healthand healthcare?

Whatlessons havebeen learnedabout theapproach toregulating healthand healthcare?

Whatlessons havebeen learnedabout theapproach toregulating healthand healthcare?

Whatlessons havebeen learnedabout theapproach toregulating healthand healthcare?

Whatlessons havebeen learnedabout theapproach toregulating healthand healthcare?

Whatlessons havebeen learnedabout theapproach toregulating healthand healthcare?

Whatlessons havebeen learnedabout theapproach toregulating healthand healthcare?

Whatlessons havebeen learnedabout theapproach toregulating healthand healthcare?

What arethelessons fromregulation forthehealthcaresystemas awhole?

Whatarethe lessonsfrom regulationfor thehealthcare systemasa whole?

2.Safeguard thepublic byactingswiftly oncomplaints, concernsand significant failings

3.Provide authoritative, independent, relevantand accessible information

4.Promote actiontoreduce inequalitiesin peopleshealth andgreater respectfor humanrights anddiversity

5.Take a leadin coordinatingand improvingthe impactand valueformoney ofassessment andregulation inhealthcare

6.Createan organisation delivering worldclass assessmentand regulation

Expenditure onservicesin 2007/08 71.5billionof which: DfESspending 60.1billionI,

Regulator(s) annualbudget 2007/08 Ofsted 216millionIII

Costof regulator(s)% sectorspend 0.30

Children and learners

Audit Commission 220millionV 57million bysix inspectoratesVI

Justice and community safety

HomeOffice expenditure 14.8billion

Expenditure onservicesin 2007/08 110billionI

Regulator(s) annualbudget 2007/08 Ofgem 35.1millionII

Costof regulator(s)% sectorspend 0.032

Ofcom 126.7 millionIII Ofwat 13.2millionV

Food Standards Agency 144millionVI

Theoverallmarketgrewby14%from2005to2006duetothestrongincreaseinprices. We haveassumedafurther10%risefrom2006to2007. OfgemCorporateStrategyandPlan20082013.

III 2007OfcomAnnualPlan2007/08. IV Baseona4%increasecomparedto2006/07whichwastheaverageofpreviousyears.11 billionindustrysizequotedinOfwatAnnualReport2007/08page1. V Ofwatannualreport2007/08pageAppendix3tableofcosts.

Selfassessment Patientand publicviews Declaration

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