Addenbrooke's Hospital, a world-renowned National Health Service (NHS) Trust and teaching hospital with university connections in Cambridge UK, was put into “special measures” this autumn after an inspection by the Care Quality Commission (CQC), the main inspectorate in the English health care system. The inspectors identified staff shortages and the use of temporary staff as the main issues impacting the quality of care. This announcement came months after Bart's Health Trust, one of the largest NHS trusts in London, was put into special measures for similar reasons. These special measures aim to ensure that providers falling short of adequate standards improve the quality of care and establish a framework for doing so within a given timeline. Additional inspections and support to assist in the recovery programme are given within this period of time.
Pressure on NHS trust hospitals comes from different directions. On the one hand, the challenges in meeting good quality of care standards reflect the increased demand for health services in England, while budgets in real terms have been reduced. On the other hand, the CQC has taken a more stringent approach to inspections after a number of scandals occurred in hospitals that had received good inspection reports. The most obvious example is the Mid Staffordshire NHS trust, one of the worst hospital care scandals of recent times.
Inspections have become more prominent in England's approach to health service regulation as a way to identify problems before they occur and are essential in improving quality of care across the NHS. England is also one of few countries to set common quality of care standards across all health care providers. Inspections can have real consequences, being able to make or break the reputation of health care providers.
While everyone agrees with the need for effective regulation for health care providers, few observers ask if regulation produces better quality of care over time. An international comparison by RAND Europe looking at six regulatory systems in health care, offers some perspectives. The report finds that the evidence of regulation contributing to better quality of care in different systems is scarce. Evidence on specific interventions such as publishing performance information, accreditation and allowing users to participate more in the design of services is weak. The evidence on inspections contributing to better quality of care is inconclusive with some studies noting a negative impact on quality of care. Anecdotal evidence on trusts placed in special measures suggests problems may continue, if not worsen, with greater staff turnover and deteriorating staff morale, trust finances, and of course, quality of care.
What works in regulating different health care systems? Our research suggests four factors. Firstly, regulatory systems need to strike a balance between the use of formal, interventionist instruments and more informal, softer approaches (such as education, feedback and publication of performance information) to ensure quality improvement more broadly. Secondly, the alignment between the incentives that providers receive and how their performance is assessed is critical. Thirdly, regulation needs to focus on the context in which health service providers operate and be flexible and adaptive to facilitate improvement and adherence to standards. Fourthly, regulation tends to be more effective when stakeholders are involved in the development and assessment of standards.
While many of these elements exist in the English health care system, we conclude that the current regulatory approach could be strengthened. The immediate budgetary pressures on health care providers will inevitably have an impact on performance. The question then is whether increased reliance on inspections to ensure adherence to a common set of standards will drive improvements in quality of care.
Evidence suggests that a more contextual and balanced regulatory approach may be needed to place more emphasis on other informal regulatory approaches and look at different and innovative pathways to improve quality of care. Regulators should also look at more coordinated/integrated operation between parts of the regulatory structure. For example Monitor, the agency responsible for monitoring and authorising NHS trusts could coordinate more closely with CQC, the inspecting body. Likewise, similar coordination could be found between regulators and those setting the overall performance framework for providers. With the evidence showing a weak relationship between regulatory structures and standards of care, finding what works in regulating health care in England is vital.
Christian van Stolk is research group director of RAND Europe's research area, Home Affairs and Social Policy.
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