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25. Value for money in health care systems

Matter for discussion submitted by the RCN London Board

That this meeting of RCN Congress discusses whether the current systems of health care regulation across the UK are proportionate and represent value for money

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Progress reports

Submitted by: London Board
Council lead and committee assigned: Jane Bovey (until October 2011), Tim Coupland (from October 2011), Nursing Practice and Policy Committee
Committee decision: Incorporated into ongoing work on system regulation
Members involved: 5,000 members participated in survey on CQC

Final summary update at May 2012

Although this was a matter for discussion and not a resolution, the RCN is undertaking a significant amount of work on regulation because of its importance to patient safety and quality of care.
In England the views of over 5,000 RCN members on the Care Quality Commission (CQC) were published in January 2012. This has been used by the Department of Health in their capability review of the CQC.

The RCN continues to contribute to the debate for system regulation as part of its work on the Health and Social Care Bill. At Congress, members will be asked for their views of the CQC at focus groups.
Regulation in Wales is through the Healthcare Inspectorate Wales and the Care and Social Services Inspectorate Wales. The RCN in Wales focuses on performance, regulation and value for money in all of its activity.

In Scotland, regulation is through Health Improvement Scotland (HIS) for the NHS and the Care Inspectorate. The RCN contributed to a review of the regulation of older people care and called for regulatory bodies to work together.

In Northern Ireland, the RCN engages with the Regulation and Quality Improvement Authority. In recent months, work has focused upon issues around health care assistants.

Update at November 2011

This Congress agenda item looks into the regulation of healthcare across the UK, and whether the different regulation systems in place are proportionate and offering value for money.

In England, system regulation has had an increased focused.  This has been driven by two main events, firstly the media coverage of Care Quality Commission (CQC) work as a result of appalling care failures in Winterbourne View (highlighted by the Panarama programme in June 2011), the 100 inspections of the care of the elderly in NHS hospitals (the Dignity and Nutrition Inspections with a summary report published in October 2011 )

Also generating interest has been the approach for system regulation under the reforms proposed under Equity and Excellence: Liberating the NHS, as well as the Health and Social Care Bill progresses through Parliament, covering the roles of the Care Quality Commission, Monitor, and the National Commissioning Board. 

This is alongside the ongoing second Francis Inquiry into care failings at Mid Staffordshire and the role of the wider agencies including the regulators.

Within the RCN there is a range of ongoing work exploring the approach of the regulators including:
• an online survey of members to explore their views of the Care Quality Commission
• continued work to respond to CQC and Monitor consultations as they refine their approaches
• regular meetings with the CQC to discuss their approach (quarterly but with regular email and phone contact)
• actively contributing to CQC’s work on how to best engage with clinicians
• meeting with Monitor to explore their early views on their approach under the reform proposals (subject to the passage of legislation in parliament).

The RCN has already called for, and continues to do so, an independent evaluation of the approach of CQC.  This should also include the value for money offered by the CQC

Within Scotland there are two scrutiny bodies – Health Improvement Scotland (HIS) for the NHS and Social Care and Social Work Improvement Scotland (SCSWIS) – previously Care Commission, which in September 2011 was changed by the Cabinet Secretary to become the ‘Care Inspectorate’. 

The Scottish Parliament’s Health and Sports Committee is currently undertaking a review of the regulation of care of older people in which the RCN submitted both written and oral evidence. The RCN’s main focus in the evidence was the need for the regulatory bodies to work together – both those that regulate services and those that regulate the people who provide the services e.g. Scottish Social Services Council and the Nursing and Midwifery Council.

Wider focus of activities of both HIS and Care Inspectorate continues to be regulation and inspection of the care of older people and Hospital Acquired Infection. In June the Cabinet Secretary asked HIS to carry out a programme of inspections to ensure that hospitals are living up to the NHS Quality Improvement Scotland care of older people in acute settings standards, first published in 2002. These inspections form part of a wider initiative where the Cabinet Secretary has asked the Chief Nursing Officer to assure the quality of care of older people in hospitals and to implement the dementia standards available on the Scottish Government’s website ( http://www.scotland.gov.uk/Publications/2011/05/31085414/0).

The RCN is a member of the strategy group and is closely monitoring the development of the assessment tools and inspection methodologies which are closely linked to those used previously for the health care environmental inspections.

In Northern Ireland, the RCN engages regularly with the Regulation and Quality Improvement Authority (RQIA). In recent months, discussions have focused upon the issues of inappropriate delegation of duties (especially in relation to the administration of medicines) to health care assistants in the domiciliary care sector, and RCN support for the training and development of health care assistants.

The Department of Health, Social Services and Public Safety (DHSSPS) has now formally abandoned its Confidence in Care programme that was considering options for the future regulation of health care assistants in Northern Ireland and in which the RCN was represented. The DHSSPS is now planning to establish a new working group that will consider this issue in light of the Coalition Government’s views on extending professional regulation. The RCN will be represented in this new programme but has stated its concerns about the abandonment of the previous work stream and will continue to reiterate its UK policy position on the regulation of health care assistants.

Debate report

Vice Chair of the London Board Ian Norris, opened this matter for discussion by listing the types of regulation and organisations who regulate health care. He stated that while there were overlaps between the regulators which could be reduced, he remained in favour of regulators ‘with teeth who take appropriate action quickly’.

Philip McCaffery joined the discussion to say that he believed that if only one bad situation is avoided then regulation is money well spent. A sentiment echoed by many of the speakers who believed the issue was not the cost of regulation but how effective it is.

Stacey Hunter cited over 300 Department of health targets as “madness to monitor at that level”.  However other speakers were keen to keep the level of regulation to ensure that standards were maintained and improved.

Regulation of health care includes both system regulation to cover the systems and processes of care, and professional regulation to cover the people delivering care.

System regulation in England has been subject to significant change as the Care Quality Commission (CQC), which replaced three former organisations, began work in 2010 to regulate providers of health and adult social care. The CQC has set out a new approach to regulation - focusing on outcomes not process, and a less inspection-based approach - for approximately 25 per cent less money than before.
 
Regulators such as Monitor and the Nursing and Midwifery Council are working with CQC to help identify problems and work out which organisation is best placed to respond. However, the role of the regulator (previously the Healthcare Commission and now the CQC) has been questioned as part of high profile investigations and media coverage of Mid Staffordshire NHS Foundation Trust where care was compromised.

Each UK country has different agencies involved in system regulation. In Northern Ireland the system is regulated by Regulation and Quality Improvement Authority, while in Wales the Healthcare Inspectorate Wales regulates and inspects NHS services and the Care and Social Services Inspectorate Wales regulates care and social services. In Scotland, Healthcare Improvement Scotland (HIS) and Social Care and Social Work Improvement Scotland (SCSWIS) are responsible for scrutinising health and social care services. All these agencies face many of the same pressures to regulate in challenging times.

Nurses across all four UK countries are regulated by the same professional regulator – the Nursing and Midwifery Council (NMC) - while the approach to other members of the nursing family, such as health care support workers, varies; for example with guidance in Scotland, and no formal professional regulation in England.

The RCN supports ‘intelligent regulation’ - a regulator with teeth taking appropriate action swiftly - and has provided briefings on the CQC and responded to several CQC consultations. The RCN has also called for CQC to be more open, to include staffing metrics in their approach, to undertake more inspections (both unannounced and announced), and be open to evaluation and learning over time.

References and further reading

Regulation and Quality Improvement Authority (2009) Corporate strategy 2009-12: informing and improving health and social care, Belfast: RQIA. Available at:
http://www.rqia.org.uk/cms_resources/RQIA%20Corporate%20Strategy%202009-12%20Published%20Version%20Apr%2010.pdf
 (accessed 8/2/11) (Web).

Royal College of Nursing Policy Unit (2008) The Care Quality Commission (CQC) in England, London: RCN (Policy Briefing 15/2008). Available at: www.rcn.org.uk
(accessed 3/2/11) (Web).

Scottish Government (no date) The Scottish Government: Health: Who’s Who, Edinburgh: Scottish Government. Available at: www.scotland.gov.uk/Topics/Health/Scrutiny/WhosWho (accessed 3/2/11) (Web).