1. European Partnership for Supervisory Organisations in Health Services and Social Care (EPSO), Sofia, 12th October How does regulation impact on the quality of care? Research to identify CQC’s contribution Alan Boyd Research Fellow in Healthcare and Public Sector Management University of Manchester, UK Web:

2. Researching healthcare regulation
Topic
Dates
Impact of clinical governance reviews on NHS trust performance
Regulatory approaches in seven sectors/industries
CQC’s new acute care regulatory model
Impact of inspection and ratings in health and social care
Supportive and streamlined approach to improving care
2017
CQC’s contribution to the quality of care

3. Impact of inspection and ratings in health and social care

4. How do we think about the impact of regulation?
Tend to focus on regulatory interventions (mostly inspections, rating or enforcement actions)
Ask about “before and after” changes – measure compliance with “directions”
But – research suggests this is a very narrow view of impact
Look at the whole regulatory regime, not just individual interventions like inspection
Look at the whole system – regulator, providers and many other stakeholders
Consider multiple pathways or mechanisms to impact
Think about both intended and unintended (or positive and negative) impacts

5. Pathways to impact – Bilateral

6. Pathways to impact - Multilateral

7. CQC’s contribution to the quality of care
Pathway
Investigation
Stakeholder
Annual stakeholder survey
Systemic
Theory of change for local system reviews
Relational
Theory of change for on-going provider relationships

8. Stakeholder impact pathway
Prospects and problems
Stakeholders can amplify/extend regulator intelligence, influence and impact
Can be problematic – capacity/capability, extent of shared interests/agenda, diffusion of responsibility, information sharing
Happens when care is poor? Challenge to organise it to support general improvement

9. Systemic impact pathway
Prospects and problems
Increasingly integrated health/care system needs regulation focused on systems or commissioners as well as individual providers
Provider-focused regulation has unintentional systemic impacts
Regulator lacks formal powers over new forms of organisation
Systemic issues such as access and resourcing raise sensitive policy issues
Structural barriers to necessary organisational cooperation E.g. funding streams, governance, culture etc.

10. Local system reviews – what works?
Power of the personal
Engaging communication – service user experiences
Respected reviewers – experience, empathy
Sustainable over the long-term?
Power of facts
Independent investigation
Objective data and thorough analysis inform evaluation
Is routine data available?
Power of ‘can do’
We / they have done it! Evidenced
Capacity? Improvement support
New insights? No one conducted system reviews recently
Power of us
Facilitative/learning/non-blaming
Open process; involve organisations
Burden?

11. Relational impact pathway Prospects and problems
Regulation is a social interaction
Informal, ‘below the line’ regulatory interaction is important
But risk that this may be at odds with the formal regulatory regime

12. On-going provider relationships – what works?
Across multiple contact points and at different levels
Interpersonal skills and training
Assessment gets in the way?
History?
Credibility
In-house and external consultants?
Clash of interests
Regulatory power
Insights in between inspections
Keeps improvement on the agenda
Build trust and greater openness?
Capture and collusion?
Resource pressures?
Time for interaction
Transactional behaviours

13. Some ideas for the future
Focus more on impact in regulatory design and development – setting out intended impacts and pathways to improvement and seeking to test them prospectively and build in evaluation
Seek to understand and build improvement capability, both internal and external to organisations
Inspection and rating consume most regulatory resources and may crowd out other more impactful activities – seek ways to have regulatory interactions short of/other than inspection, use regulatory intelligence and judgement, and be cautious about the value of ratings
Recognise that regulation is a social process, and invest in the quality and development of the people who are the regulator
Seek ways to co-opt other stakeholders – patients, service users, commissioners, professional associations, etc – to the purposes and processes of regulatory regime

14. Questions for discussion
How are you addressing stakeholder, systemic and relational impact?
What issues are coming up?
What research do we need to resolve key uncertainties and gaps in knowledge?