By Dr Hugo Mascie-Taylor.
Dr Mascie-Taylor has worked in the NHS under many different guises. He has been a clinical director, medical director and director of commissioning and interim chief executive. He was appointed by Monitor as Trust Special Administrator in Mid-Staffordshire, ending with the successful dissolution of the Trust in October 2014. He is currently the Medical Director of Monitor, where he is leading on patient and clinical engagement.
Dr Charlotte Michael. ST4 in Emergency Medicine and Clinical Fellow in Education at Leeds Teaching Hospitals NHS Trust.
Dr Mascie-Taylor’s talk broke down the some what complex topic of healthcare regulation into a comprehensive yet digestible overview of who, why and how we regulate healthcare in the UK. He also introduced us to the changing identity and role of Monitor, the sector regulator for health services in England.
What is regulation?
Dr Mascie-Taylor opened with the statement that regulation seems to be the ‘vogue’ thing. It is a growth industry with ever growing numbers of individuals and organisations being regulated. With the growing fashion for regulation we need to keep at the forefront of our minds what we are aiming to achieve by regulating and the pros and cons of different regulation strategies.
Who is regulated?
Doctors have been regulated for a long time by the General Medical Council (GMC) but increasing numbers of individuals and groups are now being regulated. Regulation of individuals includes individual doctors and nurses. Dr Mascie-Taylor postulated that other groups such as healthcare assistants and possibly hospital managers might be next to have formal regulation. Regulation at an organisational level also exists such as the regulation of hospital trusts, Clinical commissioning Groups and General Practices
What is the Objective of Regulation?
Dr Mascie-Taylor explained that the overall aim of regulation is to improve patient safety and experience. This can be done in three main ways; by excluding the ‘not fit for purpose’, creating whole system improvement and eradicating rogue performers.
- Exclude the not fit for purpose
Excluding the not fit for purpose brings with it the initial challenge of defining what is ‘not fit for purpose’ or not good enough. We can use a statistical approach, defining ‘normal’ as within two standard deviations from the average. However what is an ‘average’ or an ‘acceptable’ doctor? Dr Mascie-Taylor proposed that the definition of an ‘acceptable’ doctor changes over time and with changes in society. What was deemed ‘acceptable’ twenty years ago might no longer be tolerated in today’s society. He pointed out that the definition of what is or isn’t acceptable is also different between the public and private sector.
In Emergency Medicine one technique of judging which departments are ‘fit for purpose’ is their adherence to the four-hour wait target. Dr Mascie-Taylor asked if this is in fact a good way to say what is “fit for purpose”. He posed the question ‘Can you compare different departments or organisations when they work in different environments? He commented that it is hard for numerical targets not to be arbitrary, how is treating a patient in 3hours 59 minutes allowed but 4 hours and 1 minute is not?
What is ‘fit for purpose’ is increasingly being measured by comparing to the norm within our own system. Unfortunately, if the overall performance of a system or organisation is very good or very bad the norm changes with it, which is why a better aim of regulation may be seen as to evoke whole system improvement, which is discussed below.
2.Whole system improvement
Whole system improvement shifts the whole performance curve to the right, which gives the far greatest benefits to patients. According to Dr Mascie-Taylor this is the single most important thing to do and is the aim of re-validation of doctors.
3. Eradicate rogue performers
According to Dr Mascie-Taylor rogue performers are harder to deal with. Their performance is often good in some areas but lacking in others making it harder to identify and classify them as under performing. To identify potential underperformers we need to be ‘suspicious’ and questioning of our colleagues and their performance, which is an uncomfortable position for many clinicians.
Concerns to rogue performers doesn’t just relate to individuals you can also have a rogue department in an organisation or a good department in a rogue organisation.
Dr Mascie-Taylor then went on to discuss how we regulate.
How do we Regulate?
Regulation is done by external bodies such as Monitor but also there is a lot of internal regulation within organisations and departments. As well as looking at who regulates Dr Mascie-Taylor explained we can look at how we regulate by considering regulation of inputs, processes and outputs.
For example setting minimum staffing levels in department. This type of regulation is relatively low cost to design if not to implement. It is quite simple to achieve.
This type of regulation is done by bodies such as the Care Quality Commission. They look at processes rather than inputs making it more complex to design and implement.
Regualtion can also be achieved by examining outputs such as mortality and morbidity figures and patient experience. This type of regulation tends to cost more, be more complex but gives better assurance. It is more debated in terms of its effectiveness and might not deal with rogue performers.
To regulate we need to look at a combination of inputs, processes and outputs but it is unclear how we balance or calibrate between these? If the inputs are poor, the processes are poor but some outcomes good – how do we judge overall the overall performance?
An introduction to Monitor:
Dr Mascie-Taylor concluded his talk by giving us an introduction to Monitor. Monitor was previously mostly an economic regulator focussing on the regulation on NHS Foundation Trusts. Its role has recently expanded and it is now the sector regulator for healthcare. Its responsibilities can be divided into four main headings of:
1.Making sure public providers are well led
2.making sure essential services are maintained
3. Making sure the NHS payment system promotes quality and efficiency
4. Making sure procurement, choice and competition operate in the best interests of patients.
Hugo Mascie-Taylor gave a concise summary of a difficult topic looking at the aims of regulation and the different approaches to achieving these.
The aims of regulation include:
- Excluding the ‘not fit for purpose’
- Creating whole system improvement
- Eradicating rogue performers
and this can be achieved by looking at inputs, processes and outputs.