The impact of regulation on quality
in UK nursing homes.
Professor Ciaran O’Neill
School of Policy Studies,
University of Ulster,
Northern Ireland.
Supported by a Harkness Fellowship from the
Commonwealth Fund
Structure
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Industry background
Regulatory arrangements
Assessment of regulation
Assessment of quality
Implications
Background
• Growth in demand for LTC
• Dominance of private sector provision
• 91% of nursing home beds, 75% of residential
home beds (England 2000) are for-profit, almost
75% of all care beds are in private sector
• Dominance of public sector finance –
• 70% of $16bn LTC industry is publicly funded
• Low reimbursement rates – impact on
closures and care quality (Netten et al, 2003)
• Average weekly fees in 2003 - $805 and $582 in
nursing and residential homes respectively: weekly
cost in an NHS bed for care of elderly $1821.
Average weekly Medicaid reimbursement 2001
$824 (BDO, 2003)
• Occupancy rates are high – rose from 90.4% to
91.8% 2002-2003, 88% in US (NNHS, 1997)
• Total market size – 577,301 adult care home places
(2003)
Regulatory arrangements
• Competition – self-regulation effected by
informed sovereign consumers
• Government regulation – effected by
informed independent regulators with
effective disciplinary powers
Assessment of regulation
• Concerns regarding market failure –
Super-complaint by Consumers Association and 28
charities to Office of Fair Trading (OFT) in 2003
prompts investigation –
• Lack of transparency on prices
• Lack of transparency in contracts – contracts may
not always exist
• Market failure may be evident in the UK
Government regulation
Until April 2004
Care Standards Act 2000
(CHI)
(NCSC)
(inspection and enforcement)
NHS
Private sector nursing homes
(189,000 beds)
(193,000 beds)
(26%)
Private sector residential homes
(345,000 beds)
(74%)
CHI = Commission for Health Improvement
NCSC = National Care Standards Commission
Concerns regarding government regulation –
• Regulators are under-resourced -7 fold increase in
beds, 3 fold increase in inspectors 1983-99
(Pollock 2004)
• Regulators lack intermediate sanctions and are
reluctant to use extreme measures
• Standards are not legally enforceable, (no
minimum staffing ratio), and are open to
interpretation
• Regulators risk “capture” by industry – industry
represented on Regulatory Impact Unit, consumers
are not. Industry has ear of government.
NCSC activity specifically on nursing and
residential care not reported but
• Inspection – only 62% of planned unannounced
inspections undertaken
• Complaints – 8,311, 74% investigated by NCSC
the remainder by the industry.
• Statutory notices – 120, Prosecutions – 0,
• Maximum fine available = $8,850
Health and Safety Executive 2003
• Notices issued = 102, Prosecutions = 12
Includes instances where patient was severely
scalded despite 7 warnings from NCSC regarding
failure to comply with standards, as well as an
instance of resident death (HSE database 2004)
• Maximum fine is unlimited – maximum issued to
date $88,500, NCSC maximum fine $8,500
More effective enforcement activity by
other agencies?
Still:
• 8,311 complaints in 2002/03 - not all relate to
nursing home care
• Worst case (all relate to NH) complaint per facility
would be approximately 1.93, compared with 2.3
in US (HealthGrades 2003)
• Mean time spent by nurses with patients higher in
England compared with US, 155.5 minutes vs
115.9 minutes per day (Carpenter et al, 1997)
• Trained nurse time as percentage of total, higher in
England than US 53.2% vs 7.5% (Carpenter et al
1997)
Assessment of quality
• Concerns regarding quality –
• Concerns regarding prescribing, staffing, access to
medical care, patient documentation (O’Neill et al,
1999; Turrell,2001)
• House of Commons Health Committee report on
Elder Abuse April 2004 – highlights lack of
information
• But fundamentally a lack of information is
apparent
“The lack of reporting (on elder abuse) results in
difficulties in determining the true scale of the
problem and this is compounded by a dearth of
research.” (House of Commons, 2004)
• Inspection reports are available on web for
England – but not Scotland, Wales or Northern
Ireland. They are not moreover readily
interpretable.
• Concerns regarding validity and reliability of
inspection – “capture of the regulators by industry”
(Kerrison, 2001)
• Change in regulatory arrangements as of April 2004
NCSC replaced by Commission for Social Care
Inspection - lack of continuity
Implications
• Strengthen regulation:
• User representation in the design of regulations
and standards
• Appropriate funding of inspectorate
• Improve operation of market
• Better information for consumers and advocates –
not necessarily more information
• Higher reimbursement – but linked to performance