The impact of regulation on quality
in UK nursing homes.
Professor Ciaran O’Neill
School of Policy Studies,
University of Ulster,
Northern Ireland.
Structure
•
•
•
•
•
Industry background
Regulatory arrangements
Assessment of regulation
Assessment of quality
Implications
Supported by a Harkness Fellowship from the
Commonwealth Fund
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
Regulatory arrangements
• 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)
Assessment of regulation
• Concerns regarding market failure –
• Competition – self-regulation effected by
informed sovereign consumers
• Government regulation – effected by
informed independent regulators with
effective disciplinary powers
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
1
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
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
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)
Concerns regarding government regulation –
• Regulators are under- resourced- 7fold 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.
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?
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
2
• 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
3