What can Australia take from the UK’s experience of reforming Aged Care quality and safety regulation?

Systemic failings in care and serious questions about the Care Quality Commission’s (CQC) ability to identify and respond to poor performance led, in 2013, to a change in approach to inspecting and rating NHS acute hospitals, general practice and residential aged care providers in the UK.

The new approach was drastically different to the model it replaced. Large expert inspection teams, in-depth, multi-day announced and unannounced inspections and a significant emphasis on performance and outcome data superseded generic care standards and light-touch inspections. Between April 2014 and January 2017 all providers, regardless of the sector, were inspected and graded against five domains (safe, effective, caring, responsive and well-led) all on a four-point scale (‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’). The results of each inspection, along with a detailed inspection report, were published online – allowing the public to compare and contrast providers within their local area.

The parallels between the pressures faced by the CQC to improve regulation and the NHS to improve quality in 2013 and the situation in aged care in Australia today, are clear. So, what can those on both sides of the regulatory relationship learn from the CQC and the UK experience?

The regulators

It is too soon to say whether the CQC’s new approach will ultimately improve care standards, however, few could deny the change in process has added much needed rigour to the system. It is also fair to say that the changes have gone some way to restore the general public’s faith in the regulatory system.

What changes seem to have had the biggest impact?

  • A regulator with teeth – an enhanced array of enforcement powers including the ability to prosecute and close down services
  • A transparent grading system – the outcomes of each inspection are simple, transparent and easy to compare and contrast
  • Use of data – a focus on ‘intelligent monitoring’ has reduced the regulatory burden on those that provide high quality care and increased the focus on those that need to improve
  • Experienced and credible inspection teams – larger teams made of subject matter experts – who are fair, objective and understand the day to day challenges of working in the sector. Teams include experienced clinical and managerial staff (who are trained by the CQC but work full-time within the health system) supported by ‘experts by experience’ (people who have personal experience of using or caring for someone who uses health services on a regular basis)
  • Support for those that need it – often those that are failing are unable to turn themselves around. The CQC has worked alongside ‘NHS Improvement’ to provide additional support to those placed in ‘special measures’ ( i.e. graded as ‘inadequate’ in ‘well-led’ and at least one other domain) to ensure they are supported to improve.
The regulated

For those providers subject to regulatory inspection and accreditation, the stress, anxiety and administrative burden can be considerable. Here is what I have learned from both preparing for a CQC inspection and helping others to do the same. Whilst these insights have been gleaned from the UK experience, many of lessons below merit further reflection in the context of the regulatory landscape in Australia today.

1. Prioritise quality and seek compliance well in advance of any inspection. Undertake a thorough and honest assessment of your service and care quality – this should include scrutinising data and meaningfully observing what is happening at the front line of care. Use the outcomes to develop a comprehensive set of quality priorities and start work towards improvement. There should be no surprises during a regulatory inspection; the intelligence you have on your own organisation should be far deeper than any inspector can dig.

2. Ensure consistency and cohesion when talking about quality and risk. There should be a consistent view across the executive in regard to the key quality and safety risks facing the organisation and these should be echoed by thoughts and experiences of your front line staff.

3. Learn from others. Undertake external or internal peer reviews. The benefit of this is two-fold: departments being reviewed gain a deeper understanding of the assessment process and quality standards and those undertaking the inspection learn from and share ideas with the areas they have inspected.

4. Support staff to become inspectors. Consider supporting front line staff to train with the regulators and become accredited inspectors themselves. This not only enhances their insight and therefore that of your organisation but also ensures that the regulators benefit from a team that are credible, current and realistic.

5. Reduce anxiety and fear in front line staff and protect them from the administrative burden of regulatory / commission preparation. Work with frontline staff to help them feel prepared and confident and inspection ready. Encourage and support staff to be open and have improvement-focused discussions with the inspection team. Wherever possible, protect front staff from the ‘tick box’ exercises and let them focus on delivering high quality care and improvement initiatives. This is not the time for disgruntled staff – the current spotlight on the Australian aged care sector should be used as a catalyst to focus staff attention on quality and good conduct, not distract them from it.

6. Have meticulous control over data submissions. Whilst the task can seem daunting, the key is to have complete oversight over what information has left the organisation and what it said about the service. It is likely that this information will lead to further exploration and review. Ask yourself, what conclusions will be drawn from the information shared? How should that shape the organisation’s preparation?

7. Celebrate and be proud. There is an odd phenomenon when it comes to quality regulation that makes us all focus on the negative – the complaints, the errors and the near-misses but we rarely give as much thought to the compliments and successes. But this needn’t be the case – we need to see this as a time to celebrate. Remind staff that if they are proud of the work they do and the quality of care they deliver – then say so! Consider displaying posters of good work, thank-you cards and compliment letters. Ask staff to think about what they have worked hard to improve and what success they have had. A good inspection should be balanced and we all have a role to play in ensuring it is.

Conclusion

Society expects that there are mechanisms in place to ensure that people in residential aged care facilities are safe, well cared for and have a good quality of life. Simply put, they want assurance that the care provided meets the ‘Mum Test’ – is it good enough for my mum or a member of my family? In addition to this, there is an expectation that organisations receiving public funding will be scrutinised to ensure that the care they deliver provides value for money. The CQC in the UK has gone some way to meet these expectations by increasing the rigour, depth and transparency of the inspection process and taking a more holistic view of the care delivered. It will a significant role for the Aged Care Royal Commission to determine how this can best be achieved in Australia.

The Commission will ask what the Australian Government, aged care industry/providers, Australian families and the wider community can do to strengthen the system of aged care services to ensure that the services provided are of high quality and safe. This is not something that the regulators alone can influence but instead requires a fundamental shift in mindset to ensure quality and safety are the number one priority and outcomes are focused on those that matter most to the recipients of care.

Whilst the Royal Commission will undoubtedly lead to some soul searching across the sector, we should not forget about the many examples of high-quality care and the thousands of staff who work hard to care for older Australians every day. After all, there is just as much to learn from what is done well as there is from care that fails to meet our expectations.


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