1. What has been the impact of
regulation in health in the past
5 years?
Professor Martin Marshall
Clinical Director, The Health Foundation
1

2. Health warnings around the
evidence....
• What is regulation?
• Attribution
• Ethical issues
• The political dimension
2

3. Scope of evidence
Healthcare • Annual Health Check
Commission • Special Investigations
• Finance
Monitor
• Governance
• Use of resources
Audit Commission
• Comprehensive Performance Assessment
3

4. Healthcare Commission
Annual Health Check: Overview
• Twice as many trusts showed improvements in quality score as
showed deterioration
• Twenty times as many trusts showed improvements in use of
resources as showed deterioration
• Strong consistency between scores for quality and use of resources –
no evidence that one prioritised over other
• FTs had higher scores than non FTs for quality and resources
• PCTs have lowest scores but most demanding targets
• Reorganised PCTs scored less highly than stable ones (but London
factor….)
Healthcare Commission, 2009. Findings are still subject to external peer review 4

5. Healthcare Commission
Annual Health Check: Quality of services
Healthcare Commission, 2009 5
NB: Not to be reproduced without permission from Monitor

6. Healthcare Commission
Annual Health Check: Use of resources
Healthcare Commission, 2009 6
NB: Not to be reproduced without permission from Monitor

7. Healthcare Commission
Annual Health Check: Experiences of Trusts
• 68% thought assessment against core standards improved quality
and safety for patients, though 55% complained of increased
workload and overlap
• 65% had embedded self-assessment in own assurance processes
• Trust experiences become more positive over time
Special investigations
• 15 formal investigations from 300 referrals, 4 found significant
failings
• Process judged to be overly slow, insufficiently focused and
required more effort to embed and spread change
Healthcare Commission, 2009 7

8. Monitor
• Since establishment, 180 assessment decisions have been
made and 114 Trusts have achieved Foundation status
• Approximately 30 FTs have been subject to formal or informal
intervention
• Some evaluation undertaken
o Ipsos MORI, 2008 (>85% 0f 175 senior executives thought Monitor had
made positive impact and that compliance framework was fit for purpose
o Internal evaluation currently being undertaken focusing on how to assess
impact and value for money
Monitor, 2009. Findings are still subject to external peer review 8

9. Monitor
Preliminary findings from evaluation: Finance
• Assessment and deferral processes incentivise efficiencies by
reducing costs and cutting out inefficient capital investment
• Interventions in FTs with financial problems leads to rapid change
• No evidence that cost reductions have come at expense of quality
• No evidence that FTs financial performance improves at faster rate
than non-FTs
Monitor, 2009. Findings are still subject to external peer review 9

10. Monitor
No evidence that FTs’ financial performance
improves at a faster rate than non-FTs*
Authorisation If FTs performance improves
at a higher rate than non-FTs
Financial performance
FT the chart would show this
relationship.
Non FT
Instead, the model identifies
a one off improvement in
trusts’ financial performance
during the assessment
Time process.
* Economic analysis currently being reviewed, this finding is
unlikely to change.
Monitor, 2009. Findings are still subject to external peer review
NB: Not to be reproduced without permission from Monitor 10

11. Monitor
Preliminary findings from evaluation: Governance
• Fundamental changes at Board level as result of interventions i.e.
Board interventions seem to be effective
• Assessment process has impact on performance on key targets
(waiting times, MRSA rates)
• No evidence that FTs non-financial performance improves at faster
rate than non-FTs
Monitor, 2009. Findings are still subject to external peer review
11

12. Audit Commission
• Main health responsibilities are to:
o audit financial accounts of NHS Trusts
o assess use of resources by NHS Trusts to feed into the annual health check
o carry out local studies on financial management
• Of relevance is the regulatory work to assess the performance of
local government:
o no equivalent to ‘performance management’ of local authorities by Whitehall (as
in NHS) so performance improvement over time in part a clearer measure of
impact of regulation
o evolution of methods from Best Value to Comprehensive Performance
Assessment (CPA: 2002-9) to Comprehensive Area Assessment(CAA: from April
2009)
Audit Commission, 2009
12

13. Audit Commission
Comprehensive Performance Assessment (2002-9)
• Councils in highest performing category increased from 15% in 2002
to 42% in 2008
• Social service departments in highest performing category increased
from 1% in 2002 to 18% in 2008 (but quality of services for children
and young people static)
• 9% of councils in lowest performing category in 2002, none by 2006
• Most Chief Executives described process as highly useful
• Local media play important role in highlighting performance
Audit Commission, 2009

14. Summary: Emerging lessons
from across sectors
• All regulators claim that they are driving up quality: there is some
evidence to support these claims
• All regulators are reflecting a trend:
o more proportionate and targeted approaches, particularly on poor performers
o self assessment and reduce inspection
o greater focus on outcomes and citizens
• The regulated tend to complain about the regulatory burden and
emphasise the negative consequences
• Public understanding of regulation is poor
• All regulators are being encouraged to examine their own value for
money, to reduce budgets and to merge
• Policy makers swing from seeing regulation as a solution to
regulation being the problem
14

15. For discussion
• Will the burden of regulation increase as a consequence of perceived
regulatory failure in the financial sector and an increased aversion to
risk? What will be the impact of the Mid-staffs experience?
• How do we encourage a greater focus on the service user?
• How can regulation reflect the complexity of delivering care
• How do we engage staff and service users with regulation?
• How do we maximise value for money of regulatory activity?
• Do regulators have sufficient understanding of the environments they
are regulating?
• How do we optimise the relationship between regulatory and
performance management functions?
• How can regulation best encourage improvement rather than just
conformance behaviours?
15