Inspecting the quality of care in changing health and social care systems

1
Inspecting the quality of care in changing
health and social care systems

• An international comparison
• Roland Bal
• Professor of healthcare governance

2
Introduction

• Goals and questions
• Theoretical framework
• Analysis
• Conclusions
• Dilemmas of supervision
• Propositions

3
Background

• Reform of health and social care systems finding
  new roles for the state
• Internationalisation of health and social care
  regimes
• Changing roles of actors within the systems
• Consequences for supervision?

4
Research goal and question

• Goal of the research providing insight in the
  structure of inspection of quality and patient
  safety in European health and social care systems
• Central question How are quality assurance and
  patient safety organised in several European
  countries and what lessons can be learned from
  this comparison?

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Sub questions

• How is the inspection on quality and patient
  safety organised in 7 selected countries? How do
  different inspectorates and supervisors relate to
  each other?
• How does this system of inspection work, and
  under what conditions/circumstances?
• What tensions and dilemmas arise and how can we
  understand and explain them?
• How do different European health and social care
  systems cope with these tensions and dilemmas and
  what lessons are to be learned?

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Theoretical Framework modes of governance
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Theoretical framework styles of accountability

• Democratic perspective
• Focused on accountability in representative fora
  (principle-agent)
• Constitutional perspective
• Focused on abuse of executive power
• Cybernetic perspective
• Focused on system learning
• Assumed relation between modes of governance and
  supervision!

8
Research Methods

• Literature
• Scientific literature
• Policy documents
• Relevant websites
• Expert interviews
• E.g. with the Ministries of Health, Inspections
  for healthcare, scientists and stakeholders from
  the field of health and social care
• Comparative research
• 7 case studies

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Case selection
10
Case selection
Netherlands
UK
UK
Netherlands
Norway
Norway
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Variables

• The institutional context
• Public/private mix market/state/society/ medical
  profession
• Federal/unitary state structure
• Health and social care system characteristics
• Bismarck/Beveridge
• Regulations on quality and patient safety
• Supervision instruments (state regulations,
  negotiations, self-regulation, contracts)
• Practices of inspection (e.g. reactive-proactive
  styles)

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Analysis Institutional level

• There are many differences between countries as
  to how inspection for health care quality and
  safety is organized and works in practice
• Centralized vs. decentralized systems
• State-led vs. professional or multi-party
  inspection systems
• Distance / responsiveness towards the field
• Pro-active and re-active inspection strategies
• Level of transparency of inspections
• Use of formal instruments

13
Analysis Institutional level

• Similarities at institutional level are found
  between countries, e.g. federal or unitary and
  Bismarck or Beveridge
• The organisation of a health and social care
  system at institutional level influences the
  organisation of inspection,
• e.g. in unitary states a high level of state
  intervention and low level of self-regulation of
  collective actors can be found, which influences
  the role and position of inspectorates
• A connection between the ideal types (see
  theoretical framework) does exist, despite the
  differences in the organization of inspection

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Analysis Institutional level

• Formally, different health and social care
  inspections within a country have separate
  inspection tasks and responsibilities
• But in daily practice tensions may occur because
  of overlap
• E.g. Netherlands competition authority ??
  healthcare inspectorate
• Different strategies in coordinating tasks
• Informal talk
• Representations in common bodies
• Coordination protocols

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Analysis Hybridisation

• Growing hybridisation of health and social care
  systems
• Beveridgean systems introduce choice and
  decentralisation
• Advance of New Pubic Management in many systems
• albeit with many remaining differences
• Increasing political (and client) pressure on
  safety (decreasing risk acceptance)
• Discourse of inspection shows more similarities
  across countries, despite different backgrounds
  and different practices
• More centralisation / coordination
• More emphasis on transparency
• Greater emphasis on pro-active, risk-based
  approaches

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Conclusions

• Changing focus and locus of accountability
  arrangements
• Increasing emphasis on transparency ? shift from
  trust in professionals towards trust in numbers
• Stronger emphasis on democratic style of
  accountability at the expense of cybernetic style
• Decentralisations and recentralisation go hand in
  hand despite decentralisation strong
  centralisation at both system and organisational
  levels
• Mode of governance explains part of differences
  in supervision arrangements, but much variation
  in practices
• ? choices are possible!

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Dilemmas and paradoxes

• Regulatory paradox
• Decentralisation of health and social care leads
  to recentralisation, stronger regulation and
  instrumentalization of supervision
• Information paradox
• Emphasis on transparency goes against informal
  forms of leaning and accounting
• Responsiveness paradox
• Hierarchical steering in decentralised system
  makes for diffuse accountabilities and
  appearance of control

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Propositions

• Accept and use the hybridity of supervisory
  arrangements
• Dominance of one style or ideal type goes against
  effectiveness in longer run
• Prevent instrumentalization of supervision
• Good working supervision needs reflexivity and
  the creation of trust next to objectivity and
  transparency
• Work from a systemic perspective of supervision
• Relations between different supervisors
  (including organisational and informal, e.g.
  clients) are crucial