User involvement in regulation: A qualitative study of service user involvement in Care Quality Commission inspections of health and social care providers in England.

BACKGROUND: High profile failures of care in the NHS have raised concerns about regulatory systems for health-care professionals and organizations. In response, the Care Quality Commission (CQC), the regulator of health and social care in England overhauled its regulatory regime. It moved to inspections which made much greater use of expert knowledge, data and views from a range of stakeholders, including service users. OBJECTIVE: We explore the role of service users and citizens in health and social care regulation, including how CQC involved people in inspecting and rating health and social care providers. DESIGN: We analyse CQC reports and documents, and 61 interviews with CQC staff and representatives of groups of service users and citizens and voluntary sector organizations to explore the place of service user voice in regulatory processes. RESULTS: Care Quality Commission invited comments and facilitated the sharing of existing service user experiences and engaged with representatives of groups of service users and voluntary sector organizations. CQC involved service users in their inspections as "experts by experience." Information from service users informed both the inspection regime and individual inspections, but CQC was less focused on giving feedback to service users who contributed to these activities. DISCUSSION AND CONCLUSIONS: Service users can make an important contribution to regulation by sharing their experiences and having their voices heard, but their involvement was somewhat transactional, and largely on terms set by CQC. There may be scope for CQC to build more enduring relationships with service user groups and to engage them more effectively in the regulatory regime.

How hospital survey teams function.

Purpose The purpose of this paper is to understand how inspection team members work together to conduct surveys of hospitals, the challenges teams may face and how these might be addressed. Design/methodology/approach Data were gathered through an evaluation of a new regulatory model for acute hospitals in England, implemented by the Care Quality Commission (CQC) during 2013-2014. The authors interviewed key stakeholders, observed inspections and surveyed and interviewed inspection team members and hospital staff. Common characteristics of temporary teams provided an analytical framework. Findings The temporary nature of the inspection teams hindered the conduct of some inspection activities, despite the presence of organisational citizenship behaviours. In a minority of sub-teams, there were tensions between CQC employed inspectors, healthcare professionals, lay people and CQC data analysts. Membership changes were infrequent and did not appear to inhibit team functioning, with members displaying high commitment. Although there were leadership authority ambiguities, these were not problematic. Existing processes of recruitment and selection, training and preparation and to some extent leadership, did not particularly lend themselves to addressing the challenges arising from the temporary nature of the teams. Research limitations/implications Conducting the research during the piloting of the new regulatory approach may have accentuated some challenges. There is scope for further research on inspection team leadership. Practical implications Issues may arise if inspection and accreditation agencies deploy temporary, heterogeneous survey teams. Originality/value This research is the first to illuminate the functioning of inspection survey teams by applying a temporary teams perspective.

Are inspectors' assessments reliable? Ratings of NHS acute hospital trust services in England.

The credibility of a regulator could be threatened if stakeholders perceive that assessments of performance made by its inspectors are unreliable. Yet there is little published research on the reliability of inspectors' assessments of health care organizations' services. Objectives We investigated the inter-rater reliability of assessments made by inspectors inspecting acute hospitals in England during the piloting of a new regulatory model implemented by the Care Quality Commission (CQC) during 2013 and 2014. Multi-professional teams of inspectors rated service provision on a four-point scale for each of five domains: safety; effectiveness; caring; responsiveness; and leadership. Methods In an online survey, we asked individual inspectors to assign a domain and a rating to each of 10 vignettes of service information extracted from CQC inspection reports. We used these data to simulate the ratings that might be produced by teams of inspectors. We also observed inspection teams in action, and interviewed inspectors and staff from hospitals that had been inspected. Results Levels of agreement varied substantially from vignette to vignette. Characteristics such as professional background explained only a very small part of the variation. Overall, agreement was higher on ratings than on domains, and for groups of inspectors compared with individual inspectors. A number of potential causes of disagreement were identified, such as differences regarding the weight that should be given to contextual factors and general uncertainty about interpreting the rating and domain categories. Conclusion Groups of inspectors produced more reliable assessments than individual inspectors, and there is evidence to support the utility of appropriate discussions between inspectors in improving reliability. The reliability of domain allocations was lower than for ratings. It is important to define categories and rating levels clearly, and to train inspectors in their use. Further research is needed to replicate these results now that the model has been fully implemented, and to understand better the impact that inspector uncertainty and disagreement may have on published CQC ratings.

The six types of rationing faced by NHS patients.

As the health service's financial challenge deepens, Ruth Robertson looks at the six types of rationing identified by Klein and Maybin and asks to what extent they apply today.

Jobs without benefits: the health insurance crisis faced by small businesses and their workers.

The share of U.S. workers in small firms who were offered, eligible for, and covered by health insurance through their jobs has declined over the past decade. Less than half of workers in companies with fewer than 50 employees were both offered and eligible for health insurance through their jobs in 2010, down from 58 percent in 2003. In contrast, about 90 percent of workers in companies with 100 or more employees were offered and eligible for their employer's health plans in both 2003 and 2010. Workers in the smallest firms--and those with the lowest wages--continue to be less likely to get coverage from their employers and more likely to be uninsured than workers in larger firms or with higher wages. The Affordable Care Act includes new subsidies that will lower the cost of health insurance for small businesses and workers who must purchase coverage on their own.

Oceans apart: the higher health costs of women in the U.S. compared to other nations, and how reform is helping.

An estimated 18.7 million U.S. women ages 19 to 64 were uninsured in 2010, up from 12.8 million in 2000. An additional 16.7 million women had health insurance but had such high out-of-pocket costs relative to their income that they were effectively underinsured in 2010. This issue brief examines the implications of poor coverage for women in the United States by comparing their experiences to those of women in 10 other industrialized nations, all of which have universal health insurance systems. The analysis finds that women in the United States--both with and without health insurance--are more likely to go without needed health care because of cost and have greater difficulty paying their medical bills than women in the 10 other countries. In 2014, the Affordable Care Act will substantially reduce health care cost exposure for all U.S. women by significantly expanding and improving health insurance coverage.

Young, uninsured, and in debt: why young adults lack health insurance and how the Affordable Care Act is helping: findings from the Commonwealth Fund Health Insurance Tracking Survey of Young Adults, 2011.

The Commonwealth Fund Health Insurance Tracking Survey of Young Adults finds that between November 2010 and November 2011, an estimated 13.7 million young adults ages 19-25 stayed on or joined their parents' health plans, including 6.6 million who likely would not have been able to do so prior to the passage of the Affordable Care Act. The findings of the survey underscore the need for policymakers to implement the remaining coverage expansions in the law. Nearly two of five young adults ages 19-29 were without health insurance for all or part of 2011, with young adults in low- and moderate-income households the most at risk. The lack of insurance had significant health and financial implications for young adults: 60 percent said they did not get needed health care because of cost and half reported problems paying medical bills or said they were paying off medical debt over time.

Gaps in health insurance: why so many Americans experience breaks in coverage and how the Affordable Care Act will help: findings from the Commonwealth Fund Health Insurance Tracking Survey of U.S. Adults, 2011.

The Commonwealth Fund Health Insurance Tracking Survey of U.S. Adults finds that one-quarter of adults ages 19 to 64 experienced a gap in their health insurance in 2011, with a majority remaining uninsured for one year or more. Losing or changing jobs was the primary reason people experienced a gap. Compared with adults who had continuous coverage, those who experienced gaps were less likely to have a regular doctor and less likely to be up to date with recommended preventive care tests, with rates declining as the length of the coverage gap increases. Early provisions of the Affordable Care Act are already helping bridge gaps in coverage among young adults and people with preexisting conditions. Beginning in 2014, new affordable health insurance options through Medicaid and state insurance exchanges will enable adults and their families to remain insured even in the face of job changes and other life disruptions.

The income divide in health care: how the Affordable Care Act will help restore fairness to the U.S. health system.

The new Commonwealth Fund Health Insurance Tracking Survey of U.S.Adults finds nearly three of five adults in families earning less than 133 percent of the federal poverty level were uninsured for a time in 2011; two of five were uninsured for one or more years. Low- and moderate-income adults who were uninsured during the year were much less likely to have a regular source of health care than people in the same income range who were insured all year. In addition, uninsured lower-income adults were more likely than insured adults in the same income group to cite factors other than medical emergencies as reasons for going to the emergency room. These included needing a prescription drug, not having a regular doctor, or saying that other places cost too much. The Affordable Care Act will substantially narrow these inequities through an extensive set of affordable coverage options starting in 2014.

Choice policies in Northern European health systems.

This paper compares the introduction of policies to promote or strengthen patient choice in four Northern European countries - Denmark, England, the Netherlands and Sweden. The paper examines whether there has been convergence in choice policies across Northern Europe. Following Christopher Pollitt's suggestion, the paper distinguishes between rhetorical (discursive) convergence, decision (design) convergence and implementation (operational) convergence (Pollitt, 2002). This leads to the following research question for the article: Is the introduction of policies to strengthen choice in the four countries characterised by discursive, decision and operational convergence? The paper concludes that there seems to be convergence among these four countries in the overall policy rhetoric about the objectives associated with patient choice, embracing both concepts of empowerment (the intrinsic value) and market competition (the instrumental value). It appears that the institutional context and policy concerns such as waiting times have been important in affecting the timing of the introduction of choice policies and implementation, but less so in the design of choice policies. An analysis of the impact of choice policies is beyond the scope of this paper, but it is concluded that further research should investigate how the institutional context and timing of implementation affect differences in how the choice policy works out in practice.

Competition in the NHS: a provider perspective.

OBJECTIVE: To analyse how competition is experienced and characterized by NHS and independent sector acute care providers in the English National Health Service (NHS). METHODS: Semi-structured interviews with 49 senior staff in 15 NHS trusts and independent sector providers between November 2008 and April 2009, in England. RESULTS: The market was predominantly defined based on geographical proximity. Competition was mainly on the periphery of catchment areas but markets were differentiated based on the scope and type of services. Niche providers, specialist hospitals and tertiary centres did not directly compete with district general hospital-type providers. Competitors were increasingly primary and community care providers, while there was little perceived threat from the private sector. There were many examples of how different providers (both NHS and independent sector) were co-operating and collaborating. Patients and general practitioners (GPs) appeared to be loyal to local providers. CONCLUSION: The providers' view of the market and the relevance of historical relationships and loyalties suggest fine grained variations in competition which is consistent with a relational rather than structural approach to competition. Also the evidence on embeddedness of relationships implies that collaboration might be a strong lever for quality improvement locally. Finally, some of the agreements found might be deemed in breach of the rules of competition but they may well be in the interests of patients and taxpayers, with implications for regulation in publicly funded health care systems.

Affordable Care Act reforms could reduce the number of underinsured US adults by 70 percent.

To provide a baseline and assess the potential of changes brought about under the Affordable Care Act, this study estimates the number of US adults who were underinsured or uninsured in 2010. Using indicators of medical cost exposure relative to income, we find that 44 percent (81 million) of adults ages 19-64 were either uninsured or underinsured in 2010-up from 75 million in 2007 and 61 million in 2003. Adults with incomes below 250 percent of the federal poverty level account for sizable majorities of those at risk of becoming uninsured or underinsured. If reforms succeed in increasing the affordability of care for people in this income range, we could expect a 70 percent drop in the number of underinsured people and a steep drop in the number of uninsured people.

When unemployed means uninsured: the toll of job loss on health coverage, and how the Affordable Care Act will help.

Chronically high unemployment has left millions of Americans without health insurance, which disappeared along with their wages and other job benefits. Although continuing health coverage through COBRA is an option for some workers, the often prohibitively high cost means that relatively few elect to purchase it. When fully implemented in 2014, the Affordable Care Act will dramatically increase health insurance options for people who lose their jobs. Even so, gaps in coverage will remain a risk for many workers who become unemployed or are transitioning to a new job. To help bridge coverage gaps until 2014, policymakers should consider reestablishing the COBRA premium subsidies that helped millions of people who lost their jobs in 2008­2010.

Women at risk: why increasing numbers of women are failing to get the health care they need and how the Affordable Care Act will help. Findings from the Commonwealth Fund Biennial Health Insurance Survey of 2010.

Women have greater health care needs than men, and generally play larger roles in the health care of family members. Rising health care costs combined with sluggish income growth has contributed to losses in health insurance among women and rising rates of problems gaining necessary health care and paying medical bills. Women who seek coverage in the individual insurance market face additional hurdles--few plans offer maternity coverage and, in most states, insurance carriers charge higher premium rates to young women than men of the same age. The Affordable Care Act is bringing change for women through required free coverage of preventive care services, small business tax credits, new affordable coverage options, and insurance market reforms, including bans on gender rating. When the law is fully implemented in 2014, nearly all the 27 million working-age women who went without health insurance in 2010 will gain affordable and comprehensive benefits.

How the Affordable Care Act is helping young adults stay covered.

The Affordable Care Act is making a difference for young adults, among the groups most at risk for lacking health insurance in the United States. Young adults up to age 26 may now stay on or join their parent's health plans if they include dependent coverage, and early reports indicate that at least 600,000 have done so. Starting in 2014, of the 14.8 million uninsured adults ages 19 to 29, an estimated 12.1 million could gain subsidized coverage once all the law's provisions go into effect: 7.2 million may gain coverage under Medicaid and 4.9 million may gain subsidized private coverage through state insurance exchanges. New findings from the 2010 Commonwealth Fund Biennial Health Insurance Survey indicate the need for these reforms: 45 percent of young adults reported delaying needed care because of costs in 2010, up from 32 percent in 2001, and 39 percent reported problems paying medical bills.

The impact of patient choice of provider on equity: analysis of a patient survey.

OBJECTIVES: To understand the impact on equity of giving patients a choice of provider. METHODS: A postal survey of 5997 patients in four areas of England about choice at their recent referral and, using a discrete choice experiment, how they would choose in hypothetical situations. Binary logistic regression and a series of multinomial and nested logit models were used to analyse the data to discover whether patients with particular characteristics were more likely to: think choice is important; be offered a choice; and, choose a non-local provider. RESULTS: The response rate was 36%. Choice was more important to older patients aged 51-80 years, patients from non-white backgrounds, women, those with no qualifications and those with a bad past experience of their local hospital. There were no significant differences in who was offered a choice in terms of education, age group or ethnicity. In both real and hypothetical situations patients with no formal qualifications and those living in urban centres were more likely to choose their local hospital, and patients with a bad or mixed past experience at the local hospital were more likely to choose an alternative. In hypothetical choices those who do not normally travel by car and without Internet access were more likely to choose their local hospital irrespective of that hospital's characteristics. CONCLUSIONS: More educated, affluent patients were no more likely to be offered a choice than other population groups, but there does appear to be a social gradient in who chose to travel beyond the local area for treatment. If these results were replicated across England, there is at least the potential risk that when local hospitals are failing, patient choice could result in inequitable access to high quality care, rather than enhancing equity as the policy's architects had hoped.

The experience of implementing choice at point of referral: a comparison of the Netherlands and England.

The implementation of choice for patients over where and when they are seen by specialists in hospital outpatient clinics has been supported by electronic referral systems in England and the Netherlands. This paper compares the implementation of 'Choose and Book' in England and 'ZorgDomein' in a region of the Netherlands. For England the analysis draws on national data and published studies on 'Choose and Book', national patient surveys, and qualitative data based on general practitioner (GP) focus groups. For the Netherlands the analysis draws on qualitative data collected during observational study as well as survey data among patients, GPs and medical specialists. We find that despite significant differences in the genesis and design of the policy, similar challenges have been faced. The electronic referral systems have forced changes to the process of care at the interface between primary and secondary care and standardisation between practices. Although these changes have the potential to generate improvements and benefits, for example, convenience, certainty and choice for patients and efficiency gains through for example reduced do not attend rates, repeat consultations and duplicative diagnostic tests; they have also generated problems during implementation including GP resistance. Policy ambitions for patient choice may not be realised if the implementation of the booking system is not carefully designed and evaluated.