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1 Rating providers for quality: a policy worth pursuing? Rating providers for quality: a policy worth pursuing? A report for the Secretary of State for Health March 2013 2 Rating providers for quality: a policy worth pursuing? About this report This report outlines the findings and recommendations from an independent review conducted by the Nuffield Trust into whether the Government should introduce ‘Ofsted-style’ performance ratings for hospitals, general practices, care homes and other adult social care providers. The review was commissioned by the Secretary of State for Health, The Rt Hon Jeremy Hunt MP, in November 2012. It has sought to assess whether ‘aggregate’ ratings of provider performance should be used in health and social care and, if so, how best this might be done. The conclusions in the report are solely those of the Nuffield Trust. The report was presented to the Government on 22 March 2013, and an accompanying summary is available to download from www.nuffieldtrust.org.uk/publications. Two main methods were employed to inform the review: engagement with policy-makers, professionals, the public and other key stakeholders; and reviews of relevant literature. The engagement process involved: a set of meetings with groups of stakeholders; an eight-week online consultation process; a series of three focus groups with the public, conducted by Ipsos MORI; and bilateral meetings with key individuals. More than 200 organisations and individuals contributed to the online consultation. These contributions have informed the conclusions and recommendations of the final report. The Nuffield Trust would like to thank those individuals and organisations again for their contributions. A range of resources on the review are available from the Nuffield Trust website at www.nuffieldtrust.org.uk/ratings-review. The Nuffield Trust is an authoritative and independent source of evidence-based research and policy analysis for improving health care in the UK. We aim to help provide the evidence base for better health care through four key activities: conducting cutting edge research and influential analysis; informing and generating debate; supporting leaders; and examining international best practice. Find out more online at: www.nuffieldtrust.org.uk/ratings-review Contents List of figures and tables 2 Executive summary 4 1. Introduction 12 2. Ratings in health and social care: a brief history 14 3. Quality in health care 36 4. Quality in social care 53 5. Purposes of a rating 65 6. Designing a rating 86 7. Which organisation? Some implications of introducing a rating system 102 8. Concluding remarks 111 References 114 Appendices 123 Appendix 1: Engagement process 123 Appendix 2: Advisory Group 127 Appendix 3: Care Quality Commission’s regulated activities 129 Appendix 4: Care Quality Commission’s essential standards 131 Appendix 5: Health care landscape and quality initiatives 133 Appendix 6: Examples of initiatives in selected countries to improve the availability of publicly reported data on the quality of health care 147 Appendix 7: Using performance information to make choices in health care: lessons from abroad 150 Appendix 8: Lessons from performance benchmarking in Germany 152 Appendix 9: Nursing Home Compare – evidence of using information on facilitating choice and improving performance 154 2 Rating providers for quality: a policy worth pursuing? List of tables and figures List of figures Figure 2.1: Common criticisms of star ratings – summary adapted from Bevan and Hamblin 2009 Figure 2.2: Performance on overall quality according to the Annual Health Check for acute and specialist trust performance in England (2006–09) Figure 2.3: Some recommendations from the Healthcare Commission approach to regulation (2004–09) Figure 2.4: Assessing performance of schools by Ofsted Figure 2.5: Overall effectiveness of schools: trends in performance 2005/06 to 2011/12 Figure 2.6: A history of ratings in health care 1999–2011 Figure 3.1: The Quality Curve, reproduced from the National Quality Board (2013) Figure 4.1: Statements of high-quality adult social care services Figure 4.2: The Quality Curve, reproduced from the National Quality Board (2013) Figure 4.3: Sector concerns in relation to the adoption of the proposed Excellence Award in Social Care Figure 4.4: Social care landscape Figure 5.1: Most important source of information when patients choose their hospital, February 2010 Figure 5.2: How a rating system might result in improved performance of providers Figure 5.3: Potential negative impact of ratings on quality Figure 6.1: The Finsbury rules. Example of rules and ratings Figure 7.1: Key features of an organisation charged with constructing ratings for health and social care providers 3 Rating providers for quality: a policy worth pursuing? List of tables Table 3.1: Quality initiatives: Government and the Department of Health Table 3.2: Quality initiatives: commissioning system Table 3.3: Quality initiatives: regulatory system Table 3.4: Quality initiatives: other national organisations Table 3.5: Quality initiatives: professionally-led initiatives Table 4.1: Number of service users receiving state-funded social care services during 2011/12 by service type and age group Table 5.1: Broad stated rationale for introducing public reporting systems in the areas of health and social care Table 6.1: Criteria for good performance indicators Table 6.2: The domains of the NHS Outcomes Framework Table 6.3: Examples of different information sources that can be used in ratings 4 Rating providers for quality: a policy worth pursuing? Executive summary Background Should there be ‘Ofsted-style’ ratings for health and social care providers? This was the main question which prompted the Secretary of State for Health, The Rt Hon Jeremy Hunt MP, in November 2012 to commission this independent Review. The specific terms of reference were: • To map the current system of assessing the quality and safety of care of providers of health and social care and the current system of accountability for quality of care. • To identify the advantages and disadvantages of aggregate assessment of providers of health and social care. • To identify in broad terms how best to combine relevant current and historic data on quality (safety, effectiveness, and user experience) and information from inspection to provide useful, credible and meaningful aggregate assessment for comparing the performance of organisations providing health care and social care. Key goals will be to use existing metrics, rather than require costly new data collection, and not to create extra burdens on providers. • To suggest priorities for developing data and testing metrics in the short to medium term to allow better aggregate comparative assessment. • To identify which organisation/s might be best placed to provide such aggregate comparative assessments. In addressing the above we defined ‘aggregate’ assessment loosely, and it was assumed to mean assessment that is reported publicly. As shorthand for ‘aggregate assessment’ of performance we use the term ‘rating’ (despite the unhelpful connotations from the past). We defined providers as being publicly or independently owned, and due to time constraints just considered the following broad groups: hospitals; general practices; and providers of adult social care – care homes (residential or nursing home providers) and domiciliary care providers. Engagement process To help gather intelligence we employed two main methods: engagement with key stakeholders; and reviews of relevant literature. The engagement process involved: a set of meetings with groups of stakeholders; an eight-week online consultation process; a series of three focus groups with the public; and bilateral meetings with key individuals (Appendix 1). We were struck by the generous contributions made by many and extend our thanks. The reviews of literature included grey and peer reviewed literature. We are grateful also to have been supported by an advisory group, the membership and terms of reference of which are shown in Appendix 2. The conclusions in the report however, are solely those of the Nuffield Trust. 5 Executive summary History of provider ratings There have been such ratings for providers before, in the period 2001–2009 in health care and 2008–2010 for social care, but these have been abolished. We outline the history in Chapter 2. The main observation is that there has been remarkable instability in the organisations doing the rating – instability which will have reduced the time for regulators to develop the system of ratings and to evaluate their impact. In health care, the rating with the longest shelf life was the Healthcare Commission’s Annual Health Check (2005–9), which applied to NHS trusts. Over that period, there is evidence to show that the performance of NHS trusts did improve, against the measures in the rating. But it was difficult to find robust evidence of whether this was a result of the rating or other factors such as the system of performance management at the time, or indeed what happened to performance against aspects of care not included in the rating. More specifically, while the costs of the organisations doing the rating were known, the costs to the organisations rated were not. For social care there is even less evidence, as the ratings were produced over a shorter period. In other words, the added value of a rating relative to the costs over other activities to improve the quality of care in providers is not clear. Nor indeed is the

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