Aged care regulation: lessons from England

Australia can take some lessons from England’s experience as it moves towards the establishment of a quality commission for aged care, an industry conference has heard.

Australia can take some lessons from England’s experience as it moves towards the establishment of a quality commission for aged care, an industry conference has heard.

Sir David Behan headed England’s Care Quality Commission from 2012 to July this year after a series of crises in the nation’s aged and disability care sectors sparked a wave of national reform.

Speaking to Community Care Review from the ACSA Summit in Sydney on Tuesday, Sir David said there were “powerful resemblances” between what happened in the UK and the current situation in Australia, where a review of serious failures at South Australia’s Oakden facility led to recommendations for the establishment of a similar regulatory body.

Sir David Behan
Sir David Behan speaks at ACSA Summit 2018

Minister for Senior Australians and Aged Care Ken Wyatt announced in April that an independent regulator, the Aged Care Quality and Safety Commission, will from next year be responsible for approval, accreditation, assessment, monitoring, compliance and complaints management of all government subsidised aged care providers.

Sir David Behan: “If I look at the history of regulation in England, it’s driven by crises and scandals, and when I read the report of Oaken there were powerful, powerful resemblances with what had gone on in some of those stories in England.

“I think what Oaken has provided you with is an opportunity to fix some of the weaknesses in the system. The opportunity is to learn from what we’ve done in England and I hope that some of those things can inform your solutions here.”

England’s quality commission, consisting of 3,000 staff, regulates all care in England and providers must be registered to deliver service. Last year it carried out 49,000 investigations.

A series of landmark scandals

Prior to the 1970s, health in England was unregulated and private care was regulated by local authorities. The move to regulation was driven largely by a series of landmark scandals.

These included the Longcare inquiry into the serious abuse of people with learning difficulties, revelations of serious neglect of elderly people at Mid Staffordshire Hospital and the Winterbourne View care home scandal.

All of these failures reflected failures of governance, Sir David said.

Since then the CQC had introduced a range of reforms, including changing the way inspections are carried out and raising the bar for registration, as well as ushering in better ways of assessing and predicting risk.

Most importantly, the public had to be confident that the regulator had their interests at heart and was neither a mouthpiece for government nor a captive of providers.

“One of the key things I learnt is the importance of having an independent regulator, a regulator that’s independent of government and independent of providers and the language I would have used in England is being on the side of people that use services,” he said.

“I always conceptualise my role as holding three constituencies – the people who use services the public, the providers and politicians.

“My responsibilities was to all three but preserving independence, speaking truth to power at times about the effectiveness of the service, was a key responsibility. You need to be independent from sector and government.”

Hard and soft levers

The purpose of the commission was to make sure providers provided safe, effective and quality care and to encourage services to improve, he said.

This ranged from using “soft levers”, like providing information, building relationships and reviewing systems, to “hard levers” like prosecution and deregistration.

“In 2014 we were given the power to take criminal prosecutions against services … and we’ve increasingly used those powers. But our ultimate sanction is not to issue a fine, it’s to remove a registration and we’ve also used that power.”

But the strongest tool was the CQC’s power to regulate, which encouraged change to come from within, rather than being externally enforced.

“Regulation plays a really important role in setting out quality standards services should work towards.

“But it doesn’t replace the responsibility of providers to provide quality services. You cannot regulate quality into services because providers put quality into services by what they do and how they do it.

“What regulation can do is assess whether there is quality in services or not, report on that and then go back and check whether improvements have taken place.

“We rate services and this has a real currency. Hospitals, general practices, care homes want an outstanding rating because they want that badge that says they provide the really great care in England. Similarly there have been services which have been rated inadequately who if they haven’t been able to improve, their registration has been removed and they no longer provide care. So the bottom end of the market, who are providers who have left the market and at the top end services have continued to improve.”

Australia’s new commission will begin operations from January 1 next year.

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3 thoughts on “Aged care regulation: lessons from England

  1. We can learn a few things from the English experience with regulation. In aged care as in every other activity the outcomes for the organisation are directly related to the leadership. The success and contribution to quality improvement of the new Aged Care Quality and Safety Commission will not be driven by changes in regulation and processes. It will be driven by the quality of the leadership of the Commission. The selection of the Commissioner may well be one of the more important appointments in aged care in decades. The capacity to remain independent of the stakeholders and know when to push which lever at what time are absolute prerequisites.

  2. A system that depends on regulation for the provision of good care is a system that is flawed and needs fixing.

    The UK, the USA and Australia have all had similar problems and recurrent regulatory failure – each resulting in repeated changes to the centrally regulated system. They have not worked either. The first step must be to change the patterns of thinking and the practices in the sector.

    All three countries provide aged care within the competitive market and this is not suited to the sector. Markets are only effective when there are empowered customers and an actively involved community. Neither exists in this sector.

    Informed regular interaction between knowledgeable and empowered people in communities is the most effective form of both regulating and changing thinking. Inappropriate ideas can be confronted, problems detected early and strong social pressures brought to bear.

    Power should be restored to local communities who should play a central role in the management and oversight of aged care services. They are the best early warning system. The role of central regulators should be to support and work with them.

    The best way to move in this direction is to build the regulatory system around an empowered visitors scheme drawn from and working with local community groups. Their role would be to work with providers to support residents and families when they have problems and advise them in making choices.

  3. Michael’s comment (above) is spot on, so I won’t repeat his contribution. I will only point out that the English Care Quality Commission (CQC) is a product of the repeated FAILURE of regulation, and the foolish belief that simply doing more of what has previously failed will eventually succeed. It won’t.

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