Aligning professional and systems regulation: Can the whole be greater than the sum of its parts?

Jon BillingsDirector of Strategy, Nursing and Midwifery Council, UK

Dubai Health Regulation Conference, 22-23 October 2014

Overview• Nursing and midwifery regulator for England,

Wales, Scotland and Northern Ireland (one of 9 professional regulators)

• Remit and powers set out in the Nursing and Midwifery Order 2001

• Subject to oversight by the Professional Standards Authority (PSA)

• Accountable to the public and to Parliament, through the Privy Council

• 680,000 nurses and midwives on register

The NMC’s regulatory functions• Holding the register of nurses and midwives

who practise in the UK• Setting standards of education and quality

assuring programme provision• Ensuring nurses and midwives continue to be

fit to practise once on the register by setting conduct and performance standards

• Taking action to prevent harm to the public where nurses and midwives fall short of required standards

Today’s discussion• Models of establishment and professional

regulation

• Drivers and challenges for integration

• International use of standards in each sector

• Possible approach to better coherence between establishment and professional regulation

Models of regulationProfessionals

• State/province run – e.g. Dubai• Professional run – e.g. Germany• Independent (from govt. and profession) –

e.g. UK, Netherlands

Institutions, establishments, ‘systems’• Statutory inspection or supervision - e.g. UK,

Ireland, Netherlands• Statutory accreditation• Voluntary accreditation

Separate v integrated regulationIntegrated

• Netherlands• Denmark• France• Dubai Health Authority

Separate• UK• Ireland• US• Australia

High profile failings have shaped UK regulatory policy

Bristol Royal Infirmary – late 1990s

- 33% of children having cardiac surgery had sub-optimal care

- caring, well motivated people lacked insight; failed to communicate and work together in the interests of patients

- lack of leadership and teamwork

Shipman enquiries - mid 2000s

- well regarded doctor; popular with patients – killing hundreds

- questions the impact of medical regulation and clinical governance

- highlighted need for intelligent use of performance indicators

Mid Staffordshire NHS Hospital – late 2000s to early 2010s

- failure to deliver acceptable care to patients

- too focused on finances rather than on experiences of patients

- need for better coordination between regulatory bodies

Challenges to a joined-up approach

• Regulators developed at different times, from different origins and with different statutory bases

• In Europe regulation split between different or overlapping government departments at national or regional/provincial/local level

• UK has many professional regulators and different systems regulator in each of its 4 jurisdictions

• Scale and specialisation in larger jurisdictions

• Standards for organisations and individuals not aligned

What do we learn from experience?• Serious failures rarely due to either systems or

individuals alone• poor performing individuals can lead to poor performing

organisations• poor performing organisations will inhibit well performing

professionals• leadership, management, openness and accountability

essential for good clinical services – organisation competence and behaviour

• Conduct, skills, training and development are paramount – professional competence and behaviour

Safety and quality: a shared agenda

Professions focus

Establishmentfocus

LeadershipGovernance

System and professional standards

EffectivenessRecruitment and credentialsTraining and development

Audit and monitoringResponding to concerns

Use of information and dataFeedback from staff and

patients

Establishment v professional standards, UK

Care Quality Commission, England

• Safe• Effective• Caring• Responsive to needs• Well led

General Medical Council

• Knowledge, skills and performance

• Safety and quality• Communication,

partnership and teamwork

• Maintaining trust

Establishment v professional standards, Ireland

Health Information and Quality Authority

• Person-centred• Effective• Safe• Better health and

well-being• Leadership• Workforce• Resources• Information

Nursing and Midwifery Board

• Respect for dignity• Responsibility and

accountability• Quality of practice• Collaboration with

others

Establishment v professional standards, US

JCI hospital standards• Safety• Access & continuity• Rights• Patient assessment• Anesthesia & surgery• Medication• Patient education• Quality improvement• Infection control• Governance• Staff qualifications

American Medical Board

• Clinical practice improvement advice

• Safety• Legal issues• Ethics• Medical science

Person-centred

Safe

Effective

Trustworthy

Towards core principles

CareCompassion

Dignity

Safety behaviourHuman factors

Team orientationReporting

Evidence-based practice

Technical skillsExperimentation

HonestyProbity

Professionalism

PersonalisationInvolvement

ListeningRights

Safety systemsSafety culture

Monitoring

Clin. guidelinesLearning

InnovationQuality control

TransparencyLeadershipGovernance

Est

ablis

hmen

tsIndividual professionals

Conclusions• Service quality (and service failure) rarely result from

either organisation or individual performance alone.• Care quality ‘happens’ between a professional and their

patient so individual competence and professionalism are vital

• But organisation structures, systems, resources and culture are crucial in setting the environment for care

• Integrated establishment and professional regulation may be optimal, but scale and specialisation are an issue in some jurisdictions

• Setting establishment and professional standards based on shared core principles may help in bridging the establishment/professional divide

Thank you

Jon Billingsjon.billings@nmc-uk.org@nmcnews@billingsjon