outline Introductory issues Enduring problems Achievements Defending the achievements
Introductory issues: healthproduction The production of health: the primary determinants of health are: Genetic endowment: Larkin Behaviour: parents again, income and education Health care: repair industry costing £105 billion
What is health? “Health is a state of physical, mental and social well being and not merely an absence of disease and infirmity” WHO 1946 1845 Lunacy Act required doctors to report regularly whether their patients were:1. Dead2. Recovered3. Relieved4. Unrelieved Fines of £2 for failure to comply Little attempt to measure and manage systematically patient outcomes: no measure of success!
The distinction betweenoutputs and outcomes An American health services researcher, Donabedian, distinguished between:1. Structure2. Process3. Outcome Policy obsessed by “redisorganisation”, and an assumption of a link between that and processes and outcomes What is “productivity”:a relation between inputs and outputs, or a relationship between inputs and outcomes?
Enduring problems Five related issues in all health care systems, public and private, create waste and inefficiency:1. Uncertainty about whether health care/medicine “works”2. Persistent variation in clinical practice, and the failure to deliver to patients what “works”3. Patient safety4. Reluctance to manage skill mix5. Outcome measurement
„Flat of the Curve‟ Medicine? Mark & Hlatky 2002, Fuchs 2004
What are the causes of uncertaintyabout clinical effectiveness? Not so much a problem of inadequate funding of R&D and clinical trials, more that the quality of research is poor.1. The problems of designing and reporting clinical trials e.g. the problem of “surrogate” end points, poor outcome measurement and biased reporting.2. What is the comparator?3. What patient groups are included in the trial?4. How long do you run the trial? Vioxx case
The failure to managevariations in England Priorities in Health and Personal Social Services (1976) from the Department of Health advocated a focus on day surgery and reducing length of stay. The first article showing the day case surgery for hernia repair was effective was in the Lancet in 1955 but there was little take up Much still needs to be done to follow this advice 30 years later e.g. the English NHS Innovation and Improvement Institute Not just a NHS problem e.g. US Medicare and the Dartmouth Atlas
Practice variations in the USA US Medicare per capita spending in 2000 was $10,550 per enrolee in Manhattan and $4823 in Portland, Oregon. Differences are due to volume effects rather than illness differences, socio- economic status or price of services. “Residents in high spending regions received 60% more care but did not have lower mortality rates, better functional status or higher satisfaction” Fisher et al Annals in Internal Medicine(2003). Potential savings of 30% of total Medicare expenditure if high spenders reduce expenditure and provide the safe practices of conservative treatment regions? (Fisher in NEJM, October, 2003)
Practice variations: why dothey persist? “the amount and cost of hospital treatment in a community have more to do with the number of physicians there, their medical specialties and the procedures they prefer than the health of residents” Wennberg and Gittelsohn(1973 in the journal Science) The English Darzi report (2008) “rediscovered” clinical variation as major policy issue! Two policy issues:1. Careful data analysis to identify outliers and to improve average=mean performance2. Use data analysis, benchmarking and improving average performance by improving non-financial and financial incentives
Patient safety: anotherrediscovery! UK cases :Shipman, the Bristol case and two gynaecologists (Ledward and Neale) Measuring error rates is difficult and the evidence base is incomplete:1. USA 3-5% of hospital admissions (Institute of Medicine, 2000)2. UK :two retrospective English studies of case notes (Vincent et al, BMJ 2001, and Sari et al (2006)) :10%3. Australia: 16% (=10% if US criteria used)
Patient safety 2 US rates of 3-5% from tow local surveys means that:1. Medical errors in hospitals kill 44,000-98,000 Americans each year2. Errors kill more Americans than motor vehicle accidents (43,458), or breast cancer (42,297) or AIDS (16,516)3. Medication errors alone kill nearly three times more Americans than 9/11
Patient safety 3 Types of errors1. Medication: wrong drug, wrong dose2. Surgery: wrong procedure3. Infection control (Semmelweiss and Nightingale in the 19th century) :what is the “cure” for poor infection control? What is the efficient level of errors (it may not be zero!). Where is the evidence base to inform efficient investment in the “hygiene code”? E.g. interventions to reduce central line infections, C.Diff and MRSA, pressure sores etc?
Patient safety The need to avoid “religious fervour” as seen in the USA (www.ihi.org ) and at the World Health Organisation In particular:1. Identify which of the many competing safety interventions are efficient i.e. improve patient outcomes at least cost2. Recognise that the efficient level of public safety is not zero errors!
Skill mix Evidence from the Cochrane reviews that nurse practitioners with full prescribing rights can act as substitutes for GP (and patient like them better!) Evidence that assistant practitioners can replace registered nurses Evidence that e.g.1. Nurse anaesthetists can replace consultants2. Nurse endoscopists are equally as proficient as consultants3. What else? But are they used as complements or substitutes!
Measurement of success i.e.outcome measurement Mortality rates: use with caution!1. Issues of small numbers2. Issues around case mix adjustments3. Use as screening device, not as a diagnostic Quality of life , pre and post treatment: patient reported outcome measurement (PROMs): reintroduce the 1845 Lunacy Act
Labour governmentachievements: evidencebased medicine and policy The National Institute for Health and Clinical Evidence (NICE). Many roles:1. Evaluating the clinical and cost effectiveness of new drugs (Technology Appraisal)2. Producing clinical practice guidelines based on clinical and cost effectiveness3. Identifying what works in public health e.g. minimum price for alcohol (and taxation of sugary drinks?)4. Improving the GP contract with evidence based incentives (after investing nearly£1 billion in incentives (quality outcomes framework(QOF)), some of which are inefficient!)
And failures Continuous “redisorganisation” of structures with no attempt to evaluate them e.g. 2006 merger of PCTs (see Select Committee report on Commissioning, 2010) Introduction of interventions to help the disadvantaged with little scientific evaluation of effect e.g. “Head Start” (see the Select Committee report on inequality, 2008)
Clinical practice variations Targets work: e.g. 18 week waiting time for elective procedures, cancer targets and 4 hour waits in A&E But “advice” slow to take effect e.g.1. NHS Institute for Innovation and Improvement illustrates variation but how good is take up?2. Poor management of the consultant contract: do they do their sessions, how many do they treat in their theatre sessions and what are their outcomes: make national audits compulsory?3. Need for greater transparency and accountability
Patient safety C.Difficile and MRSA: avoidable infections with better hand hygiene and better antibiotic policy Beginning of benchmarking of rates of e.g. pressure sores drug errors, wrong site surgery , falls and items left in patients after surgery E.g. failure to give patients prescribed drugs in hospital. The new “quality account” of UH Birmingham benchmarked drug omissions for the first quarter of 2009 and is now managing them down. Omission rates on their website: 11% for antibiotics and 20% for other drugs. To incentivise change should we “pay „em or flay „em”? Are financial incentives the new “solution”!?
Potential risks ofincentivising change: pay forperformance (P4P) It is difficult to see if employees make the right decision e.g. the results of decisions may not be evident for years P4P attracts risk takers rather than those who want steady employment Employees may manipulate the system e.g. “exemptions” in the GP-QOF P4P crowds out intrinsic rewards i.e. P4P rewards may drive out the natural inclination of workers to do a good job Thus Akerlof and Kranton (2010) argue that “people want to do a good job because they think they should and because it is the right thing to do” In efficient firms the goals of workers and their organisations are aligned. Comments on CQUIN - Maynard and Bloor, BMJ, February 2010
Skill mix Invest in workforce substantial in terms of numbers and pay increases Innovatory practices but little evaluation Problems remain:1. Enforcement of contracts e.g. Agenda for Change2. Lack of focus on what savings can be made by altering skill mix3. Continued wide pa y differentials e.g. porters and other ancillaries near NMW and no quid pro quo for consultant pay increases
Measuring Patient Outcomes in the English NHS Procedure Condition-specific Generic Primary Unilateral Hip Replacement Oxford Hip Score EQ5D Primary Unilateral Knee Replacement Oxford Hip Score EQ5D Groin Hernia Repair None EQ5D Varicose Vein Procedures Aberdeen Varicose Vein EQ5D Questionnaire Plus a standard set of patient-specific questions in all casesSource: DH Operating Framework, Guidance on the routine collection of patient-reported outcome measures, Department of Health 2007
Changes in health for five surgical procedures from LSHTM pilot Hip Knee Hernia Veins Cataract Improve 358 (82.1% ) 329 (73.3% ) 203 (47.2% ) 148 (55.6% ) 150 (20.9% ) No change 21 (4.8% ) 45 (10.0% ) 127 (29.5% ) 72 (27.1% ) 335 (46.7% ) W orsen 18 (4.1% ) 34 (7.6% ) 71 (16.5% ) 34 (12.8% ) 190 (26.5% ) Mixed change 39 (8.9% ) 41 (9.1% ) 29 (6.7% ) 12 (4.5% ) 42 (5.9% ) Total 436 449 430 266 717Source:Using the EQ-5D as a performance measurement tool in the NHS Nancy Devlin a,David Parkin a, and John Browne b. EuroQol Group Scientific Plenary, Baveno, Italy, 11-13th September 2008.
Overview for Labourachievements in health care Need to boast about and retain:1. NICE: international excellence in analytical rigour2. Targets3. Focus on outcome measurement and management Can do better on1. Evaluation of “redisorganisations”2. Evaluation of “storm” of policy initiatives3. Low pay4. “Value for money”: variations in processes and outcomes ignored too often.5. Commissioning: weak exercise of purchasing power.6. Nursing processes and quality
The future…….. Budget squeeze with shift out of hospital financing to primary and social care |massive Tory “redisorganisation” from April 2012 PCTs gutted and replaced by GP consortia NHS Board with Regional Offices replacing SHAs Fate of targets and NICE uncertain, with the latter threatened by industry Static pay: but maybe pay cuts above say £25000 and graduated? The challenge: measurement and management of data and evidence rather than random “surgery”!