Evidence-based purchasing o Pearson Professional Ltd /9Y7

Gray J D, Donaldson Lclmproving the quality ofhealth care through contracting: a studyofhealth authority practice. Qual Health Care 1996; 5: 201-205

Quality specifications in purchasingcontractsfor care were imprecise andoflimited effect

Objective

To identify methods used by district healthauthorities to improve quality throughpurchasing contracts.

Setting

England.

Method

A survey was undertaken of II purchasingorganizations covering the contractingperiod I April 1993 to 31 March 1995.

Literature review

No explicit strategy; 18 references.

Outcome measures

The presence of quality specifications andtheir scope and content in relation toevidence-based criteria for measuring healthcare quality.

Analysis

The quality topics covered were analysed toidentify if it was possible to measure eitherachievement of, or failure to achieve, thequality target.

The types of issue covered by thespecifications were classified into sixgroupings; requirement for audit to becarried out, specific issues relating to servicedelivery, waiting times for treatment, thelevel of skill required, consumer issues, and

clinical care standards. 'None of thepurchasers specified explicit measures ofperformance for clinical care in their generalquality documents.' Standards of medicalpractice were specified in 5'70 of servicecontracts.

Results

109 quality specifications were foundcovering six specialties - general medicine,general surgery, trauma and orthopaedics,ophthalmology, obstetrics, and psychiatry;eight were general quality specifications,and 121 were specific to the relevantspecialties.

Authors' conclusions

The authors conclude that 'attempting toachieve key quality improvements throughcontracts ... is not an approach which isundertaken consistently, rigorously or in away which is likely to achieve desiredquality goals.'

Commentary

In the early days of the UK health carereforms, there was a flurry of activity ashealth authorities attempted to describe theservices they purchased as servicespecifications. This paper suggests that thisactivity was not effective in improvingquality of health care. My personalexperience of, and the rather cynical reactionof many clinical colleagues to, the process ofspecification would support this.

There probably is a role for contracts inquality improvement. This though is only atthe end of a long process of collaborativework on specific health care programmeswhere clinical processes have been agreedwith and supported by clinicians and users.This means that purchasers of health care areonly able to tackle issues of service qualityfor a small range of health care programmes.Choice of programme is crucial; to make animpact the programme must be one thatrepresents large health care spend andinvolves many health care workers .Monitoring is an essential element of thisapproach, as with any quality process. Thecomplexity of data gathering, however, is ahuge barrier to obtaining useful information.Outcome data is still a remote wish for manyproviders and purchasers and reliance isplaced on processes that are supported bygood quality evidence.

Another approach to qualityimprovement that is gaining support frompurchasers (and providers) is that of externalquality assurance, as in the breast andcervical screening programmes. Otherexamples include the King's Fundorganizational audit, and growing interest inaccreditation of clinical services.

Purchasers also have a wider role in theprocess of clinical quality through theirinfluence on the clinical audit and widerquality improvement. Again specifying andcontracting are not likely to be an effectiveway of influencing and making changeexcept as the last step in a long process ofnegotiation and agreement. There is a longway to go still to the point where purchaserscan be assured that primary and secondaryhealth care providers have established robustquality improvement processes. Given thatspecifications will never adequately describethe full range of health care purchased,assurance that generic quality improvementprocesses are in place must be the aim.

The implication of this useful andimportant paper is therefore that purchasersneed to reduce reliance on specifications andcontracts to improve quality, and tocollaborate with primary and secondary careproviders and with users of the service toestablish appropriate frameworks andmechanisms to put quality improvement atthe centre of health care provision.

Dr Alison IfillDirector ofPublic Health

Bucking/willshire Health Authority

8 EVIDENCE-BASED HEALTH POLICY AND MANAGEMENT 1997