By

Alan Maynard

Email:akm3@york.ac.uk

outline Introductory issues

Enduring problems

Achievements

Defending the achievements

Introductory issues: health production 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. Dead

2. Recovered

3. Relieved

4. Unrelieved

Fines of £2 for failure to comply

Little attempt to measure and manage systematically patient outcomes: no measure of success!

The distinction between outputs and outcomes An American health services researcher,

Donabedian, distinguished between:

1. Structure

2. Process

3. 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 safety

4. Reluctance to manage skill mix

5. Outcome measurement

„Flat of the Curve‟ Medicine?

Mark & Hlatky 2002, Fuchs 2004

What are the causes of uncertainty about 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

Hogarth

The failure to manage variations 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 do they 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: another rediscovery! 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 year

2. 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?

Lessons from the 19th century

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 cost

2. 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 consultants

2. Nurse endoscopists are equally as proficient as consultants

3. 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 numbers

2. Issues around case mix adjustments

3. 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 government achievements: evidence based 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 of incentivising change: pay for performance (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 Change

2. Lack of focus on what savings can be made by altering skill mix

3. 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 Questionnaire

EQ5D

Plus a standard set of patient-specific questions in all cases

Source: DH Operating Framework, Guidance on the routine collection of patient-reported outcome measures, Department of Health 2007

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% ) Worsen 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 436 449 430 266 717

Source: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.

Changes in health for five surgical procedures from LSHTM pilot

Overview for Labour achievements in health care Need to boast about and retain:

1. NICE: international excellence in analytical rigour

2. Targets

3. Focus on outcome measurement and management

Can do better on

1. Evaluation of “redisorganisations”

2. Evaluation of “storm” of policy initiatives

3. Low pay

4. “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”!