Is the quality of health care changing? GPs' views

Examines the debate on quality in health care in light of GP fundholding and the Patients' charter. Focuses on the development of quality issues in General Practice by carrying out research based on two stages: first, an exploratory stage aimed at the understanding of key issues; and second, a questionnaire made up primarily of attitude elements drawn from stage one. Concludes that, in the changing political and public environment, GPs are facing the challenges of managing service quality.     

What is adequate health care and how can quality of care be improved?

Attempts to improve patient care, its increasing cost and the aggressive malpractice environment have highlighted the need for standards of professional accountability. However, current measures of quality of care have mostly been met with skepticism by the medical community. These measures have been criticized for their uncertain validity and for focusing on secondary aspects of service that measure what is minimally acceptable. The objective of this essay is to review quality improvement methods that have been reported to be feasible, effective and acceptable by practicing physicians. The successful implementation of these methods seems to be related to their being nonintrusive, nonthreatening, and based on agreed upon standards of care. We believe that these three features are essential for a continuous quality improvement process in health care.     

Getting to the truth? Researching user views of primary health care

In countries at all levels of development, assessing the opinions of health service users is increasingly promoted as an integral part of quality evaluations. However, there has been much debate on how best to measure user opinions. This article discusses findings from a study in South Africa, which employed both closed-ended facility exit interviews (total 337) and open-ended community-based focus group discussions (total 14) to obtain users' views on the same set of primary care providers. We outline various difficulties encountered in the interpretation of the data. First, in the absence of explicit and universal standards, users evaluated providers against their experiences with other health care services available to them in their areas. Responses were thus highly context specific, dependent on the particular configuration of services in each site. Secondly, the focus group discussions provided a very different (generally more negative) picture of providers to the exit interviews, suggesting that where and how views of health services are elicited has a large bearing on the results obtained. Thirdly, the focus group discussions appeared to encourage dramatic representations of what was, on observation, a banal everyday reality. Both methods defied superficial reading, and each appeared to have limitations in establishing the 'truth' about people's opinions. We conclude that there is a need for greater recognition, in quality assessments and in quality assurance, that user and community opinion is a social rather than a technical phenomenon. As such it is dynamic, bound to particular contexts and difficult to capture in single, 'snap-shot' assessments, no matter how well designed. In the context of quality assurance programmes, time spent assessing user views may be better used in other ways such as training and supporting health care workers to engage directly in dialogue with communities around needs and expectations.     

What is consumer-directed health care?

To control health care costs, someone must choose between health care and other uses of money. The value of most health care is experienced subjectively, as is the value of other goods and services. No one is in a better position to make these subjective trade-offs than patients themselves. The current system not only systematically denies patients the opportunity to make such choices, it distorts the incentives of providers in the process. Chronic patients in particular would be much better off if they could manage more of their own health care dollars and if providers were free to compete to meet their needs.     

What is the health care product?

Because of the current competitive environment, health care providers (hospitals, HMOs, physicians, and others) are constantly searching for better products and better means for delivering them. The health care product is often loosely defined as a service. The authors develop a more precise definition of the health care product, product line, and product mix. A bundle-of-elements concept is presented for the health care product. These conceptualizations help to address how health care providers can segment their market and position, promote, and price their products. Though the authors focus on hospitals, the concepts and procedures developed are applicable to other health care organizations.     

Healthy partnerships,healthy citizens? An international review of partnerships in health and social care and patient/user outcomes

As a result of changes in the governance of health and social care organizations across developed welfare states they are under increasing pressure to work in partnership with each other (at an organizational and inter-professional level) and with the private and voluntary sector. Drawing on a comparative literature review of the theoretical and empirical evidence from health and social care partnerships across developed welfare states, this paper aims to examine the policy drivers behind such changes and the effects the changes have had on the governance of health and social care, the results for service commissioners and practitioners, and particularly the results for patients and service users. It examines some of the evidence that suggests that patient/user involvement and outcomes may at best be unaffected, and at worst be negatively compromised by shifts towards increasing partnership working in health and social care. It will conclude by discussing what lessons can be drawn about service re-organization and user involvement in welfare organizations generally, and how best to protect the interests of vulnerable and disenfranchised groups of service users.     

Healthy partnerships,healthy citizens? An international review of partnerships in health and social care and patient/user outcomes

As a result of changes in the governance of health and social care organizations across developed welfare states they are under increasing pressure to work in partnership with each other (at an organizational and inter-professional level) and with the private and voluntary sector. Drawing on a comparative literature review of the theoretical and empirical evidence from health and social care partnerships across developed welfare states, this paper aims to examine the policy drivers behind such changes and the effects the changes have had on the governance of health and social care, the results for service commissioners and practitioners, and particularly the results for patients and service users. It examines some of the evidence that suggests that patient/user involvement and outcomes may at best be unaffected, and at worst be negatively compromised by shifts towards increasing partnership working in health and social care. It will conclude by discussing what lessons can be drawn about service re-organization and user involvement in welfare organizations generally, and how best to protect the interests of vulnerable and disenfranchised groups of service users.     

Does country influence the health burden of informal care? An international comparison between Belgium and Great Britain

The aim of this paper is to determine whether the association between the provision of informal care and the health status of caregivers is affected by the country of residence. We focus on two European countries, Belgium and Great Britain, and develop a methodology, which consists of matching a subset of areas from Britain with areas in Belgium that are demographically and socioeconomically similar. These pairs of areas are then used as fixed effects in logistic regressions of poor health. This allows us to take into account the influence of area type on health and to remove the influence of these local contextual characteristics from the estimated country effects. Results suggest that, although caregiving is more prevalent in Britain, the health burden associated with heavy caregiving activities is lower in Britain than in Belgium. This may be explained by the better targeting of long-term home care policies towards more severely dependent patients in Britain than in Belgium.     

Unobserved health care expenditures: How important is censoring in register data?

Accurate information on individuals' health service use is important for evaluating health policies and analyzing health care demand. Although register data are considered to be more reliable than survey data, little is known about the extent and effect of censoring of the expenditure distribution in register data. We exploit a recent change in the health provider remuneration system in several Swiss cantons to empirically investigate whether censoring occurs when individuals do not have to disclose their health service use below their deductible level. Applying a difference‐in‐differences approach, we find that between CHF 6.70 (1.7%) to CHF 9.64 (2.4%) of all health service use paid out‐of‐pocket are not observed (per capita per year). This effect seems to be driven by high‐deductible plans where observed out‐of‐pocket expenditures declined by CHF 30.34 (7.6%) after the change. Although statistically significant, these effects are almost negligible in economic terms. We therefore concluded that, if anything, censoring is a very limited issue in Swiss health insurance claims data.     

Do health plans influence quality of care?

OBJECTIVE: To investigate the relative impact of physician groups and health plans on quality of care measures. DESIGN: Secondary data analysis of receipt of preventive care services included in the Health Plan Employer Data and Information Set (HEDIS) among 10 758 patients representing 21 health maintenance organizations and 22 large provider groups in the San Francisco and Los Angeles, California, areas in 1997. Each patient was eligible for (at least) one of six HEDIS-measured services. Data identify whether or not the service was provided, the patient's health plan, and the provider group responsible for the care. We used logistic regression to examine variations across plans in HEDIS rates, and whether variations persist after controls for provider groups are included. SETTING: Patients from 21 health maintenance organizations serving San Francisco and Los Angeles, California, in 1997. MAIN OUTCOME MEASURES: Breast cancer screening, childhood immunizations, cervical cancer screening, diabetic retinal exam, prenatal care in the first trimester, and check-ups after delivery among patients for whom these services are appropriate. RESULTS: There are statistically significant differences across health plans in utilization rates for the six services examined. These differences are not substantially affected when we control for the provider group that cared for the patient. That is, controlling for provider group does not explain variations across plans, consistent with the view that health plans have an impact on HEDIS quality measures independent of the providers that they contract with. CONCLUSIONS: There are activities that plans can undertake which influence their HEDIS scores. On the face of it, these results suggest that plans can independently improve quality, in contrast to hypotheses that plans would be "too far" from patients to have an influence. Continued attention to collecting plan-level data is warranted. Further work should address other possible sources of variations in HEDIS scores, such as variability in the quality of plan administrative databases.     

How comprehensive are the basic packages of health services? An international comparison of six health insurance systems

OBJECTIVES: Interest in the composition of the health care menu has grown. Its outwardly comprehensive nature is as rhetorical as the slogans of universal access and affordability. This paper summarizes the international part of a report to the Swiss government, in which we explored the basic package of services covered by social health insurance in France, Germany, Israel, Luxembourg, The Netherlands and Switzerland. The aim of the initial report was to check the appropriateness of the Swiss catalogue, with special attention to the risk of unequal access to health care by rationing of effective services. In this paper, we highlight the major differences in service coverage between the countries and address the possible factors explaining those differences. METHODS: The contents of the basic packages of the six countries were compared using data from government ministries and sickness funds. RESULTS: Coverage is most comprehensive in Germany and Switzerland; these are also the countries with the greatest total health expenditure. Three countries separated nursing care from other types of health care by creating an independent insurance scheme. Some health care benefits are also covered under the heading of social care. High out-of-pocket payments are increasingly used as hidden rationing instruments. CONCLUSIONS: The present comparison highlights the multi-factorial character of the choices made in six countries in order to keep their health care menu within the possibilities offered by available resources.     

How important is sex in later life? The views of older people

Stereotypes of an asexual old age remain pervasive, shaping not only popular images of older people, but also research and policy agendas. However, older people's own attitudes towards the role and value of sex in later life remain relatively unexplored. This paper draws on both quantitative and qualitative data to examine how sex is prioritised in middle age and later life. Data collection methods involved completion of two quality of life measures (WHOQOL-100 and WHOQOL Importance Scale), followed by semi-structured interviews. In total the sample comprised 69 individuals recruited from the age/sex register of a general practice in Sheffield in the UK. This paper will focus upon the accounts of 21 men and 23 women aged 50-92 years. Ratings of the importance of sex to participants were gathered from the WHOQOL Importance Scale; the in-depth interviews enabled the basis for this prioritisation to be explored. Analysis identified the following key themes. Participants who did not consider sex to be of any importance to them neither had a current sexual partner, nor felt that they would have another sexual partner in their lifetime. Indeed, all participants who had a current sexual partner attributed at least some importance to sex, with many rating sex as 'very' or 'extremely' important. However, experiencing barriers to being sexually active led them to place less importance on sex; this was particularly apparent when health problems and widowhood were experienced. Age was seen as facilitating coping when sex became less frequent, or stopped altogether. This was explained in terms of sexual desire decreasing with age (for some male participants), the cessation of sex being easier to cope with in a relationship of long duration and the expectation that sex will become less possible with 'normal ageing'. The discussion considers the implications of these findings for this developing field.