Quality indicators for primary care mental health services

Objectives: To identify a generic set of face valid quality indicators for primary care mental health services which reflect a multi-stakeholder perspective and can be used for facilitating quality improvement.

Design: Modified two-round postal Delphi questionnaire.

Setting: Geographical spread across Great Britain.

Participants: One hundred and fifteen panellists representing 11 different stakeholder groups within primary care mental health services (clinical psychologist, health and social care commissioner, community psychiatric nurse, counsellor, general practitioner, practice nurse/district nurse/health visitor, psychiatrist, social worker, carer, patient and voluntary organisations).

Main outcome measures: Face validity (median rating of 8 or 9 on a nine point scale with agreement by all panels) for assessing quality of care.

Results: A maximum of 334 indicators were rated by panels in the second round; 26% were rated valid by all panels. These indicators were categorised into 21 aspects of care, 11 relating to general practices and 10 relating to health authorities or primary care groups/trusts. There was variation in the total number of indicators rated valid across the different panels. Overall, GPs rated the lowest number of indicators as valid (41%, n=138) and carers rated the highest number valid (91%, n=304).

Conclusions: The quality indicators represent consensus among key stakeholder groups in defining quality of care within primary care mental health services. These indicators could provide a guide for primary care organisations embarking on quality improvement initiatives in mental health care when addressing national targets and standards relating to primary care set out in the National Service Framework for Mental Health for England. Although many of the indicators relate to parochial issues in UK service delivery, the methodology used in the development of the indicators could be applied in other settings to produce locally relevant indicators.

     

What do health authorities think of population based health outcome indicators?

OBJECTIVES: To determine the role of population based indicators of health outcome in local health outcome assessments; the constraints of using such indicators; how they could be made more useful; and whether health authorities had developed their own indicators of health outcome. DESIGN: A structured telephone interview with representatives of 91 of the 100 English health authorities. RESULTS: Interviewees, asked to give details on two clinical areas in which population health outcome assessments had been of most value, nominated 147 examples in over 30 clinical areas. They chose 50 (34%) of the examples because of an outlying national indicator, and 20 (14%) because of local variations in a national indicator. The main perceived constraints in the use of population based indicators of health outcome were: data validity and timeliness; the attributability of these health outcomes to the quality of health care; the difficulties of changing clinical behavior; and organisational change within health authorities. To make these indicators more useful interviewees wanted an increased use of process indicators as proxies for health outcome, indicator trend data, and indicator comparisons of districts with similar population structures. Some recent publications have started to consider some of these issues. 27 (30%) health authorities had developed their own indicators, mostly provider based process indicators. 10 of these used their own indicators to manage the performance of local provider units. CONCLUSIONS: Population based indicators of health outcome had an important role in prompting districts to undertake population health outcome assessments. Health authorities also used these indicators to examine local variations in health outcome. They helped to highlight areas for further investigation, initiated data validation, and enabled the monitoring of changes to services. Comparative population based indicators of health outcome may have an increasing part to play in assessing the performance of health authorities.     

Interregional variations in measures of health from the Health and Lifestyle Survey and their relation with indicators of health care need in England.

STUDY OBJECTIVE--The aim was to assess the extent to which a range of routinely available need indicators which have been suggested for use in NHS spatial resource allocation formulas were associated geographically in England with the different dimensions of population health status collected in the 1985/86 Health and Lifestyle Survey (HLS). DESIGN--Regional health authorities were ranked according to each of the HLS health variables which varied significantly between authorities. The HLS health variables were regressed on a selection from the range of routinely available morbidity and socioeconomic indicators available from the 1981 census. The potential need indicators were also regressed on the health variables. SETTING--The analyses were undertaken at individual level and at regional health authority level in England. SUBJECTS--The study comprised the English component of the HLS random sample representative of the population in private households in Great Britain. MAIN RESULTS--The different HLS health variables did not yield consistent regional health authority rankings. Among the variables, forced expiratory volume in one second (FEV1) and self assessed health appeared to be associated with most of the other health and need variables except longstanding illness. Longstanding illness was not strongly associated with any of the other HLS health variables but appeared to show some association with three deprivation indices constructed from the 1981 Census. CONCLUSIONS--There may be a case for including a measure of chronic ill health in the new NHS system of capitated finance in addition to the all cause standardised mortality ratio which is used currently as a measure of need for health care.     

Mortality amenable to health care in the United States: the roles of demographics and health systems performance

This article examines associations of socio-demographic and health-care indicators, and the statistic 'mortality amenable to health care' (amenable mortality) across the US states. There is over two-fold variation in amenable mortality, strongly associated with the percentages of state populations that are poor or black. Controlling for poverty and race with bi- and multi-variate analyses, several indicators of health system performance, such as hospital readmission rates and preventive care for diabetics, are significantly associated with amenable mortality. A significant crude association of 'uninsurance' and amenable mortality rates is no longer statistically significant when poverty and race are controlled. Overall, there appear to be opportunities for states to focus on specific modifiable health system performance indicators. Comparative rates of amenable mortality should be useful for estimating potential gains in population health from delivering more timely and effective care and for tracking the health outcomes of efforts to improve health system performance.     

The use of preventable hospitalization for monitoring the performance of local health authorities in long-term care

ObjectiveThe objective of the study was to examine whether there are differences in the performance of long-term care programs between local health authorities, using preventable hospitalization as an indicator.MethodsA retrospective cohort study compared the rate of preventable hospitalization for local health authorities in Tuscany (Italy) between January 2012 and September 2016. Several administrative datasets for the patients in long-term care programs were linked at the individual (patient) level. Elderly disabled patients 65 years of age and older in long-term care programs in Tuscany from both types of programs: nursing homes (n = 4 196) and home care (n = 15 659) were included in the study.ResultsThe rate of preventable hospitalization differed considerably between local health authorities. Three out twelve local health authorities had a significantly lower and one had a significantly higher preventable hospitalization rate than the regional average.ConclusionThere was a large variation in the rate of preventable hospitalization among the local health authorities. Applying preventable hospitalization as an indicator for quality, with implications for periodical audit can be used for monitoring the performance of a long-term care program.     

The equity lens in the health care performance evaluation system

The main objective of this paper is to describe how indicators of the equity of access to health care according to socioeconomic conditions may be included in a performance evaluation system (PES) in the regional context level and in the planning and strategic control system of healthcare organisations. In particular, the paper investigates how the PES adopted, in the experience of the Tuscany region in Italy, indicators of vertical equity over time. Studies that testify inequality of access to health services often remain just a research output and are not used as targets and measurements in planning and control systems. After a brief introduction to the concept of horizontal and vertical equity in health care systems and equity measures in PES, the paper describes the ‘equity process’ by which selected health indicators declined by socioeconomic conditions were shared and used in the evaluation of health care institutions and in the CEOs' rewarding system, and subsequently analyses the initial results. Results on the maternal and child path and the chronicity care path not only show improvements in addressing health care inequalities, but also verify whether the health system responds appropriately to different population groups. Copyright © 2013 John Wiley & Sons, Ltd.     

Towards medicines regulatory authorities' quality performance improvement: value for public health

The purpose of this article is to explore the possibility of implementing total quality management (TQM) principles in national medicines regulatory authorities in Europe to achieve all public health objectives. Bearing in mind that medicines regulation is a governmental function that serves societal objectives to protect and promote public health, measuring the effective achievement of quality objectives related to public health is of utmost importance. A generic TQM model for meeting public health objectives was developed and was tested on 10 European national medicines regulatory authorities with different regulatory performances. Participating national medicines regulatory authorities recognised all TQM factors of the proposed model in implemented systems with different degrees of understanding. An analysis of responses was performed within the framework of two established criteria—the regulatory authority's category and size. The value of the paper is twofold. First, the new generic TQM model proposes to integrate four public health objectives with six TQM factors. Second, national medicines regulatory authorities were analysed as public organisations and health authorities to develop a proper tool for assessing their regulatory performance. The paper emphasises the importance of designing an adequate approach to performance measurement of quality management systems in medicines regulatory authorities that will support their public service missions. Copyright © 2014 John Wiley & Sons, Ltd.     

The way ahead for district health systems

The weakest level in most health systems is probably that of the district, and the failings of district services have been cited in attempts to discredit the whole notion of primary health care. A district health system cannot function properly in isolation: in particular it should have firm links with its provincial authorities, and should benefit from the comprehensive involvement of the community it serves.     

Targeting the poor in times of crisis: the Indonesian health card

This paper looks at targeting performance of the Indonesian health card programme that was implemented in August 1998 to protect access to health care for the poor during the Indonesian economic crisis. By February 1999, 22 million people had received a health card. The health card provided a user fee waiver for public health care. Targeting of the health card was pro-poor, but with considerable leakage to the non-poor. Utilization of the health card for outpatient care was also pro-poor, but conditional on ownership, the middle quintiles were more likely to use the card. Targeting of the health card followed a decentralized design combining geographic targeting with community-based targeting instruments. This design facilitated the rapid implementation of the programme, but targeting performance suffered from a lack of information on the regional impact of the crisis, while at local level not all barriers to accessing health care services were overcome by the health card. Indirect and direct costs of seeking health care seem to be the main deterrent to using the health card, and are higher in more remote areas. Micro-simulations show that geographic targeting can contribute considerably to improving targeting performance, but most of the targeting gains are to be made at the local level, with district programme management and public health care providers. This study highlights the need for adequate and up-to-date social welfare indicators. In addition, further research would need to focus on how local knowledge can be utilized for signalling poverty dynamics and local barriers to access.     

Policy requirements and performance indicators for good practice in workplace health: public health perspectives

The author lists the main objectives, work areas and benefits of good practice in health, environment and social management in enterprises (GP HESME). History of this cross-sectoral and multidisciplinary approach to management of occupational, lifestyle, environmental and social health determinants is outlined. Health policy requirements and performance indicators are provided to facilitate GP HESME implementation at the enterprise and local levels. The role of local authorities and networking of enterprises, representing various sectors is highlighted.     

Comprehensive measurement of health system performance at district level in India: Generation of a composite index

There have been limited attempts at measurement of health system performance at decentralized levels in low‐ and middle‐income countries. This study was undertaken to develop a composite indicator to measure health system performance at district level in India. Primary data were collected from 377 public health facilities in 21 districts of Haryana state in India using health facility surveys. In addition, 1700 health care providers and 800 clients visiting health facilities were interviewed. Routine health management information system data at district and state level were also analyzed. These data were used for computing 67 input and process indicators covering six health system building blocks. Indicators were normalized and aggregated to generate domain‐specific and overall composite health system performance index (HSPI) for each district. Several sensitivity analyses were performed to assess robustness of results. Overall, Panchkula and Ambala districts were found to be the best performing in the state (with HSPI scores of 0.64 and 0.62 out of 1), while Mewat, Faridabad, and Palwal districts had the poorest performance (with HSPI scores of 0.46, 0.49, and 0.48 out of 1). Significant variation in performance was observed for each health system building block. Sensitivity analyses results showed that study findings were robust to variations in methods of aggregation of indicators. Our study provides a framework and methods to measure health system performance at district level in a comprehensive manner. The composite indicator provides a summary snapshot to benchmark performance, while building block and domain scores provide critical information for programmatic action.     

Performance indicators

Performance indicators have been introduced by the DHSS for scrutinizing the activity of regional and district health authorities. Because these are based on routine information, there are a number of problems in understanding what these indicators mean and there is a need to look at alternative ways of measuring performance.     

Cervical screening and health inequality in England in the 1990s

STUDY OBJECTIVE:s: To examine changing inequality in the coverage of cervical screening and its relation to organisational aspects of primary care and to inequality in cervical cancer incidence and mortality. DESIGN: Retrospective time trends analysis (1991-2001) of screening coverage and cervical cancer incidence and mortality in England. SETTING: The 99 district health authorities in England, as defined by 1999 boundaries were used to create a time series of incidence and mortality rates from cervical cancer per 100 000 population. A subset of 60 district health authorities were used to construct a time series of screening coverage data and GP and practice characteristics. Health authorities were categorised into one of three "deprivation" groups using the Townsend Deprivation Index. PARTICIPANTS: Women aged <35 and 35-64 were selected from health authority populations as the main focus of the study. RESULTS: Cervical cancer screening coverage was consistently higher in affluent areas from 1991-9 but ratio rates of inequality between affluent and deprived health authorities narrowed over time. The increase in coverage in deprived areas was most closely associated with an increase in the number of practice nurses. Cervical cancer incidence and mortality rates were consistently higher in deprived health authorities, but inequality decreased. Screening coverage and cervical cancer rates were highly negatively correlated in deprived health authorities. CONCLUSION: A primary health care intervention such as an organised programme of cervical screening can contribute to reducing inequality in population health.     

Health,policy and geography: Insights from a multi-level modelling approach

Improving the health and wellbeing of citizens ranks highly on the agenda of most governments. Policy action to enhance health and wellbeing can be targeted at a range of geographical levels and in England the focus has tended to shift away from the national level to smaller areas, such as communities and neighbourhoods. Our focus is to identify the potential for targeting policy interventions at the most appropriate geographical levels in order to enhance health and wellbeing. The rationale is that where variations in health and wellbeing indicators are larger, there may be greater potential for policy intervention targeted at that geographical level to have an impact on the outcomes of interest, compared with a strategy of targeting policy at those levels where relative variations are smaller. We use a multi-level regression approach to identify the degree of variation that exists in a set of health indicators at each level, taking account of the geographical hierarchical organisation of public sector organisations. We find that for each indicator, the proportion of total residual variance is greatest at smaller geographical areas. We also explore the variations in health indicators within a hierarchical level, but across the geographical areas for which public sector organisations are responsible. We show that it is feasible to identify a sub-set of organisations for which unexplained variation in health indicators is significantly greater relative to their counterparts. We demonstrate that adopting a geographical perspective to analyse the variation in indicators of health at different levels offers a potentially powerful analytical tool to signal where public sector organisations, faced increasingly with many competing demands, should target their policy efforts. This is relevant not only to the English context but also to other countries where responsibilities for health and wellbeing are being devolved to localities and communities.     

Working invisibly: health workers talk about capacity-building in health promotion

A series of six focus groups was held with health promotion workers to explore the meaning and experience of 'capacity-building', a term which is used variously in the literature. The research is part of a participatory, practice-based project to develop outcome indicators in capacity-building. Capacity-building was defined as seeking to develop health promotion skills and resources, and also problem-solving capability, at five levels: the individual; within health care teams; within health organisations; across organisations; and within the community. While workers had little difficulty in identifying outcomes of capacity-building, indicators of quality or good process were more difficult to articulate. This was partly because capacity-building was described as an invisible, even secret process. Capacity-building is hidden from funders and administrators because it is not generally regarded as a legitimate project activity; that is, it is not directly linked to risk factor behaviours in priority areas such as cancer, heart disease and injury control. Capacity-building is also hidden from other workers in order to make it more effective. This is particularly the case with health promotion workers working within what they perceive to be hostile climates, such as health care settings experiencing funding cut backs. The invisibility of practitioners' capacity-building work has implications for quality control guiding theory, practice ethics, peer support, worker morale and funding mechanisms in health promotion.     

Regional risk factors for health inequalities in Scotland and England and the “Scottish effect”

This paper uses data from the Scottish Health Survey 2003 and the comparable Health Survey for England 2003 to look at whether Scotland's poor health image and mortality profile is reflected in regional inequalities in prevalence of four risk factors for cardiovascular disease: fruit and vegetable consumption, smoking, obesity and diabetes. It also looks at the “Scottish effect” – how much of any difference between and within Scotland and England remains once socio-demographic factors have been taken in to account. The paper then uses regional analyses to determine the extent to which areas within England and Scotland contribute to their national health advantage and disadvantage. All 2003 strategic health authorities in England and Scottish health boards were compared with Greater Glasgow health board as the reference category.The results showed that significant geographic variation in the risk factors remained once individual economic status was taken into account, but the relationship was complex and varied in strength and direction depending upon risk factor involved and gender of respondent. A small number of areas had significantly lower odds of fruit and vegetable consumption of five portions or more a day in men, compared with Greater Glasgow. In contrast some areas had significantly higher odds of fruit and vegetable consumption for women compared with Greater Glasgow.There was greater geographic variation in the odds of smoking in women than in men. Respondents in the south west and southeast of England (areas which usually show health advantage) did not show significantly lower odds of smoking compared with Greater Glasgow once socio-economic variation, age and urban residence was taken into account. It was respondents from central England that had lower odds of smoking than might be expected. Obesity stood out as the single risk factor that had demonstrated a “Scottish effect” in women only.     

Were practice nurses distributed equitably across England and Wales, 1988-1995?

OBJECTIVE: To examine whether variations in the number of whole-time equivalent (wte) practice nurses across family health services authorities (FHSAs) can be explained by population characteristics and the organisation of general practice. METHODS: Analysis of nine health and 16 social indicators for 98 FHSAs identified three factors underlying health care needs. These factors and seven practice characteristics were analysed by stepwise regression. A formula for allocating health care resources and a logistic growth model were used to estimate the 'expected' number of nurses. RESULTS: Past trends indicate an eventual (wte) practice nurse workforce of 12,500 (95% CI +/- 3500). Although geographical disparities have declined, there was a two-fold variation in nurse numbers across FHSAs. Around 2000 (wte) posts would be required to bring under-provided areas, mostly in northern England and metropolitan districts, up to the highest level of provision. There were more nurses in areas with higher proportions of elderly people but fewer where deprivation, morbidity and mortality levels were above average. The number of general practitioners was the most significant predictor of practice nurse provision (t = 5.0); population needs and practice characteristics explained 24% of the variation. CONCLUSIONS: The distribution of practice nurses scarcely corresponded with health care needs at the FHSA level. Despite a lack of evidence that nurses are a cost-effective addition to the primary health care team, their role and numbers will be driven by the extent to which they take on responsibilities performed by doctors. Achieving equity in practice nurse provision probably requires explicit consideration in a formula for allocating primary care funds, backed by audit of the services they provide.     

Performance assessment in the context of multiple objectives: a multivariate multilevel analysis

The pursuit of multiple objectives by public sector organisations makes it difficult to assess and compare their performance. Considering objectives in isolation ignores the possibility of correlations between objectives, and a single index of performance requires subjective judgements to be made about the relative value of each objective. An alternative approach is to estimate a multivariate system of equations in which objectives are analysed individually but correlations across objectives are considered explicitly. We analyse the performance of English health authorities against 13 objectives using hierarchical data for electoral wards that are nested within health authorities. We find evidence of correlation across objectives, suggesting that some are complementary and others subject to trade-off. The estimates generated when assessing performance with multivariate multilevel models as compared to ordinary least squares or multilevel models differ, with the magnitudes varying by objective and health authority.     

Addressing the phenomenon of bypassing in Albania: the impact of a primary health care strengthening intervention

The purpose of this study is to assess the impact of a primary health care strengthening intervention on bypassing behavior in Albania, a middle-income country that has experienced substantial structural changes that affect PHC and where bypassing among health care clients is common. The intervention aimed to improve the quality of health care in low-level facilities through improved availability and use of health information, the adoption of clinical practice guidelines, and provider training. The study employs a quasi-experimental research design to evaluate the impact of the intervention on health care utilization. The survey findings suggest that the pilot areas outperformed the control areas with respect to a number of key population-based indicators of health care utilization. For example, in the 2-year period between December 2002 and December 2004, bypassing for treatment of simple acute health problems during the month prior to the survey decreased by 47%, and the percentage of chronically ill health care clients who utilized PHC facilities for treatment in the month prior to the survey increased by 29%. These differences, which are statistically significant at the 10% level or better, suggest that the improved performance in the pilot areas is attributable to the intervention.