Benchmarking in national health service procurement in Scotland.

The paper reports the results of a study on benchmarking activities undertaken by the procurement organization within the National Health Service (NHS) in Scotland, namely National Procurement (previously Scottish Healthcare Supplies Contracts Branch). NHS performance is of course politically important, and benchmarking is increasingly seen as a means to improve performance, so the study was carried out to determine if the current benchmarking approaches could be enhanced. A review of the benchmarking activities used by the private sector, local government and NHS organizations was carried out to establish a framework of the motivations, benefits, problems and costs associated with benchmarking. This framework was used to carry out the research through case studies and a questionnaire survey of NHS procurement organizations both in Scotland and other parts of the UK. Nine of the 16 Scottish Health Boards surveyed reported carrying out benchmarking during the last three years. The findings of the research were that there were similarities in approaches between local government and NHS Scotland Health, but differences between NHS Scotland and other UK NHS procurement organizations. Benefits were seen as significant and it was recommended that National Procurement should pursue the formation of a benchmarking group with members drawn from NHS Scotland and external benchmarking bodies to establish measures to be used in benchmarking across the whole of NHS Scotland.     

Comparing patients' experience of mental health services in England: a five-Trust survey

The implementation of the Care Programme Approach (CPA) in English mental health services has been slow to proceed despite general support, both in England and in other countries, of its principles of good practice. This study set out to evaluate the implementation of the CPA directly from patients' experience using the "Your Treatment and Care" assessment tool. The results of a survey of 503 patients across five NHS Trusts in England showed that many patients did not have a copy of their care plan and had not been involved in the care planning procedure. Many reported shortcomings in their experience of their key worker and their psychiatrist. However, there was substantial variation in experience across services. "Your Treatment and Care" showed good internal reliability, was acceptable to users, and appeared to be able to access actual experiences better than a traditional "satisfaction" item. It appears to be very useful as a benchmarking tool and is now being used in services across the UK, the USA and Australia.     

Assessment and improvement of the Italian healthcare system: first evidence from a pilot national performance evaluation system

The Italian National Health System (NHS), established in 1978, follows a model similar to the Beveridge model developed by the British NHS (Beveridge 1942; Musgrove 2000). Like the British NHS, healthcare coverage for the Italian population is provided and financed by the government through taxes. Universal coverage provides uniform healthcare access to citizens and is the characteristic usually considered the added value of a welfare system financed by tax revenues. Nonetheless, in Italy the strong policy of decentralization, which has been taking place since the early 1990s, has gradually shifted powers from the state to the 21 Italian regions. Consequently, the state now retains limited supervisory control and continues to have overall responsibility for the NHS in order to ensure uniform and essential levels of health services across the country. In this context, it has become essential, both for the ministry and for regions, to adopt a common performance evaluation system (PES). This article reports the definition, implementation, and first evidences of a pilot PES at a national level. It shows how this PES can be viewed as a strategic tool supporting the Ministry of Health (MoH) in ensuring uniform levels of care for the population and assisting regional managers to evaluate performance in benchmarking. Finally, lessons for other health systems, based on the Italian experience, are provided.     

Primary Care Groups and NHS Rationing: Implications of the Child B Case

Implementing The new NHS and the 1997 NHS (Primary Care) Act will gradually extend cash-limiting into primary health care, especially general practice. UK policy-makers have avoided providing clear, unambivalent direction about how to 'ration' NHS resources. The 'Child B' case became an epitome of public debate about NHS rationing. Among many other decision-making processes which occurred, Cambridge and Huntingdon Health Authority applied an ethical code to this rationing decision. Using new data this paper analyses the rationing criteria NHS managers and clinicians used at local level in the Child B case; and the organisational structures which confronted them with such decisions. Primary Care Groups are likely to confront similar rationing decisions in respect of 'gate-kept' NHS services. However, such rationing processes are not so easily transposed to open-access services such as general practice. NHS rationing decisions, especially in PCGs, will require a much more specific ethical code than hitherto used. This revised version was published online in July 2006 with corrections to the Cover Date.     

Use of contraception in women who present for termination of pregnancy in inner London

Objectives: To describe the contraceptive usage of women undergoing termination of pregnancy in order to identify problems with contraception, and therefore suggest ways in which contraceptive services can be improved.Design: Prospective study of attenders for NHS termination of pregnancy over a three month period.Setting: Community based assessment clinics for NHS termination of pregnancy in inner London.Subjects: Two hundred and sixty-nine women asking for assessment for NHS termination of pregnancy.Main Outcome Measures: Source of contraception, method used around time of conception, and problems experienced.Results: Respondents fell into three groups: those using contraception around the time they became pregnant; those who had ceased to use contraception; and those that had never used contraception. The method of contraception used by the majority of the first group was the condom and the main source of the method was the chemist shop. The second group had most commonly used oral contraceptives in the past and had ceased use in many cases as a result of side effects. The majority of the third group did not speak English and had limited knowledge of methods of contraception.Conclusions: High usage of chemists means women avoid service providers who could offer help and advice. Women were prepared to put themselves at risk of unwanted pregnancy rather than return for further help and the lack of knowledge about emergency birth control was of some concern. The needs of black and ethnic minority women requires detailed work to improve access and acceptability of contraceptive services.     

Provision and staffing of NHS occupational health services in England and Wales

OBJECTIVES: To establish the extent of Occupational Health (OH) service provision in the National Health Service (NHS). METHODS: Two postal questionnaires were used to obtain information from purchasers and providers in the NHS in England and Wales. RESULTS: 99.6% of trust and health authority employers claim to provide some form of OH service to their employees indicating widespread recognition of need, but virtually no service is provided to other staff such as general practitioners (GPs), general dental practitioners (GDPs), and their staff. There is a wide variability in the range and quality of OH services, suggested by the enormous differences in medical staffing levels, and the contractual restrictions where the OH service is provided by another NHS employer. Only about a third (highest estimate) to a quarter (lowest estimate) of NHS staff have access to a specialist occupational physician. CONCLUSIONS: Substantial inequality of access to OH services exists for the NHS workforce, despite previous guidance. There is no real evidence to suggest why the extent of provision of OH services varies so greatly between institutions.

 

     

Access to health care in nursing homes: a survey in one English Health Authority

The objective of the study was to establish the arrangements for provision of general practitioner (GP), nursing advice, chiropody, physiotherapy and speech and language services to nursing homes and to establish the charging policies for those services. To this end a telephone survey of the managers of the 51 nursing homes registered with one English health authority, Merton, Sutton and Wandsworth Health Authority, was undertaken. Forty-nine homes (96%) with 1541 residents responded. Twenty per cent of homes had no regular GP visits and half the homes had no planned medication reviews. One in five homes (27% of residents) had access to all health-care services. Eight homes (10% of residents) did not have access to therapy services or nursing advice. Thirty-three homes used private or both private and NHS chiropody services and 16 homes used the NHS service only. Seventeen homes used private or both private and NHS physiotherapy services with 10 homes receiving a regular private service. Twenty homes used the NHS service and 12 homes (15% of residents) had used no physiotherapy service. None used private speech and language services. Twenty-four of the 33 homes using private chiropody charged extra for this service compared with two of 10 homes using regular private physiotherapy. The findings suggest that there are inequalities in access to health care services in nursing homes. Moreover, there has been a deterioration in access to and levels of provision of NHS nursing and physiotherapy services since the national survey undertaken by the Office Population Censuses and Surveys (OPCS) in Great Britain in the mid-1980s. The new regulatory framework for older people must include systems for monitoring the provision of health services.     

Sickness absence and health at work in the NHS

Presents summary results from two surveys which the Institute for Employment Studies conducted in 1994 for the Health Education Authority. The first of these surveys reports national benchmarking data on rates of sickness absence and accidents at work in NHS provider and purchaser organizations. The second survey concerns implementation of the Health at Work (HaW) in the NHS initiative in NHS hospital worksites. Discusses structures and processes of HaW implementation.     

NHS occupational health services in England and Wales--a changing picture

AIMS: To establish the extent of doctor input to occupational health (OH) service provision in the UK National Health Service (NHS) in 2001 and to compare this with inputs in 1998. METHOD: A postal questionnaire was used to obtain information from OH medical staff employed by the NHS in England and Wales. RESULTS: The NHS OH service has seen an increase between 1998 and 2001 in the amount of doctor time per employee. Doctors tend to work now for more sessions per week. The proportion of doctors holding specialist qualifications has also increased. An increased number of NHS employees now have access to consultant care for occupational medicine. OH departments increasingly tend to provide services to employees beyond the NHS and are thereby able to generate income to further the development of the service. CONCLUSIONS: Steady progress is being made in improving the provision of OH services within the NHS. However, substantial variation exists in the apparent level of access to such provision. The government policy for all NHS staff to have access to a consultant-led service is not yet met. NHS Plus will impact on this picture and deserves study in the future.     

The impact of a quasi-market on sexually transmitted disease services in the UK.

This article reports the results of a study of the impact of quasi-market reforms on sexually transmitted disease (STD) services in one UK health region. An internal or quasi-market was introduced into UK health care in the 1991 reforms of the National Health Service (NHS). Health authorities (HAs) and general practitioner fundholders were given major new responsibilities for purchasing (later called commissioning) health services. The NHS quasi-market was designed to address recurrent difficulties in acute health services by promoting efficiency and consumer choice. The arrangements for commissioning STD services are important because these diseases are major threats to public health and HAs face a number of constraints in bringing about service changes through market mechanisms. In the UK, STD services are provided on a self-referral and confidential basis; patients experience STDs as stigmatizing and often have low expectations of service and little desire for involvement in commissioning decisions. HAs have only limited routine intelligence about STD services and little or no choice of local providers. This study adopted a qualitative case-study approach to examine HA commissioning of STD services. The study found that the introduction of the NHS quasi-market did not equip HAs with mechanisms for bringing about change in STD service provision or STD-related health outcomes. The findings are consistent with other recent studies of HA commissioning and provide further cumulative evidence of the limits to HA leverage in the NHS quasi-market. The study concludes that the commissioning of STD services is likely to remain a low priority in the new NHS structures based on primary care groups.     

Healthy workplace indicators: costing reasons for sickness absence within the UK National Health Service

Sandwell Healthcare NHS Trust has been developing a tool for monitoring the reasons and costs of long-term sick leave (> 7 days). The data obtained from this process has been used to modify the type of occupational health and safety services provided for the Trust. Adoption of more standardized tools of this nature throughout the National Health Service (NHS) would help trusts to compare, and where appropriate enhance, the services provided by occupational health. Musculo-skeletal and mental health problems, account for the greatest costs arising from long-term sickness absence. It may therefore be prudent for NHS employers and their occupational health services to target their efforts on these particular problems.     

A qualitative study of choosing and using an NHS Walk-in Centre

BACKGROUND: NHS Walk-in Centres have been introduced to improve access to healthcare in the UK. Little is understood about why people choose Walk-in Centres from among the range of options available to them. OBJECTIVES: To explore users' accounts of choosing and using an NHS Walk-in Centre. METHODS: Semi-structured interviews with 23 users who had recently attended an NHS Walk-in Centre were conducted. Analysis was based on the constant comparative method. RESULTS: Participants' accounts revealed two types of service use: those who knew what was wrong with them and had a clear idea of what treatment was required, and those seeking professional advice. Users reported "solidarity" with the NHS and other NHS users, and were highly sensitive to the demands on both Accident and Emergency and GP services in their choice of services. The Walk-in Centre appeared to function as a means of overcoming the barriers to healthcare associated with other healthcare services, although there was some lack of clarity about the purpose of the Walk-in Centre. CONCLUSIONS: Users' accounts suggest that NHS Walk-in Centres improve access to healthcare by opening up an alternative means of seeking a professional opinion or treatment. It is especially important in allowing people to use the NHS without feeling that they are increasing the burden on general practice and A&E facilities, and to feel that they are behaving responsibly while still meeting their own needs.     

Benchmarking patient relations within ambulatory care: lessons from a high-risk pregnancy program

Ambulatory care providers are being challenged to deliver high-quality care at low cost with easy access. Patient satisfaction with services hinges on the ability of providers to meet these often elusive benchmarks. This article focuses on the barriers to benchmarking patient relations in ambulatory care organizations and strategies for improving patient relations through internal benchmarking that encourages service innovation and performance emphasis. A case study of programmatic benchmarking in the Lovelace Health System is used to illustrate how patient relations can benefit from establishing internal performance thresholds that guide service delivery. Examples from Lovelace's High Risk Pregnancy Program demonstrate the value of benchmarking efforts. The implications for patient relations benchmarking in other ambulatory care settings are discussed.     

Provider incentives and access to dental care: Evaluating NHS reforms in England

Changes were made to the management and delivery of primary dental care in the NHS in England in 2006 aimed at improving access to NHS dental services among populations with low use. These included: (i) commissioning of NHS dental services by primary care trusts (ii) replacing item of service patient charges by Course of Treatment cost bands and (iii) changing the remuneration of dentists providing NHS dental care. Using longitudinal data from the 1991-2008 waves of the British Household Panel Survey, we estimate the effects of these changes on the levels and distribution of dental care in the population and on the public–private mix of primary dental care services in England using dynamic probit models. We find evidence of a decrease in NHS use, driven by reductions in use among populations with previously good access to care and a positive effect of the reforms on consumer transitions from NHS to private practice. Our results highlight the potential (unintended) consequences of reforming public health care systems. It appears that contrary to expanding NHS access, the dental reforms contracted NHS use amongst those with previously good access. This contraction relied upon the ability of the private sector to absorb this group.     

Charging for NHSPlus: an inferential study based on the internal provision of occupational health services within the National Health Service

BACKGROUND: 'NHSPlus' was conceived as a national agency that would provide occupational health services to organizations, for a fee, without imposing any financial burden on the taxpayer. This self-funding requirement brings into focus the resource implications for such a service and the determination of the charges to be made to external clients. AIM: The existing provision of occupational health services to >100000 National Health Service (NHS) staff by 13 NHS occupational health services of various sizes was analysed, with the objective of determining an appropriate charge-out rate to third parties. METHOD: Two focus groups were questioned on their work external to the NHS. Data collected on the allocation of doctors and nurses to occupational health services in relation to the number of NHS clients serviced were used to investigate the nature of the resourcing relationship using regression analysis. RESULTS: The relationship was found to be stable enough to provide a good estimate of staff requirements (the key resource requirement). Combining this with costing information allowed inferences to be drawn concerning the economic cost and hence the break-even rate of charge for the service. This was then compared with the employer charge rates in the NHSPlus published case studies. CONCLUSIONS: The results suggest that the per capita charges to external clients are lower than the per capita cost of internal occupational health provision within the NHS, raising questions about the viability of the service.     

Learning from contract change in primary care dentistry: A qualitative study of stakeholders in the north of England

The aim of this research was to explore and synthesise learning from stakeholders (NHS dentists, commissioners and patients) approximately five years on from the introduction of a new NHS dental contract in England. The case study involved a purposive sample of stakeholders associated with a former NHS Primary Care Trust (PCT) in the north of England. Semi-structured interviews were conducted with 8 commissioners of NHS dental services and 5 NHS general dental practitioners. Three focus group meetings were held with 14 NHS dental patients. All focus groups and interviews were audio recorded and transcribed verbatim. The data were analysed using a framework approach. Four themes were identified: ‘commissioners’ views of managing local NHS dental services’; ‘the risks of commissioning for patient access’; ‘costs, contract currency and commissioning constraints’; and ‘local decision-making and future priorities’. Commissioners reported that much of their time was spent managing existing contracts rather than commissioning services. Patients were unclear about the NHS dental charge bands and dentists strongly criticised the contract's target-driven approach which was centred upon them generating ‘units of dental activity’. NHS commissioners remained relatively constrained in their abilities to reallocate dental resources amongst contracts. The national focus upon practitioners achieving their units of dental activity appeared to outweigh interest in the quality of dental care provided.     

Evaluation of an independent, radiographer-led community diagnostic ultrasound service provided to general practitioners

BACKGROUND: Health care services traditionally offered in a secondary setting are increasingly being offered in a primary setting. There has been little assessment of quality and efficiency of diagnostic services such as ultrasound delivered in primary settings and no studies have looked at independently provided services. AIMS: To assess the benefits and disadvantages of a radiographer delivered, primary care-based mobile diagnostic ultrasound service by comparing it to an NHS Trust diagnostic ultrasound service. DESIGN: A retrospective, comparative study. SETTING: A primary care area in the West Midlands. METHOD: Random samples of 200 and 193 adult patients who underwent diagnostic ultrasound in 2001/2002 with the community and NHS Trust services respectively, and all GP principals in the area were identified. Patient access (including wait for appointments), patient and GP satisfaction, clinical quality of services, and cost-effectiveness were assessed by postal questionnaires, interviews, review of stored ultrasound images, patient record review and collection of data on unit costs. RESULTS: Mean wait for an appointment was 17.44 (15.85-19.02) and 44.53 days (38.83-50.23) for the community and NHS Trust services respectively. Response rates from the community and hospital patient groups were 52.9 percent and 44.6 percent, respectively. Demographic characteristics of the two groups of respondents did not differ significantly, therefore justifying comparison between the two groups of respondents. High proportions of patients from both services reported time and location of appointment as convenient. Access to secondary care following an abnormal ultrasound was not systematically different for the services. Patients were highly satisfied with both services. GPs were markedly less satisfied with the NHS Trust service compared to the community service. Quality of stored ultrasound images and reports were comparable for the services. Cost per abnormality detected was higher for the community service (107.69 pound sterling compared to 77.35 pound sterling for the NHS Trust service, not statistically significant). CONCLUSION: The community diagnostic ultrasound service offers reduced waiting times compared to the NHS Trust service, and is of comparable quality. This benefit, together with high patient and GP satisfaction levels, may justify the possible reduced cost-effectiveness of the service compared to the NHS Trust service.     

Back to the future in NHS reform.

PURPOSE: In the mid 1990s the NHS "did" competition, in the mid 2000s the NHS is "doing" choice. This paper aims to cut through the rhetoric, highlight the differences and parallels between then and now and identify if these differences will have a different or the same impact on local services. DESIGN/METHODOLOGY/APPROACH: Following a review of literature from the 1990s, a qualitative research study is used to examine the impact of competition and markets in the 1990s. The discussion examines the implications of this study for current system reform. FINDINGS: Patient choice recreates many of the features of the internal market, but despite concerns at the time, the internal market did not have a significant impact on services. It is likely that patient choice will similarly have a limited impact. RESEARCH LIMITATIONS/IMPLICATIONS: The research is a case study confined to Day Surgery in one part of the North of England. ORIGINALITY/VALUE: The paper reminds academics and practitioners what happened last time the NHS attempted to introduce a market-based system.