Adrian Bull

Specifying Quality in Health Care

Quality should be a central issue in the commissioning and provision of health care. This requires a systematic approach to defining and monitoring quality. Such an approach should address: quality characteristics such as efficiency, accessibility, effectiveness (which may conflict with each other); the several levels at which quality may be specified, from general (across all health care) to specific (particular conditions or patient groups); and the methods of quality monitoring which include documented policies, clinical audit, inspection visits/patient surveys, and routine information returns. Shows how a matrix for quality surveillance can be devised which provides a framework for purchasers and providers to work together in developing quality in health care.

Purchaser and provider relations in the UK: a perspective from the private sector.

Gives an overview of the major features of the general changes in the UK health care system, and describes how PPP healthcare is taking advantage of those changes in developing and implementing strategies for relations with both hospitals and specialists. Notes that similar issues are faced by public sector purchasers. Points out that many of the initiatives described are being adopted, in one form or another, in health care industries across the world. Suggests that new insights or understandings may be found by seeing and considering those issues and initiatives in the context of health care economies.

Difficult Choices in Health Care

Considers the two issues of the range of health care services and balances within the range. Notes the necessity of conducting a national debate concerning the range and limits of service provision within the health service framework. Stresses the importance of making decisions of balance within the range at local level. Unless there is a rational framework for decision making at both levels, both patients and society itself will suffer from inconsistency, confusion and inequity.

Problems of Prioritisation and Our Duty to Care

Limited resources must be invested wisely. Society′s humanitarian duty to care must be satisfied as well as the economic imperative to use resources rationally. This cannot properly be achieved by reduction of all considerations to a single number which represents a ratio of health gain to resource cost.

Trial and Audit: A Confusion of Aims and Method

Clinical audit is the analysis of whether a predetermined standard of care is achieved over a given period of time. Evaluation of methods of care is an analysis of the benefits that might be expected to accrue from a particular method of treatment by statistical analysis of observations made on sample populations. The two activities have very different aims and approaches; they should not be confused.

Commissioning community health care: missing the point

Discusses commissioning community health care and the fact that present mechanisms do not enable commissioning to meet the needs of patients requiring community care relevant to their needs. The focus on efficiency, money and simple activity does not take into account the complex nature of community care and the need to take a variety of factors into account if commissioning is to be effective.

Audit and a Sense of Direction

Audit activity is now widespread. There are a range of views about its prime purpose. Unless the audit programme has a clear purpose and direction, it will falter. As commissioning develops, there will be more explicit considerations of standards of care. Those standards will address both the processes of outcomes of care, focusing on effectiveness and appropriateness. They will best be generated by local agreement between purchasers, providers and clinicians, based on the knowledge available through research. Audit can provide a systematic appraisal of practice against such standards, while ensuring confidentiality for individual patients and clinicians. Property resourced, audit can play a valuable role directly linked to the commissioning process, which will ensure that the medical profession is fully engaged in the new dynamics of the NHS.

Making Sense of Purchasing, Audit, Guidelines and Research

Explores purchasing in relation to audit, guidelines and research. Notes that the purchasing function is still embryonic, as the NHS struggles to integrate the new reforms. Notes that the different threads need to be woven into a coherent pattern if the full potential of the NHS reforms is to be realized.