Allyson M Pollock

An Examination of the UK Treasury's Evidence Base for Cost and Time Overrun Data in UK Value-for-Money Policy and Appraisal

UK government procurement policy rests on Treasury claims that the private finance initiative (PFI) has reduced cost and time overruns. We review the five studies cited by the Treasury in support of this claim and find that only one purports to compare PFI with traditional procurement. The results of this single study are uninterpretable because of selection bias, small sample size (only 11 out of 451 PFI projects are included) and fundamental flaws in the analysis. There is thus no evidence to support the Treasury cost and time overrun claims of improved efficiency in PFI. We conclude that Treasury appraisal guidance, the ‘Green Book’ which compares PFI with other methods of procurement, is not evidence based but biased to favour PFI.

THE PRIVATE FINANCING OF NHS HOSPITALS: POLITICS, POLICY AND PRACTICE

This article outlines and critiques the main fiscal and economic rationales for the Private Finance Initiative and examines the impact of the policy on the long-term financial viability of NHS trusts. It concludes that the PFI funding of capital investment is highly problematic. Its high costs can have a negative impact on the finances of health systems.

Independent sector treatment centres: evidence so far

The government plans to continue using NHS funds to contract with commercial healthcare providers in the second phase of the independent sector treatment centre programme, but Allyson M Pollock and Sylvia Godden argue that no good evidence is available to support this policy

Rugby union injuries in Scottish schools

BACKGROUNDnRugby union is the most popular worldwide collision sport, yet concerns have been raised regarding the safety of the sport due to the physical, high impact nature and an increasing number of injuries.nnnMETHODSnA prospective, cohort study of the incidence, pattern and severity of injuries in rugby players in six Scottish schools during the second half of the 2008-09 season. Definition of injury and severity of injury were taken from International Rugby Board (IRB) consensus guidelines. Injury report forms and exposure data for match play were completed by a nominated staff member.nnnRESULTSnFour hundred and seventy consent forms with survey information were returned. Of 37 rugby injuries in the study, 11 occurred during training. Head and face were the most injured body part and sprain/ligament injury the most common injury. Twenty injuries required attendance at Accident & Emergency with one admission. The tackle was the commonest phase of play causing injury. In the 193 matches played, the injury incidence during the match play was 10.8 injuries per 1000 player hours.nnnCONCLUSIONSnThis study confirms the feasibility of collecting relevant injury data in schools rugby in Scotland. The findings are consistent with other studies with respect to incidence and profile of injuries sustained.

Global Burden of Disease estimates of depression – how reliable is the epidemiological evidence?:

Summary Objectives To re-assess the quality of the epidemiological studies used to estimate the global burden of depression 2000, as published in the GBDep study. Design Primary and secondary data sources used in the global burden of depression estimate were identified and assigned to country of origin. Each source was assessed with respect to completeness and representativeness for national/regional estimates and against the inclusion criteria used by the scientific team estimating GBDep. Setting Not applicable. Participants Not applicable. Main outcome measures Not applicable. Results First, National estimates: The 28 scientific sources cited in the GBDep study related to 40 of the 191 WHO member countries. The EURO region had studies relating to 15 of 52 countries whereas AFRO region had studies for only three of 46 countries. Only six of the 40 countries had data drawn from a nationally representative population: the three AFRO country studies were based on a single village or town and, likewise, SEARO region had no nationally representative data; second, GBDep criteria: GBDep inclusion criteria required study sample size of more than 1000 people; 19 (45%) of the 42 studies did not meet this criterion. Sixteen (44%) of 36 studies did not meet the requirement that studies show a clear sample frame and method. GBD estimates rely on estimates of incidence; only two of the 42 country studies provided incidence data (Canada and Norway), the remaining 34 studies were prevalence studies. Duration of depression is based on three studies conducted in the USA and Holland. Conclusions Most studies exhibit significant shortcomings and limitations with respect to study design and analysis and compliance with GBDep inclusion criteria. Poor quality data limit the interpretation and validity of global burden of depression estimates. The uncritical application of these estimates to international healthcare policy-making could divert scarce resources from other public healthcare priorities.

Private finance initiatives during NHS austerity

Allyson Pollock, David Price, and Moritz Liebe believe that ring fencing of private finance initiative payments prioritises investor returns over patient care and call for tighter monitoring and renegotiation

A Review of the Evidence of Third Sector Performance and Its Relevance for a Universal Comprehensive Health System

UK policy promotes third sector organisations as providers of NHS funded health and social care. We examine the evidence for this policy through a systematic literature review. Our results highlight several problems of studies comparing non-profits with other provider forms, questioning their usefulness for drawing lessons outside the place of study. Most studies deem contextual factors and the regulatory framework in which providers operate as much more important than ownership form. We conclude that the literature does not support the policy of a larger role for the third sector in healthcare, let alone a switch to a market-based system.

Has the NAO Audited Risk Transfer in Operational Private Finance Initiative Schemes

The governments main justification for using private finance is that it provides value for money by transferring project risks to the private sector. However, of the 622 PFI deals signed by October 2007, the National Audit Office (NAO) has examined the relationship between risk transfer and risk premiums in only three. The governments justification for the policy is largely unevaluated and unscrutinized by Parliament, raising wider issues of public accountability for public expenditure.

Policy on the rebound: trends and causes of delayed discharges in the NHS

Summary Objectives The Community Care (Delayed Discharges, etc.) Act, 2003 was aimed at reducing the number of patients whose discharge from hospital was delayed, incorporating financial incentives based on a model from Sweden. The Act permitted NHS hospital trusts to charge local authority Social Service Departments for delays they were deemed responsible for and was accompanied by grants aimed at supporting improvements in the transfer of care. This study aims to assess how far the subsequent reduction in delays has been due to the operation of the Act, and to evaluate the extent that the legislation increased efficiency across health and social care. Design Analysis and interpretation of a range of official routine health statistics plus unpublished performance data. Setting Data on patients delayed in hospital in England from 2001–2002 to 2006–2007 and trends in hospital activity. Main outcome measures Trend analysis of health statistics and performance data relating to delayed discharges and other relevant indicators. Results Althought there has been an overall reduction in delayed discharges, this trend predates the implementation of the Act. Overall, bed- days lost to delayed discharges accounted for only a small proportion of all bed-days – 1.6% in 2006–2007, and over the period studied the causes of the majority of delays were attributed to the NHS (68%). Conclusions These findings indicate lttle evidence to support the policy of charging social services to improve public sector efficiency. The focus on reducing delays should be set in the context of the wider health economy. There are a number of pressures to reduce the time patients spend in hospital including fewer beds and increasing numbers of admissions, plus a rise in emergency readmission rates is noted. There are few good data available to monitor the impact of earlier discharge, such as on the quality and availability of post-discharge care.

Independent sector treatment centres: the first independent evaluation, a Scottish case study.

Summary Objectives The £5 billion English Independent Sector Treatment Centre (ISTC) programme remains unevaluated because of a lack of published contract data and poor quality data returns. Scotland has a three-year pilot ISTC, the Scottish Regional Treatment Centre (SRTC), the contract for which is now in the public domain. This study aims to conduct an independent evaluation of the performance of the SRTC during the first year of operation. Design A retrospective analysis of the SRTC comparing activity as reported by hospital episode statistics returned to ISD Scotland with: volume and cost data in the SRTC contract; a 10-month audit carried out by management consultants Price Waterhouse Coopers (PWC); and an internal NHS Tayside performance report. Setting All day-case and inpatient activity at the SRTC from 1 December 2006 to 31 January 2008. Main outcome measures Activity and cost. Results The annual contract was based on patient referrals to the SRTC and not actual treatments. The contract was awarded on the basis of 2624 referrals a year, total value of £5,667,464. According to ISD data, the SRTC performed 831 procedures (32% of annual contract) in the first 13 months worth £1,035,603 (18%). PWCs figures report 2200 referrals (84%) to the SRTC at a cost of 2,642,000 (47%) in the first 10 months. Conclusions Basing the SRTC contract on payments for referrals rather than actual treatment represents a major departure from normal standards of reporting and commissioning and may have resulted in over-payment for referrals for patients who did not receive treatment of up to £3 million in the first 10 months. The PWC report falls well below the standards one would expect of an independent evaluation and we were unable to validate PWCs analysis and the claim of value for money. If wave-one ISTCs in England perform similarly to the SRTC then as much as £927 million may have been paid for patients who did not receive treatment. We recommend a moratorium on all ISTC contracts until the contracts have been published and properly evaluated with respect to work paid for and actual work carried out and quality of care.