Andrew Rouse

Bristol, Shipman, and clinical governance: Shewhart's forgotten lessons

During the past century, manufacturing industry has achieved great success in improving the quality of its products. An essential factor in this success has been the use of Walter A Shewharts pioneering work in the economic control of variation, which culminated in the development of a simple yet powerful graphical method known as the control chart. This chart classifies variation as having a common cause or special cause and thus guides the user to the most appropriate action to effect improvement. Using six case studies, including the excess deaths after paediatric cardiac surgery seen in Bristol, UK, and the activities of general practitioner turned murderer Harold Shipman, we show a central role for Shewharts approach in turning the rhetoric of clinical governance into a reality.

Performance league tables: the NHS deserves better

League tables are frequently used to depict comparative performance in sport and commerce. However, extension of their use to rank services provided by healthcare agencies has attracted resistance, criticism, and anxiety. In this article we discuss the benefits and drawbacks of league tables and suggest that an alternative technique, based on statistical process control, could be introduced in their place. We believe that this technique would have the dual advantage of being less threatening to providers of health services and would be more easily understood and correctly interpreted by patients, auditors, and commissioners of services. ### Summary points League tables are an established technique for displaying the comparative ranking of organisations in terms of their performance League tables provoke anxiety and concern among health service providers for several reasons, including concerns over adjustment for case mix and the role of chance in determining their rank Control charts, used for monitoring and control of variation in the manufacturing industry, overcome these problems by displaying performance without ranking and helping to differentiate between random variation and that due to special causes League tables are useful for comparing quality or outputs from different systems, whereas control charts are more useful for comparison of units within a single system, such as the NHS Control charts avoid stigmatising “poor performers” and promote the use of a systems approach to quality improvement For many years league tables have been used to rank the quality of goods or services provided by competing organisations. They are commonly published in the popular press and magazines, specialist journals, and the internet. These tables range from those that simply rank crude performance on indicators to those that report sophisticated comparisons of summary adjusted statistics (such as those with uncertainty intervals around the rank). The public is prepared to pay intermediaries, such as financial advisers, …

The extent and implications of sphygmomanometer calibration error in primary care

Aim: The sphygmomanometer is an essential piece of diagnostic equipment, used in many routine consultations in primary care. Its accuracy depends on correct maintenance and calibration. This study was designed to: (1) assess the maintenance and calibration of sphygmomanometers in use in primary care; (2) assess the clinical, ethical, legal and public health implications of our findings.Method: A researcher assessed the accuracy of mercury and aneroid sphygmomanometers in use in 231 English general practices. He also made enquires about arrangements for the maintenance and calibration of sphygmomanometers. We conducted a small telephone survey in general practices across the country to determine maintenance and calibration arrangements across the country. We carried out a modelling exercise to explore the clinical, ethical and public health implications of our findings.Results: Of 1462 sphygmomanometers, 9.2% gave readings were more than 5 mm Hg inaccurate. No practice had arrangements for maintenance and calibration of sphygmomanometers. Nationally, one of 54 practices had an arrangement for maintenance and calibration. True hypertension is very uncommon in women under 35, a blood pressure which is measured as high is much more likely to be caused by calibration error than by hypertension.Conclusion: It is rare for sphygmomanometers used in primary care to be maintained and calibrated. Because of this women under 35 are at risk of misclassification and inappropriate treatment. This has ethical and public health implications. Clinicians using equipment which has not been maintained and calibrated may be medically negligent.

Resource implications and health benefits of primary prevention strategies for cardiovascular disease in people aged 30 to 74: mathematical modelling study

Abstract Objective: To develop a model to determine resource costs and health benefits of implementing guidelines for the prevention of cardiovascular disease in primary care Design: Modelling of data from six strategies for prevention of cardiovascular disease. Strategies incorporated two ways of identifying patients for assessment: traditional (assessment of all adults) and novel (preselection of patients for assessment using a prior estimate of their risk of cardiovascular disease). Three treatment strategies were modelled in conjunction witheach identification strategy Setting: England Subjects: Patients aged 30 to 74 eligible for primary prevention strategies for cardiovascular disease who were selected from a hypothetical population of 2000. Main outcome measures:Resource costs of assessing eligible adults, providing treatmentand follow up to those eligible, and number of cardiovascular events this should prevent. Results: Novel strategies prevented more cardiovascular disease, at lower cost, than traditional strategies. Some treatment strategies prevent more cardiovascular disease with fewer resources than others. The findings were robust across a range of different assumptions about workload. Conclusion: Preselecting patients for assessment makes better use of staff time than assessing all adults. Treating many patients with low cost drugs is more efficient than prescribing a few patients intensive antihypertensives and statins. Authors of guidelines should model workload implications and health benefits of following their recommendations.

Randomised controlled trial of the effect of evidence based information on women’s willingness to participate in cervical cancer screening

Study objectives: To assess whether providing women with additional information on the pros and cons of screening, compared with information currently offered by the NHS, affects their intention to attend for screening. Design: Randomised controlled trial. Participants were randomly assigned to receive either the control, (based on an NHS Cervical Screening Programme leaflet currently used), or the intervention leaflet (containing additional information on risks and uncertainties). Setting: Three general practices in Birmingham. Participants: 300 women aged 20 to 64 attending the practices during a one month period. Main outcome measures: Intention to attend for screening. Main results: 283 women (94.3%) completed the study. Fewer women in the intervention (79%) than the control group (88%) expressed intention to have screening after reading the information leaflet (difference between groups 9.2%, 95% confidence intervals (CI) 3.2% to 21.7%). The crude odds ratio (OR) and 95% CI was 0.50 (0.26 to 0.97). After adjusting for other factors, the trend persisted (OR 0.60, 95% CI 0.28 to 1.29). Having a previous Pap smear was the only significant predictor of intention to have screening (adjusted OR 2.54, 95% CI 1.03 to 6.21). Subgroup analysis showed no intervention effect in intended uptake between women at higher and lower risk of cervical cancer (p=0.59). Conclusions: Providing women with evidence based information on the risks, uncertainties, and the benefits of screening, is likely to deter some, but not differentially those at higher risk.

Increasing the QOF upper payment threshold in general practices in England: impact of implementing government proposals

BACKGROUND General practices in the UK receive incentive payments for managing patients with selected chronic conditions under the Quality and Outcomes Framework (QOF) scheme. Payments are made when a negotiated threshold percentage of patients receive the appropriate intervention. AIM From 2013-2014 in England the Department of Health has proposed that this negotiated threshold is replaced with a value equal to the 75th percentile of national performance to attract maximum payments. This is an investigation of the potential impact of this change on practice income and workload. DESIGN AND SETTING Analysis of 2011-2012 QOF dataset (the latest available) which covers 8123 GP practices and 55.5 million patients in England. METHOD The 75th percentile of performance was calculated for 52 clinical indicators and applied to 2011-2012 performance. Estimations were made of financial and workload impacts on practices, and whether practices with different characteristics would be disproportionately affected. RESULTS The proposed changes will result in an increase in the upper payment threshold of each clinical indicator by a mean of 7.47% (range 2.16-38.87%). If performance remains static practices would lose a mean of 47.68 (0-108.33) QOF points, equivalent to a mean financial change of -£279.60 (-£35 352.50 to +£19 957.78) per practice for these 52 indicators. CONCLUSION Increasing the QOF upper payment threshold to the 75th percentile of national performance will, if clinical performance remains static, substantially reduce the mean number of QOF points achieved per practice. However, this translates into only a small mean loss of income per practice.

Go for targeted screening

The benefit of any screening programme is a function of the likelihood that ( a ) patients with a risk condition have already been given a diagnosis or recently been offered a screening test and ( b ) those screened and found to have a risk condition will be treated effectively.1 Using these two principles we estimated the benefit of …

Improving MMR coverage in Birmingham

Achieving herd immunity in an ethnically mixed deprived area is a realistic goal.1 Between 2004 and 2006, the Heart of Birmingham primary care trust increased measles, mumps, and rubella (MMR) vaccination coverage from 82% to 94% and maintained similar levels for seven years. The elements of our intervention are similar—creating a database of apparently unvaccinated children, list …