Gwyn Bevan

Hitting and missing targets by ambulance services for emergency calls: effects of different systems of performance measurement within the UK

Following devolution, differences developed between UK countries in systems of measuring performance against a common target that ambulance services ought to respond to 75% of calls for what may be immediately life threatening emergencies (category A calls) within 8 minutes. Only in England was this target integral to a ranking system of ‘star rating’, which inflicted reputational damage on services that failed to hit targets, and only in England has this target been met. In other countries, the target has been missed by such large margins that services would have been publicly reported as failing, if they had been covered by the English system of star ratings. The paper argues that this case-study adds to evidence from comparisons of different systems of hospital performance measurement that, to have an effect, these systems need to be designed to inflict reputational damage on those that have performed poorly; and it explores implications of this hypothesis. The paper also asks questions about the adequacy of systems of performance measurement of ambulance services in UK countries.

Have targets done more harm than good in the English NHS? No

James Gubb argues that the focus on targets has ignored underlying problems important to patient care but Gwyn Bevan (doi:10.1136/bmj.a3129) believes it has resulted in real improvements in care

The Interplay between Economic and Political Logics: Path Dependency in Health Care in England

The purpose of this article is to use the ideas of path dependency to understand why policies implemented by governments for health care in England were and are suboptimal in terms of the control of total costs, the equitable distribution of hospital services, and efficiency in delivery. We do this by relating the economic logic of achieving these objectives to the political logic of a state-hierarchical system in which ministers are accountable for the effects of policies and doctors largely decide the supply and demand of health care. The initial policy path of the National Health Service (NHS) controlled costs but lacked systems to achieve equity and efficiency in the funding of hospitals. Policies were introduced to achieve equity, but not efficiency, in the 1970s. The Thatcher government sought efficiency through a budgetary squeeze in the 1980s, which culminated in the NHS funding crisis of 1987 - 1988. The result was the policies of the NHS internal market, which promised efficiency by introducing a purchaser-provider split and a system of provider competition in which money would follow the patient. These promises justified an injection of extra funds for three years, but only a pallid model of the internal market was implemented. The Blair government abandoned the rhetoric of competition but maintained the purchaser-provider split and continued to constrain total NHS costs, which resulted in the funding crisis of 1998 - 1999. Current policies are to substantially increase spending on health care and reintroduce a system of provider competition in which money will follow the patient.

Effect of diverging policy across the NHS

Since devolution in 1998, it has become more difficult to collect comparable data across the four UK countries, particularly on NHS expenditure and waiting times. - NHS activity and health outcomes seem more dependent on how healthcare resources are deployed than higher levels of resources. - The most striking difference between the countries in 2002 was the shorter waiting times in England, which introduced enforced targets for waiting.

Observational intensity bias associated with illness adjustment: cross sectional analysis of insurance claims

Objective To determine the bias associated with frequency of visits by physicians in adjusting for illness, using diagnoses recorded in administrative databases. Setting Claims data from the US Medicare program for services provided in 2007 among 306 US hospital referral regions. Design Cross sectional analysis. Participants 20% sample of fee for service Medicare beneficiaries residing in the United States in 2007 (n=5 153 877). Main outcome measures The effect of illness adjustment on regional mortality and spending rates using standard and visit corrected illness methods for adjustment. The standard method adjusts using comorbidity measures based on diagnoses listed in administrative databases; the modified method corrects these measures for the frequency of visits by physicians. Three conventions for measuring comorbidity are used: the Charlson comorbidity index, Iezzoni chronic conditions, and hierarchical condition categories risk scores. Results The visit corrected Charlson comorbidity index explained more of the variation in age, sex, and race mortality across the 306 hospital referral regions than did the standard index (R2=0.21 v 0.11, P<0.001) and, compared with sex and race adjusted mortality, reduced regional variation, whereas adjustment using the standard Charlson comorbidity index increased it. Although visit corrected and age, sex, and race adjusted mortality rates were similar in hospital referral regions with the highest and lowest fifths of visits, adjustment using the standard index resulted in a rate that was 18% lower in the highest fifth (46.4 v 56.3 deaths per 1000, P<0.001). Age, sex, and race adjusted spending as well as visit corrected spending was more than 30% greater in the highest fifth of visits than in the lowest fifth, but only 12% greater after adjustment using the standard index. Similar results were obtained using the Iezzoni and the hierarchical condition categories conventions for measuring comorbidity. Conclusion The rates of visits by physicians introduce substantial bias when regional mortality and spending rates are adjusted for illness using comorbidity measures based on the observed number of diagnoses recorded in Medicare’s administrative database. Adjusting without correction for regional variation in visit rates tends to make regions with high rates of visits seem to have lower mortality and lower costs, and vice versa. Visit corrected comorbidity measures better explain variation in age, sex, and race mortality than observed measures, and reduce observational intensity bias.

Setting Targets for Health Care Performance: Lessons from a Case Study of the English NHS

This paper examines problems of setting targets for health care performance in which the centre sets a uniform set of targets and levels of performance. The case study examined by the paper is from...

Measuring geographic inequities in the Portuguese health care system: an estimation of hospital care needs.

Portugal created a NHS to achieve greater equity of access to health care. Successive governments continued to assert the importance of equity in the face of evidence of inequities in supply of hospital resources, but lacked methods to provide sound information on the degree of inequities in Portugal and hence how to achieve greater equity. Capitation formulae have been increasingly used in other countries with a NHS to measure geographical inequities and allocate resources to reduce them. The main objective of this paper was to develop a capitation formula to measure need for hospital care for the Portuguese system by transferring this technology from methods used in other countries, and, in particular, in England. We find, however, problems with the common use of standardised mortality ratios (SMRs) as a measure of need and found age-specific mortality ratios to offer more soundly-based estimates. We also raise questions on the use of empirical estimates of utilisation of health care by age and sex as they appear to reflect inadequacies of health care in Portugal. We also believe it is important to improve knowledge of health insurance and care outside the NHS. Our results show that there are considerable inequities on the distribution of hospital resources in Portugal.

Performance measurement of “knights” and “knaves”: differences in approaches and impacts in British countries after devolution

Abstract Policies for publicly-financed health care in Britain have traditionally assumed that all the key players were “knights” who struggled to deliver the best possible services within the constraints of available resources, and hence if they failed to do so, needed extra resources. The Labour government elected in 1997 was confronted with a National Health Service in a parlous state, which following devolution became a challenge for four different territorial governments. The governments in Scotland and Wales used systems of performance measurement of hospitals that assumed “knightly” behaviour and were ineffective: the government in Scotland assumed that hospitals did not need to be held to account for performance measured by an intelligence system to identify and act on shortcomings; and the government in Wales assumed that, as hospitals would endeavour to achieve targets for waiting times, if they failed to so, they needed extra resources. Only England introduced a ranking system of performance measurement dominated by targets for waiting times that aimed to discriminate between “knights” and “knaves” and “name and shame”“failing” hospitals, which resulted in dramatic improvements in reported performance and gaming. Analysis of these different approaches to performance measurement of hospitals in Britain, and of ranking systems in the US, suggests that, for a system of performance measurement to have an impact, it needs to have potential to inflict reputational damage by producing information that is reliable, robust to criticism from the hospitals being assessed, understood in broad terms by the public, and published and widely disseminated.

The Search for a Proportionate Care Law by Formula Funding in the English NHS

Although the National Health Service was created to achieve equity of access to health care in 1948, over twenty years later an ‘inverse care law’ was seen to operate. The 1976 Report of the Resource Allocation Working Party laid the principles of formula funding to achieve an equitable distribution of resources, to move, over time, towards the operation of a proportionate care law. These principles have been applied ever since in England. This paper describes the context, governance and subsequent development of formulas and three persistent problems: accounting for populations, their needs and variations in the unavoidable costs of providers. The paper concludes by outlining continuing problems from the past and new challenges of formula funding in England to reduce ‘avoidable’ inequalities in health.

Changing paradigms of governance and regulation of quality of healthcare in England

Abstract This paper outlines the way in which professional self regulation of quality of healthcare was integral to the creation of the National Health Service (NHS) in 1948, and to the way the NHS was organized for the next 50 years. It describes the crisis in quality that emerged in the late 1990s. It describes the governments initial responses to that crisis, which were to require NHS organizations to implement systems of clinical governance, and create the Commission for Health Improvement (CHI) to inspect its implementation through visits to each NHS organization. The paper discusses Reports from Inquiries into three scandals, and considers the further changes made to governance and regulation of quality with the abolition of CHI and the National Care Standards Commission, which inspected the private sector, to be succeeded by the Healthcare Commission with a new approach to regulation. It examines three promises of that new approach: the use of national standards; being ‘light touch’ and proportionate using ‘intelligent’ (or ‘smart’) information, as opposed to being organized on a comprehensive programme of visits; and developing a common approach to the NHS and private sectors.