Mónica Duarte Oliveira

A multi-criteria model for auditing a Predictive Maintenance Programme

Auditing tools can play a key role in the continuous improvement of maintenance policies, in particular to enhance predictive maintenance (PM). This paper proposes a multi-criteria model for auditing a Predictive Maintenance Programme (PMP) developed and implemented in the General Hospital of Ciudad Real (GHCR) in Spain. The model has a two-level structure, with top level auditing areas specified by second level auditing criteria on which the performance of the PMP should be appraised. This structure resulted from the analysis and discussion of an internal questionnaire to the management, technical and consulting staff of GHCR. This also guided the association of a performance scale with each criterion, describing several reference levels of accomplishment. Using the MACBETH (Measuring Attractiveness by a Categorical Based Evaluation Technique) approach, a hierarchical additive value model was constructed, with criteria weights and value scales derived from staff judgments of comparison of different reference levels and profiles of performance. This model enables managers to measure the performance of the PMP and its added value for the hospital, not only against each audit criterion individually, but also on each area and in overall terms. Integrated in a management “tableau de bord”, the model outputs permit the identification of PMP deficiencies requiring urgent intervention and corrective measures for its continuous improvement.

Location–allocation approaches for hospital network planning under uncertainty

This study proposes two location–allocation models for handling uncertainty in the strategic planning of hospital networks. The models aim to inform how the hospital networking system may be (re)organized when the decision maker seeks to improve geographical access while minimizing costs. Key features relevant in the design of hospital networks, such as hospitals being multiservice providers operating within a hierarchical structure, are modelled throughout a planning horizon in which network changes may occur. The models hold different assumptions regarding decisions that have to be taken without full information on uncertain parameters and on the recourse decisions which will be made once uncertainty is disclosed. While the first model is in line with previous literature and considers location as first-stage decisions, the second model considers location and allocation as first-stage decisions. Uncertainty associated with demand is modelled through a set of discrete scenarios that illustrate future possible realizations. Both models are applied to a case study based on the Portuguese National Health Service. The results illustrate the information that can be obtained with each model, how models can assist health care planners, and what are the consequences of different choices on the decisions to be taken without complete information. The second model has shown to be advantageous on grounds that location–allocation decisions are not scenario dependent, and it appears to be more flexible to handle the planning problem at hand.

Financing mental health care in Europe

Background: Some of the most heated discussions about health policy concern financing and the funding base for services. How have west European countries approached the financing of their mental health systems? Aims: To describe the financing arrangements for mental health care in 17 European countries, and to identify the consequences for system efficiency, access and development. Method: A structured questionnaire was completed by partners in the Mental Health Economics European Network (MHEEN) to describe funding levels and financing arrangements in their countries. Responses were interpreted in the context of the wider literature on health care financing. Results: All participating countries are committed to collective pre-payment modes of financing of health care in general, and mental health care in particular. However, there is growing reliance on voluntary (private) health insurance, at the margins at least, with implications for targeting and equity. The movement of some support responsibilities into social care and housing sectors could further shift funding burdens onto individuals and families. Conclusions: Europes long-term commitment to social solidarity and mutuality must not be threatened by changes to funding arrangements that could undermine recent efficiency and equity achievements in mental health systems. Efforts to contain health care expenditure may have adverse consequences for mental health care access and utilization. Declarations of interest: The Mental Health Economics European Network Phase I was supported by a grant (SPC.2002397) from the European Commission, Health and Consumer Protection Directorate. There are no conflicts of interest.

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.

Organizing hospitals into networks: a hierarchical and multiservice model to define location, supply and referrals in planned hospital systems

Health care planners in countries with a system based on a National Health Service (NHS) have to make decisions on where to locate and how to organize hospital services, so as to improve the geographic equity of access in the delivery of care while accounting for efficiency and cost issues. This study proposes a hierarchical multiservice mathematical programming model to inform decisions on the location and supply of hospital services, when the decision maker wants to maximize patients’ geographical access to a hospital network. The model considers the multiservice structure of hospital production (with hospitals producing inpatient care, emergency care and external consultations) and the costs associated with reorganizing the hospital network. Moreover, it considers the articulation between different hospital services and between hospital units, and the ascendant and descendent flows related to two-way referrals of patients in the hospital hierarchy. The proposed approach differs from previous literature by accounting simultaneously for these issues and provides crucial information for health care planners on referral networks, on hospital catchment areas, on the location and structure of hospital supply as well as on the costs required to improve access. The results from applying the model are illustrated in an application to the South region of the Portuguese NHS. Three scenarios are portrayed to describe how the model can be used in distinct institutional settings and policy contexts and when there is uncertainty concerning the key parameters of the model.

Modeling the demand for long-term care services under uncertain information

Developing a network of long-term care (LTC) services is currently a health policy priority in many countries, in particular in countries with a health system based on a National Health Service (NHS) structure. Developing such a network requires proper planning and basic information on future demand and utilization of LTC services. Unfortunately, this information is often not available and the development of methods to properly predict demand is therefore essential. The current study proposes a simulation model based on a Markov cycle tree structure to predict annual demand for LTC services so as to inform the planning of these services at the small-area level in the coming years. The simulation model is multiservice, as it allows for predicting the annual number of individuals in need of each type of LTC service (formal and informal home-based, ambulatory and institutional services), the resources/services that are required to satisfy those needs (informal caregivers, domiciliary visits, consultations and beds) and the associated costs. The model developed was validated using past data and key international figures and applied to Portugal at the Lisbon borough level for the 2010–2015 period. Given data imperfections and uncertainties related to predicting future LTC demand, uncertainty was modeled through an integrated approach that combines scenario analysis with probabilistic sensitivity analysis using Monte Carlo simulation. Results show that the model provides information critical for informing the planning and financing of LTC networks.

Moving beyond the mental health care system: An exploration of the interfaces between health and non-health sectors

Background: Many interventions both to promote good mental health and to tackle the consequences of poor mental health may be funded and/or delivered outside the health care sector. Aims: To describe the interfaces between health and other sectors, particularly social care, in 17 European countries, and to look at potential ways in which challenges to the efficient and fair delivery of services across sectors may be overcome. Methods: A structured questionnaire was completed by partners in the Mental Health Economics European Network (MHEEN) to review the extent to which mental health related services are funded and delivered outside the health care sector, with a particular emphasis on social care services. This was augmented by a review of the literature. Results: The boundaries between health and other sectors differ across and within countries. The provision and funding of services may be highly fragmented and poorly coordinated, with little incentive for funding to follow individuals along the care pathway. Out-of-pocket payments for non-health sector services can be substantial and much responsibility may fall to families. Conclusions: Differing rules of entitlement, as well as fragmentation and poor coordination between health and non-health services can act as barriers to a truly holistic approach to mental health across Europe. Useful insights on how to overcome some of these barriers may be drawn from experiences of joint working and innovative financing arrangements in respect of older people and those with physical disabilities. However as yet there have been comparatively few attempts to smooth the sector interfaces that confront those with mental health needs. Declaration of interest: The Mental Health Economics European Network Phase I was supported by a grant (SPC.2002397) from the European Commission, Health and Consumer Protection Directorate.

Modelling hospital costs to produce evidence for policies that promote equity and efficiency

Third party payers for health care, when introducing policies to promote equity, through formulas for resource allocation by capitation, and efficiency, through prospective payment by case-mix, have sought to make adjustments for “unavoidable” hospital costs, which are caused by structural characteristics and are beyond the scope of local hospital management. To date, however, most published studies of such estimates have been inadequate. This paper reports the development of a generalisable model that aims to produce sound estimates of “unavoidable” hospital costs and shows how this stochastic multilevel model can be used to estimate unavoidable costs per unit of measurable output, identify sources of allocative inefficiency, and capture systematic variations in costs between different types of hospitals, through prospective payment by case-mix or formulas for resource allocation by capitation The application of the model to Portuguese hospitals has identified various causes of allocative inefficiencies: centrally-determined distributions of beds and doctors, a lack of local flexibility, systems with perverse incentives, and the existence of diseconomies of scale.

Nondecision Making and Inertia in Portuguese Health Policy

Despite there having been a positive context for initiating health care reforms in Portugal in the past fifteen years (accompanied by political consensus on the nature of the structural problems within the health care system), there has been a lack of reform initiatives. We use a process-based framework to show how institutional arrangements have influenced Portuguese health care reform. Evidence is presented to demonstrate inertia and nondecision making in three critical areas of Portuguese health policy: clarifying the public-private mix in coverage and provision, creating financial incentives and motivation for human resources, and introducing changes in the pharmaceutical market. Several factors seem to explain these processes, namely, problems in the balance of power within the political system, which have contributed to a lack of proper policy discussion; a lack of pluralism in the formation of health care policies (with low participation from citizens and high mobilization among structural interest groups); and the low priority of health care in public sector reforms. Portuguese politicians should be aware of the pitfalls of the current political system that constrain participatory arrangements and pluralism in policy making. In order to pursue health care reform, future governments will need to counterbalance the strong influence of structural interest groups.

An integrated approach for planning a long-term care network with uncertainty, strategic policy and equity considerations

Considering key uncertainties and health policy options in the reorganization of a long-term care (LTC) network is crucial. This study proposes a stochastic mixed integer linear programming model for planning the delivery of LTC services within a network of care where such aspects are modeled in an integrated manner. The model assists health care planners on how to plan the delivery of the entire range of LTC services – institutional, home-based and ambulatory services – when the main policy objective is the minimization of expected costs and while respecting satisficing levels of equity. These equity levels are modeled as constraints, ensuring the attainment of equity of access, equity of utilization, socioeconomic equity and geographical equity. The proposed model provides planners with key information on: when and where to locate services and with which capacity, how to distribute this capacity across services and patient groups, and which changes to the network of care are needed over time. Model outputs take into account the uncertainty surrounding LTC demand, and consider strategic health policy options adopted by governments. The applicability of the model is demonstrated through the resolution of a case study in the Great Lisbon region in Portugal with estimates on the equity-cost trade-off for several equity dimensions being provided.