Sylvia Godden

No evidence that patient choice in the NHS saves lives

The Health and Social Care Bill 2011 has been framed to abolish direct parliamentary control and public accountability for the National Health Service (NHS) in England. In the face of enormous public opposition to the Bill, the UK Government stood down the legislative process between April and June, 2011. Prime Minister David Cameron used the temporary pause to advance the case for the Bill and argued “Put simply: competition is one way we can make things work better for patients. This isn’t ideological theory. A study published by the London School of Economics found hospitals in areas with more choice had lower death rates.” The study to which Cameron referred was a working paper by Zack Cooper and colleagues. However, contrary to Cooper and colleagues’ claims, their study did not show a causal inverse relation between patient choice and death rates. A statistical association is not the same as causation. As set out by Bradford Hill in his seminal paper, certain factors must be considered when determining whether a statistical association is likely to be causal: ”experiment” or study design, plausibility of intervention and outcomes, strength, consistency, specifi city, coherence, temporality, and quality of data. Cooper and colleagues’ study does not meet scientifi c standards. In the absence of evidence proving that competition improves health, Cooper and colleagues’ work should not be cited as scientifi c evidence in support of choice, competition, or the current market-oriented Health and Social Care Bill 2011. A revised version of the study, published in The Economic Journal, clarifi ed points of detail, but Cooper large comparative studies, one reporting data from two academic institutions and one from a multicentre community-based cohort, both noted—after many adjustments for case-mix and disease risk—substantially improved outcomes after surgery compared with radiation. The community-based analysis also recorded, as did Warde and colleagues, better out comes after either surgery or radiation than after androgen deprivation monotherapy. In both studies, diff erences between treatments were small for men with low-risk disease, and increased progressively as risk rose. Warde and colleagues have provided the strongest evidence to date that androgen deprivation therapy alone for men with high-risk prostate cancer is not adequate. These patients require an aggressive, multimodal approach incorporating prostate-directed local therapy. However, the crucial question—whether the optimum initial strategy should include radiation combined with androgen deprivation therapy, or surgery followed by selective radiation on the basis of pathological fi ndings and early biochemical outcomes— is still open. The defi nitive answer will only come through trials of men with high-risk disease randomly assigned to receive surgery or radiation as an initial treatment.

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

How private finance is moving primary care into corporate ownership.

A central aim in establishing the NHS was to integrate primary care and health and social services in health centres. But this aim was compromised by the absence of public capital and the reluctance of the Treasury to buy out practice premises owned by general practitioners. Although there was some grant funding for health and local authority owned health centres, by 1974 only 15% of general practitioners operated out of these.1 General practitioner owned practice premises remained the dominant model from 1966 until 1989, financed by government loans and funded from NHS revenue under the rental reimbursement schemes. The privatisation of the government loan body in 1989 saw a switch to private finance and the entry of commercial companies and for-profit corporations. The amount of capital that can be raised by the private sector for new investment in the NHS is unrestricted. However, these debts have to be repaid through NHS funds or user charges. The renewed impetus for integrated services in the 1997 white paper, The New NHS ,2 means that more sophisticated buildings are required to accommodate advanced clinical technology and information systems. The complex financing and funding arrangements, combined with demographic factors, makes it likely that as general practitioners opt for a salaried service, the trend to for-profit corporations owning and buying out practice premises will accelerate. #### Summary points Healthcare companies and property developers are rapidly expanding into the ownership and provision of primary care premises Under the private finance initiative, there are no restrictions on the amounts that can be borrowed or invested “Bundling” of diverse NHS and non-NHS facilities into one project allows the commercial sector to target new sources of revenue No data are collected centrally on the different types of public-private partnerships in primary care or on the various methods of financing and …

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.

Waiting list and waiting time statistics in Britain: a critical review.

OBJECTIVES The measurement of access to health care in the National Health Service is dominated by waiting list and waiting time targets which depend on the collection and publication of a range of government statistics. The aim of this study was to describe the purposes for which waiting statistics are collected, and the different methods of data collection in the countries of Britain, in order to assess the extent to which published data meet their objectives. STUDY DESIGN Systematic review. METHODS A systematic evaluation of waiting statistics in England, Scotland and Wales based on official published data collections in each country, plus a review of the relevant literature. RESULTS Waiting statistics are collected for a number of purposes, but are primarily for performance monitoring against waiting time targets and for local planning. One method of data collection may not best serve all objectives, and there are differences in the practices of the countries of Britain. An important purpose should be to measure access to health care according to individual patient need, and limitations in the statistics were identified in this respect due to methodological issues, omissions and exclusions, hidden waits, the emphasis on achieving targets, and interpretation. CONCLUSIONS Although there are merits in maintaining the existing series, the use of waiting statistics as the primary method of measuring and monitoring access to services has limitations, not least because statistics do not contain the information required to assess whether time waited is appropriate to need.

Dismantling the signposts to public health? NHS data under the Health and Social Care Act 2012

A shift away from area based populations in England will have severe implications for population health data, argue Allyson M Pollock, Alison Macfarlane, and Sylvia Godden

Information on community health services. More and better information is needed--not less.

The current thrust of government policy in the United Kingdom is to shift acute care to alternative settings. The critical question is whether these arrangements will meet the health and social care needs of the local community, and that question can be answered only if there are data on needs, service use, and outcomes. The fragmented arrangements for providing and funding health and social care present a compelling case for universal standardised data collection. Yet the NHS information strategy, far from strengthening community information, suggests its contraction Data sets and data collection for community NHS services have a chequered history in the NHS. In 1981 Dame Edith Korners steering group on health services information recommended standardised datasets for community health services and acute hospital services. As a result, three types of community data are collected: on staff groups, on facilities including beds, and on patient contacts.1 Despite limitations, the data have proved essential for …

Using SitReps performance data to monitor the delayed discharge process.

Situation Reports (SitReps) is an internal Department of Health performance data collecting system. Although intended primarily for internal use, the data are also used to answer parliamentary questions, brief ministers and to inform national performance indicators. This paper reviews the data collection system and data-set, and shows how it can be used to evaluate delays in hospital discharge under the Community Care (Delayed Discharges etc.) Act 2003. However, limitations in the data include the fact that the data have only recently been extended to National Health Service (NHS) non-acute settings and do not include NHS patients in the private acute sector. Further, as the data-set derives from a weekly aggregate return rather than from individualized person-based records, it cannot be used to evaluate length of delay, or to link to other relevant data such as emergency readmissions. The provision of individualized data to facilitate linkage and extending coverage would increase its potential future use. Categories of delay should be further refined to facilitate monitoring of delays due to disputes about eligibility.

Capital Investment in Primary Care— The Funding and Ownership of Primary Care Premises

The authors describe the complexity of the financing arrangements of primary care premises. They explain how the early vision of integrating health and social services within local health centres failed to be realized, with GP-owned practice premises remaining as the dominant model. There was a switch to private finance when the government loan body (General Practice Finance Corporation) was privatized in 1989. Although capital can now be freely raised by the private sector for investment in the National Health Service (NHS), these debts have to be repaid through NHS funds or user charges. The complexity, combined with demographic factors, makes it likely that as GPs opt for the Personal Medical Services (PMS) scheme and a salaried service, the trend towards for-profit corporations owning and buying out GP premises will accelerate.

Monitoring access to out-of-hours care services in Scotland – a review

Objectives Changes in the contractual responsibilities of primary care practitioners and health boards have resulted in a plethora of arrangements relating to out-of-hours healthcare services. Rather than being guaranteed access to a GP (usually either their own or another through a local GP co-operative), patients have a number of alternative routes to services. Our objective was to identify and assess the availability and adequacy of relevant standards, responsibilities and information systems in Scotland to monitor the impact of contractual changes to out-of-hours healthcare services on equity of access. Design Cross-sectional study. Setting All providers of primary care out-of-hours services in Scotland. Participants Not applicable. Main outcome measures First, identification and policy review of current standards and performance monitoring systems, data and information, primarily through directly contacting national and local organizations responsible for monitoring out-of-hours care, supplemented by literature searches to highlight specific issues arising from the review; and second, mapping of data items by out-of-hours provider type to identify overlap and significant gaps. Results In Scotland, data monitoring systems have not kept pace with changes in the organization of out-of-hours care, so the impact on access to services for different population groups is unknown. There are significant gaps in information collected with respect to workforce, distribution of services, service utilisation and clinical outcomes. Conclusions Since 2004 there have been major changes to the way patients access out-of-hours healthcare in the UK. In Scotland, none of the current systems provide information on whether the new services satisfy the key NHS principle of equity of access. There is an urgent need for a comprehensive review of data standards and systems relating to out-of-hours care in order to monitor and evaluate inputs, processes and outcomes of care not least in respect of access and fairness of distribution of resources.