Can contracts drive clinical care?

Using clinical audit, qualitative data from patients and feedback from general practitioners to decrease delay in the referral of suspected colorectal cancer

RATIONALE

There was local concern over possible delays in the diagnosis and referral of patients with suspected colorectal cancer and interest in understanding more about patients' experiences of diagnosis.

AIMS AND OBJECTIVES

To use clinical audit, qualitative data from patients and feedback from general practitioners (GPs) to identify possible delays in referral, and to decrease these by implementing referral guidelines.

METHODS

Audit of endoscopy referrals assessed how often these recorded rectal examination and whether patients were seen within 2 weeks. Qualitative interviews with 19 patients explored their experience of referral and diagnosis. Review of 33 case records assessed other possible delays.

RESULTS

Most patients referred for endoscopy were seen within 2 weeks (67%, 119/177), but only 47% (71/151) of available referral letters mentioned rectal examination. Patients perceived most delay in secondary care and case records suggested that this occurred after non-urgent referral. Patients also identified some problems with communication, information and support about the diagnosis. We used the results to stimulate local acceptance of national referral guidelines and wider discussion about care. A consultation exercise with GPs informed the development of a faxable urgent referral pro forma and supporting educational meetings. We designed a database to monitor changes in waiting times and made plans to improve communication and support after diagnosis.

DISCUSSION

Feeding back qualitative data from patients together with audit results seemed a powerful lever to stimulate action about hospital delays. Average waiting times dropped quickly and remained low due to the continuing national focus upon them. Seeking GP views may have promoted the use of referral pro formas, but monitoring waiting times distracted from a more thorough evaluation of their use. Qualitative data from patients raised awareness of their experience, but was time-consuming to collect and we had limited success in using it for specific initiatives around communication and support.

Priority setting and evidence based purchasing

The purpose of this paper is to consider the role that values play in priority setting through the use of EBP. It is important to be clear about the role of values at all levels of the decision making process. At one level, society as a whole has to make decisions about the kind of health provision that it wants. As is generally accepted, these priority setting questions cannot be answered by medical science alone but involve important judgements of value. However, as I hope to show values come into priority setting questions at another level, one not often explicitly recognised in much of the literature: that of the very definition of the effectiveness of treatments. This has important consequences for patient care. If we do not recognise that the effectiveness of a treatment involve subjective elements--a patient's own assessment of the value of the treatment--then this could lead to the belief that we can purchase one treatment that is the most effective for all patients. This might result in a detrimental reduction in the range of options that a patient is given with some patients not receiving the treatment that is most effective for them.

Obstetric anaesthesia: an approach to improving the standards of services

There has been considerable discussion about obstetric anaesthesia standards and about the role of peer review in quality improvement. We carried out two postal surveys in 1990 and 1991 in major obstetric departments in Northern England, in order to assess practice and facilities against professionally derived standards, with the aim of stimulating and reviewing change. The reference standards were a local adaptation of those produced by the Obstetric Anaesthetists Association, and covered operating facilities, anaesthetic equipment, management and manpower, training, and protocols. In 1990, considerable variation in practice and facilities was identified with deficiencies in all hospitals. After feedback of the results of the first survey, a further survey conducted in 1991 identified improvement in 23/26 standards. Reference to standards was widely included in business plans and contracts for services. Following further feedback of the second survey and some revision of standards, a third survey was carried out using site visits. This revealed further improvement in 8/26 standards, but apparent deterioration in 11/26. The overall change from the first to the third survey was of apparent improvement in 15/26 standards and deterioration in 6/26. Surveys of practice against professionally derived standards and the targeted feed back of results can lead to improvements in practice and facilities.

From cooperation to competition in national health systems--and back?: impact on professional ethics and quality of care

Ethical behaviour in health workers is the jewel in the crown of health services. Health system policies need to nurture a professional service ethic. The primary health care policy envisioned a national health system led by the public sector and based on a philosophy of cooperation. A common theme of 'health sector reform' in OECD countries, introduced in the context of neoliberalism, has been the use of 'managed competition' to increase efficiency. Some countries that flirted with health system competition have returned to cooperation. Market relationships tend to be oppositional and to stimulate self-seeking behaviour. Health system relationships should encourage patient and community centred behaviour. The World Bank and bilateral donors have exported health sector reform theories from the north to the south, involving privatization and marketization policies. This is despite the lack of evidence on their desirability or feasibility of implementing them. Private health care has increased in many developing countries, more as a result of economic crisis and liberalization than specific health sector reforms. Much of this private practice is unlicensed and unregulated, and informal privatization has had a damaging effect on health worker ethics. The lead policy should be reconstruction of the public health system, involving decentralization, democratization and improved management. Commonsense contracting of an existing private sector is different from a policy of proactive privatization and marketization. Underlying the two approaches is whether health care should be viewed as a human right best served by socialized provision or a private good requiring governments only to correct market failures and ensure basic care for the poor. It is a matter of politics, not economics.

An audit of the organization of adult epilepsy services in the UK: a comparative review of epilepsy and general neurology clinics

A survey of all consultant neurologists was carried out to investigate the current provision of hospital-based adult epilepsy services in the UK and to compare the level of services offered by epilepsy and general neurology clinics. The valid response rate was 75%. Fifty-four epilepsy clinics were identified led by 43 neurologists in 46 hospitals. Over half the major neurological centres represented in the dataset had epilepsy clinics (31/58). Epilepsy clinics were significantly more likely than general neurology clinics to have on-site provision of a wide range of relevant investigations and associated specialists, and also shorter waiting times to see new patients with suspected seizures. There were also significant differences between epilepsy clinics and general neurology clinics in the provision of written information and counselling. Epilepsy clinics have definite advantages for patients over general neurology clinics in improving access to investigations and specialists and provision of psychosocial support, but the extent to which these translate into positive health outcomes needs further evaluation. A second survey of directors of public health concerning purchasing arrangements for epilepsy services confirmed that purchasers, as yet, are making little use of the contracting process to influence the quality of epilepsy services offered by providers of care.

Using clinical audit to promote evidence-based medicine and clinical effectiveness--an overview of one health authority's experience

Health care purchasers are facing increasing pressure to make the best use of their limited resources and to purchase only those services known to be clinically effective. This paper describes one health authority's experience of promoting clinical effectiveness through clinical audit and clinical guidelines. It highlights the central role of public health physicians in working closely with clinicians on the one hand and managers on the other, to promote evidence-based medicine. The recent changes in the funding arrangements for audit have allowed purchases to have more say in what should be audited, and link audit and clinical effectiveness with contracts.