The Economics of Clinical Governance

1
The Economics of Clinical Governance

• www.bradfordvts.co.uk
• Brian Ferguson, Professor of Health Economics,
  Nuffield Institute for Health, University of
  Leeds
• and Head of Clinical Governance, North Yorkshire
  Health Authority

2
Professors

• a professor is a person who tells you what you
  know already, but in a way you cannot understand

3
Principles underlying the approach to clinical
effectiveness (August 1997)

• co-operation between providers and local
  commissioning groups, based on jointly agreed
  priorities
• recognise the need to develop effective links
  between clinical audit, continuous professional
  development and local RD initiatives
• recognising the importance of culture is vital
• this is a long-term agenda behavioural change
  takes time
• the focus should be upon improving health
  outcomes for patients and the public in general
• there are limits to the evidence-based approach
  which if taken too far can place a
  disproportionate emphasis upon guidelines,
  protocols and a rational, mechanistic approach.

4
Some reflections

• changing practice takes time
• what gets in the way?
• suspicion about motives
• perceived lack of resources
• structural change
• working across 1o and 2o care is essential in
  bringing about changes in patient care

5
One of the two great lies

• Im from the Health Authority and Im here to
  help......

6
Clinical governance more than a new label

• same elements as the previous label (clinical
  effectiveness)
• a statutory duty for quality on all NHS
  organisations
• explicit link to performance
• an opportunity for resources to follow measurable
  improvements in quality

7
Clinical Governance what can the dismal
science contribute?
8
Economics and theories

• A first-rate theory predicts, a second-rate
  theory forbids and a third-rate theory explains
  after the event

9
Important elements of clinical governance

• identifying the best available evidence base on
  clinical and cost-effectiveness
• continuous professional development
• clinical guidelines
• clinical risk management
• RD
• advice on clinically and cost-effective
  prescribing
• clinical audit
• performance assessment (of quality standards and
  changes)
• analysis and interpretation of information on
  current practice

10
Some principles

• there are limits to guidelines and protocols
• recognising the importance of culture is vital
• McKee and Clarke (1995) the most enthusiastic
  advocates....may have paid insufficient attention
  to the uncertainty inherent in clinical practice,
  with the imposition of a spurious rationality on
  a sometimes inherently irrational process

11
Service excellence in health care (1)

• Mayer and Cates (1999)
• Journal of the American Medical Association,
  Volume 282, Number 13

12
Service excellence in health care (2)

• patients want reports on both the quality of
  clinical care and the quality of service
• patients perceptions of service satisfaction
  have a clear impact on their perceptions of
  quality of care
• technical expertise must be combined with service
  excellence in health care, as well as the
  patients perception of that care, to improve
  clinical care overall

13
Health care professionals distinctions between
patients and customers (Mayer and Cates, 1999)
Acutely ill or injured
Less severely ill
Dependent on physician
Independent
Power / control with physician
Power / control with customer
Less choice
More choice
Technical expertise required
Service skills required
Higher satisfaction for clinician
Lower satisfaction for clinician
High clarity of treatment
Less clarity of treatment
Time-dependent
Service-dependent
14
A less scientific distinction between patients
and customers

• the more horizontal they are, the more they are
  a patient the more vertical they are, the more
  they are a customer

15
Improving process efficiency

• could patient details be recorded more
  efficiently?
• could information on the risks and benefits of
  different care pathways be provided more
  efficiently?
• if ophthalmology services were configured
  differently, could demand be managed better?

16
Factors in effective clinical teams

• showing a positive attitude to patients
• finding out what patients and colleagues think
  about the quality of care delivered
• assuming collective responsibility for
  performance
• showing leadership and competent management
• having clear values and standards
• demonstrating an enthusiasm to learn
• communicating well
• caring for each member of the team

17
Are Guidelines Following Guidelines? the
methodological quality of clinical practice
guidelines in the peer-reviewed medical literature

• Shaneyfelt, Mayo-Smith and Rothwangl, JAMA, May
  26, 1999

18
The cost of improving quality
Cost
MC
qmin
qm
Quality
qmax
q
19
Measuring performance

• measurement alone does not hold the key to
  improvement....measuring could be an asset in
  improvement if and only if it were connected to
  curiosity - were part of a culture primarily of
  learning and enquiry, not primarily of judgement
  and contingency
• Berwick (1998)

20
Incentives

• aligning financial and clinical incentives to
  improve quality
• money following quality?

21
Health Authorities the co-ordinators of
clinical governance arrangements

• PCGs commissioning decisions within HImP
  framework
• longer-term service agreements between HAs/PCGs
  Trusts need to reflect overall approach to
  quality and performance assessment within the
  HImP
• national guidelines will need to be implemented
  consistently within and across PCGs and Trusts
• CHI HAs and providers will be expected to
  resolve local difficulties but HA can trigger RO
  / CHI involvement

22
Projects aimed at bringing about evidence-based
change in North Yorkshire

• cost-effectiveness of a one-stop prostate
  assessment clinic
• improving the quality of information on
  orthopaedic surgery

23
One-stop prostate assessment clinic at Airedale
General Hospital

• Objectives
• to develop shared care guidelines, evidence-based
  where possible
• to evaluate the operational efficiency of the
  clinic within established evidence on best
  practice
• a joint project between Trust, HA and local GPs
• clinic aims to provide a one-stop diagnosis for
  patients with BPH and then to refer for
  appropriate treatment and follow-up

24
Operational efficiency assessment (1)

• little published evidence on the efficiency of a
  one-stop clinic but evidence of effectiveness for
  the diagnostic steps carried out within the
  clinic
• established a flow diagram of the different paths
  patients visiting the clinic could take
• this revealed that for most patients the clinic
  was not one-stop

25
Operational efficiency assessment (2)

• attached times and notional costs to the extra
  visits patients made to the clinic
• identified the barriers to the clinic being truly
  one-stop
• ultrasound
• test results
• business case developed for providing the clinic
  with the facilities to carry out ultrasound
  testing on the same day as the clinic

26
Evidence base(Total Hip Replacement)

• health needs assessment volume 1 (1994)
• Effective Health Care Bulletin (October 1996)
• Health Technology Assessment Report (1998)
• cemented designs show good 10-15 year survival
  results
• models with good comparable results include the
  Stanmore, Howse, Lubinus, Exeter and Charnley
• economic model estimates total expected costs
  based on Charnley survival data and actual
  hospital costs

27
Evidence base (Total Knee Replacement)

• health needs assessment volume 1 (1994)
• the gold standard knee prosthesis is not clear
  from the literature and a consensus of opinion is
  needed
• only five TKR implants on the UK market have
  published survival analyses of 10 years or more
  Liow and Murray, 1997

28
Issues for consideration

• evidence-based (cost-effective) prosthesis
  purchasing
• improving the quality of data
• measuring outcomes
• clinical measures
• patient outcome measures
• revision rates
• criteria for referral and prioritising waiting
  lists

29
The role of N.I.C.E.

• to give a strong lead on clinical and cost
  effectiveness, drawing up new guidelines and
  ensuring they reach all parts of the health
  service
• to improve the quality of clinical services
  across the NHS
• by evaluating new drugs and new technologies to
  see if they have a cost-effective role in the
  NHS
• by formulating guidelines on numerous conditions
  for doctors, carers and patients
• by advising on methods of audit in relation to
  guidelines.

30
Why should clinical guidelines matter to Health
Authorities?

• a quality assurance tool
• one means of ensuring equitable (access to)
  health care
• an implicit or explicit aid to prioritisation
  decisions
• a route to improving health outcomes

31
Economic questions

• if guidelines lead to greater centralisation of
  services, what resources can be expected to be
  released locally?
• fixed, semi-fixed and variable cost elements
• what are the likely costs and benefits of
  targeting different risk groups?
• marginal effects of targeting different groups

32
Some general (unresolved) issues

• designing appropriate incentive systems for
  developing clinical governance achieving
  measurable improvements in quality of care
• making the PCG clinical governance agenda the
  agenda of all the constituent practices
• anticipating and tackling poor clinical
  performance
• reconciling independent contractor status and
  professional self-regulation with clinical
  governance
• accessing clinical data and improving data coding
  quality
• establishing processes for supporting practices /
  individuals where consistently poor performance
  is identified
• ensuring a focus on clinical teams (relative
  performance is frequently a reflection of system
  rather than individual success or failure)

33
Some concluding points

• many of the issues of clinical governance are
  economic in nature
• aligning clinical and financial incentives will
  be important
• real co-operation across organisations and care
  boundaries is essential
• service quality and technical expertise should go
  hand-in-hand with patients perceptions of care
• Health Authorities and PCGs have a responsibility
  to take the wider view to protect the individual
  clinician / patient relationship