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 R&D 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 • “I’m from the Health Authority and I’m 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 • R&D • 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 patient’s 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 qmax q* Quality

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