Use of Targets to Improve Health System Performance: English NHS Experience and Implications for New Zealand

The setting of quantitative, time-limited ?targets? backed up by institutional and managerial rewards and sanctions has been a notable feature of performance improvement efforts in the National Health Service (NHS) in England since 1998 and especially in the period 2000-2004. Performance improved in the areas covered by English NHS targets, most markedly in relation to waiting times, but also in relation to treatment outcomes. None of the other parts of the United Kingdom followed England and similar trends were not observed, particularly not in waiting times, despite similar injections of funds. Despite the improvements in performance in target areas, targets were criticised, principally, for having perverse and unintended consequences (e.g. distorting priorities, encouraging ?gaming?, etc) which could have potentially out-weighed their benefits. On the other hand most experts in performance improvement in public services argue that carefully chosen, incentivised targets are a useful part of the performance management repertoire when used well (e.g. when sanctions and rewards are proportionate). Some dysfunctional consequences are to be expected, but can be mitigated. Given the similarities between the English NHS and the New Zealand public health system, there is scope to use targets and related incentives sparingly to improve performance in New Zealand in areas of high importance to government and the public.performance measurement; performance management; performance improvement methods; target-setting; control of public services

A Review of Options for Health and Disability Support Purchasing in New Zealand

The introduction of an internal market into New Zealand's publicly financed health system based on a purchaser-provider separation was highly controversial. From four Regional Health Authorities, the purchasing side of the internal market was subsequently reconfigured into a single national purchasing agency, the Health Funding Authority, in 1997. This Working Paper reviews the original rationale for the separation of purchase from provision, discusses the recent experience of the separation in New Zealand and reviews options for the possible evolution of the purchasing function. The options reviewed include vertical integration (ie, the abolition of the purchaser-provider split). It is argued that there are benefits associated with the separation of purchaser and provider, and that, on balance, it was a good thing, although its application to all services was probably inadvisable. However, no one model of purchaser organisation can fulfil all the requirements described by proponents of system change. Health services' purchasers are inescapably in a weak position vis-à-vis their providers. Whichever model of purchasing/planning services is implemented, purchasers will need to develop a new set of relationships with primary care providers, especially general practitioners, since primary care services are important for the functioning of the remainder of the health system. There are currently few incentives on primary care providers to consider the wider implications of their decisions for the rest of the sector and the delivery of primary care is imperfectly coordinated with other services. This paper is a background paper and does not provide policy advice, nor does it propose any particular course of action. The Treasury has chosen to publish it (or make it available) in order to encourage peer comment with a view to ensuring that it is of good quality. The views expressed in the paper is/are those of the author(s) and do not necessarily reflect the views of the New Zealand Treasury. The Treasury takes no responsibility for any errors or omissions in, or for the correctness of, the information contained in this paper.

Describing the impact of health research: a Research Impact Framework.

BACKGROUND: Researchers are increasingly required to describe the impact of their work, e.g. in grant proposals, project reports, press releases and research assessment exercises. Specialised impact assessment studies can be difficult to replicate and may require resources and skills not available to individual researchers. Researchers are often hard-pressed to identify and describe research impacts and ad hoc accounts do not facilitate comparison across time or projects. METHODS: The Research Impact Framework was developed by identifying potential areas of health research impact from the research impact assessment literature and based on research assessment criteria, for example, as set out by the UK Research Assessment Exercise panels. A prototype of the framework was used to guide an analysis of the impact of selected research projects at the London School of Hygiene and Tropical Medicine. Additional areas of impact were identified in the process and researchers also provided feedback on which descriptive categories they thought were useful and valid vis-à-vis the nature and impact of their work. RESULTS: We identified four broad areas of impact: I. Research-related impacts; II. Policy impacts; III. Service impacts: health and intersectoral and IV. Societal impacts. Within each of these areas, further descriptive categories were identified. For example, the nature of research impact on policy can be described using the following categorisation, put forward by Weiss: Instrumental use where research findings drive policy-making; Mobilisation of support where research provides support for policy proposals; Conceptual use where research influences the concepts and language of policy deliberations and Redefining/wider influence where research leads to rethinking and changing established practices and beliefs. CONCLUSION: Researchers, while initially sceptical, found that the Research Impact Framework provided prompts and descriptive categories that helped them systematically identify a range of specific and verifiable impacts related to their work (compared to ad hoc approaches they had previously used). The framework could also help researchers think through implementation strategies and identify unintended or harmful effects. The standardised structure of the framework facilitates comparison of research impacts across projects and time, which is useful from analytical, management and assessment perspectives

The experience of potentially vulnerable people during cold weather: implications for policy and practice

To examine the experience of potentially vulnerable people during cold weather to inform interventions aimed at improving well-being. Qualitative study. Telephone interviews with 35 individuals who could be considered to be potentially vulnerable during cold weather. Individuals were interviewed on two occasions during the winter of 2012-13, one or two days after a level 3 cold weather alert, as defined by the Cold Weather Plan for England, had been issued. Participants were largely unaware of the health risks associated with low temperatures, especially cardiovascular risk. There was a clear distinction between the thermal experience of people in social housing, which was newer, had efficient heating, was well insulated and well-maintained, and owner occupiers living in older, harder to heat homes. Most participants relied on public transport, and many faced arduous journeys to reach basic facilities. Vulnerability to cold was mediated to a significant extent by practical social support from family members. Resources should be targeted at people in hard to heat homes and those that are socially isolated. The repertoire of initiatives aimed at reducing cold-related mortality and morbidity could usefully be augmented by efforts to reduce social isolation and build community resilience

The Multiple Purposes of Policy Piloting and Their Consequences: Three Examples from National Health and Social Care Policy in England

AbstractIn England, policy piloting has become firmly established in almost all areas of public policy and is seen as good practice in establishing ‘what works’. However, equating piloting with evaluation can risk oversimplifying the relationship between piloting and policy-making.Using three case studies from health and social care – the Partnerships for Older People Projects (POPP) pilots, the Individual Budgets pilots and the Whole System Demonstrators (WSD) – the paper identifies multiple purposes of piloting, of which piloting for generating evidence of effectiveness was only one. Importantly, piloting was also aimed at promoting policy change and driving implementation, both in pilot sites and nationally. Indeed, policy makers appeared to be using pilots mainly to promote government policy, using evaluation as a strategy to strengthen the legitimacy of their decisions and to convince critical audiences. These findings highlight the ambiguous nature of piloting and thus question the extent to which piloting contributes to the agenda of evidence-based policy-making.</jats:p

Effect of a telephonic alert system (Healthy Outlook) for patients with chronic obstructive pulmonary disease: cohort study with matched controls

Background: Healthy Outlook was a telephonic alert system for patients with Chronic Obstructive Pulmonary Disease (COPD) in the United Kingdom. It used routine meteorological and communicable disease reports to identify times of increased risk to health. We tested its effect on hospital use and mortality. Methods: Enrolees with a history of hospital admissions were linked to hospital administrative data. They were compared with control patients from local general practices, matched for demographic characteristics, health conditions, previous hospital use and predictive risk scores. We compared unplanned hospital admissions, admissions for COPD, outpatient attendances, planned admissions and mortality, over 12 months following enrolment. Results: Intervention and matched control groups appeared similar at baseline (n=1,413 in each group). Over the 12 months following enrolment, Healthy Outlook enrolees experienced more COPD admissions than matched controls (adjusted rate ratio 1.26, 95% CI, 1.05 to 1.52) and more outpatient attendances (adjusted rate ratio 1.08, 95% CI 1.03 to 1.12). Enrolees also had lower mortality rates over 12 months (adjusted odds ratio 0.61, 95% CI, 0.45 to 0.84). Conclusion: Healthy Outlook did not reduce admission rates, though mortality rates were lower. Findings for hospital utilisation were unlikely to have been affected by confounding

Reforming primary health care: is New Zealand's primary health care strategy achieving its early goals?

BACKGROUND: In 2001, the New Zealand government introduced its Primary Health Care Strategy (PHCS), aimed at strengthening the role of primary health care, in order to improve health and to reduce inequalities in health. As part of the Strategy, new funding was provided to reduce the fees that patients pay when they use primary health care services in New Zealand, to improve access to services and to increase service use. In this article, we estimate the impact of the new funding on general practitioner and practice nurse visit fees paid by patients and on consultation rates. The analyses involved before-and-after monitoring of fees and consultation rates in a random sample of 99 general practices and covered the period from June 2001 (pre-Strategy) to mid-2005. RESULTS: Fees fell particularly in Access (higher need, higher per capita funded) practices over time for doctor and nurse visits. Fees increased over time for many in Interim (lower need, lower per capita funded) practices, but they fell for patients aged 65 years and over as new funding was provided for this age group. There were increases in consultation rates across almost all age, funding model (Access or Interim), socio-demographic and ethnic groups. Increases were particularly high in Access practices. CONCLUSION: The Strategy has resulted in lower fees for primary health care for many New Zealanders, and consultation rates have also increased over the past few years. However, fees have not fallen by as much as expected in government policy given the amount of extra public money spent since there are limited requirements for practices to reduce patients' fees in line with increases in public funding for primary care

Responding to the mental health consequences of the 2015–2016 terrorist attacks in Tunisia, Paris and Brussels: implementation and treatment experiences in the United Kingdom

Objectives: To explore whether the Screen and Treat Programme to support United Kingdom citizens potentially affected by terrorist attacks in Tunisia (2015), Paris (2015) and Brussels (2016) was effective in identifying and referring people to mental health services, to examine the programme’s acceptability to users and to understand how agencies involved worked together. Methods: Individuals offered screening by the programme (n = 529) were invited to participate in the study and were sent a questionnaire. Follow-up interviews were conducted with questionnaire respondents who consented and with employees of agencies involved in the programme’s planning and delivery. Seventy-seven people affected by the attacks completed questionnaires, 35 of those were also interviewed, and 1 further person only participated in an interview. Eleven people from agencies organizing and delivering the programme and five clinician-managers were also interviewed. Results: Most service users said the attacks had a major impact on their lives. Many reported anxiety, depression, difficulty going out or travelling, sleep problems, panic attacks, flashbacks and hyper-vigilance. A third had reduced their working hours and a similar proportion had taken sick leave. Two-thirds sought help from their General Practitioner (GP) before being contacted by the programme, but almost all thought their GP had not been helpful in dealing with post-traumatic stress disorder (PTSD) or referring to appropriate care. Several people were prescribed psychotropic medication; only a few were referred to mental health professionals. Many participants used help offered by organizations external to National Health Service, with mixed experiences. Waiting times for treatment varied from no delay to a few months. Most interviewees thought the programme should have started sooner and provided more information about sources of support. Most users found treatment received via the programme helpful. Professionals involved in organizing and delivering the programme thought that bureaucratic delays in setting it up were key limitations on effectiveness. Clinician interviewees thought an outreach approach was needed to identify at-risk individuals. Conclusions: Users who took part in the programme were satisfied with their treatment, although many thought it should have been offered sooner. Funding and data sharing between agencies were the main barriers to timely contact with affected individuals. Self-referral, GP identification of PTSD and GP referral to appropriate care were regarded as ineffective, suggesting that people affected by similar future incidents should be supported better and assisted more promptly to access treatment