Embed Size (px)
Citation preview
Appendix 1.
Better Allocation for Better Health and Healthcare: The First Annual Population Value Review
1
Better Allocation for Better Health and Healthcare:
The First Annual Population Value Review
Peter Brambleby, Andrew Jackson and J. A. Muir Gray
Foreword by: Duncan Selbie, Commissioning Director
NHS National Knowledge Service Commissioning Directorate Department of Health
2
Contents
Foreword
Programme Budgeting for commissioners: in brief What is the aim of commissioning?
What is the aim of the annual population value review?
Why have an annual population value review?
How can we improve healthcare locally through the annual population value
review?
How do I conduct an annual population value review?
What is the right answer?
What will be the outcome of this annual population value review?
Section 1: Taking the plunge into Programme Budgeting and Marginal Analysis
What is Programme Budgeting and Marginal Analysis (PBMA)?
What data and resources are available to undertake Programme Budgeting?
Data on expenditure
Data on outcomes
How is the information collected?
What do I do now?
Additional resources to support commissioners
Section 2: What tasks do I need to do for the general assessment of the whole budget?
Proformas 2.1 and 2.2
Section 3: What tasks do I need to do for the specific assessment of a programme budget for a single disease category? Section 4: The future
What further information will be available to increase the usefulness of
Programme Budgeting?
More detailed programme and sub-programme financial data
More reliable data
More outcome and output data
Marginal analysis
Further reading
3
Annex 1: Background to Programme Budgeting
What is the National Programme Budgeting Project?
Why is Programme Budgeting important now?
What is the history of Programme Budgeting?
When was Programme Budgeting introduced into the NHS?
The National Programme Budget Project Board
What are the benefits of Programme Budgeting for the NHS?
What are the advantages of Programme Budgeting to individual NHS
organisations?
How will Programme Budgeting be used in the long term?
Annex 2: The Annual Review of Evidence, Process, Outcomes and the Configuration of the 50 major health problems (EPOC) Programme
4
Foreword Dear Colleagues,
Welcome to the first Annual Population Value Review.
One of the core functions of commissioners is resource allocation to different population
groups based on an analysis of need. Excellent work has been done by the Programme
Budgeting Team within the Department of Health, and clear information about spend on
each patient group can now be provided for each PCT. In the first instance, this will raise
questions about the accuracy of the data, however, this will improve with use.
Before the start of the next financial year (2007-2008), each primary care trust (PCT)
might want to reflect upon the distribution of resources among the different groups and
how the distribution compares with the distribution of other commissioners, particularly
commissioners who are serving populations that have a similar socio-economic profile.
Some of you will already be experienced in the technique of Programme Budgeting, but
for those of you who are not we have been fortunate in obtaining the skill and experience
of both Peter Brambleby, lately Director of Public Health at Norwich PCT, and Andrew
Jackson from the DH Finance Directorate to help promote and disseminate this work.
For those to whom this technique is new, the main objective this year is to reflect upon
the distribution of resources across and within programme categories, and to identify
areas that would reward further investigation and analysis. For those who have already
carried out programme budgeting before, data can offer the opportunity for more detailed
analysis and action.
It is our intention to produce guidance on marginal analysis at a later date. For many of
you, this will be of most use during the second annual value population review, which
will be based on 2006-07 data available from November 2007.
Throughout 2007, more detailed work on individual programme budgets relating to
disease groups and then specific conditions within each disease group will take place as
part of the work for the National Knowledge weeks, introduced by the National
Knowledge Service with the focus on individual conditions.
I commend this work to you and look forward to seeing its impact on the ground.
Duncan Selbie
Commissioning Director
5
Programme Budgeting for commissioners: in brief
Over the last year, there has been an acceleration of the commissioning function in the
NHS.
In July 2006, the Department of Health published the Commissioning Framework for
Hospital Services and the complementary Commissioning Framework for Health and
Well-being was published in December 2006.
In November 2006, Richard Douglas wrote to the NHS explaining that data on
programme budgets and outcomes was available to commissioners.
What is the aim of commissioning? When commissioning health services, the aim is to maximise value for the population
served from the resources invested on the population’s behalf. This can be done in two
ways: directly and indirectly.
The commissioner can maximise value directly by allocating the resources they control
among the patient and population groups within the population to best effect. The
resources can be invested with specific health objectives, as follows:
• to reduce health inequalities and improve equity;
• to promote and improve the health of the population;
• to improve the value and quality of healthcare.
Value derived from investment in healthcare is maximised when it is impossible to
reallocate resources from one patient or population group to another to achieve more
benefit or less harm. This is sometimes referred to as allocative efficiency, a task
increasingly shared with local authorities as service providers.
The commissioner can maximise value indirectly by using their contracting power to help
providers of health services improve the quality and safety of the healthcare they provide
while minimising its cost. This is sometimes referred to as technical efficiency.
What is the aim of the annual population value review? The aim of the annual population value review is to improve healthcare for the local
people for whom the commissioner is responsible by clarifying the allocation decisions
that have been made, both explicitly and implicitly.
In order to do this we need to initiate NHS learning from expenditure and outcomes data
that will enable us to improve the planning and delivery of services based on need rather
than traditional patterns of investment.
6
Why have an annual population value review? The annual population value review for 2007 will be the first in a series.
The first annual population value review will give commissioners an opportunity to
reflect on the distribution of resources among different programmes according to the
programme classification developed by the Department of Health from the International
Classification of Diseases version 10 (ICD10) Classification.
It will also enable commissioners in newly created primary care trusts (PCTs) to reflect
on the pattern of investment in health services that they have inherited following the
recent re-organisation.
The second Annual Population Value Review will be launched in December 2007.
However, it will be preceded by training opportunities to improve commissioners’ skills
in marginal analysis
How can we improve healthcare locally through the annual population value review? The first steps that need to be taken before we can improve healthcare locally are to
identify:
• the distribution of resources between different population groups;
• how the amount invested in each major health category compares with those for
the national average;
• how the amount invested in each major health category compares with the
amounts invested by the commissioners serving populations that have a similar
socio-economic profile.
This gives us the foundation from which we can assess the appropriateness and
effectiveness of these investments in terms of the health outcomes achieved for the local
population.
How do I conduct an annual population value review? The first phase in conducting an annual population value review is to compile a summary
of expenditure in the programme budget categories. Having done this, circulate the data
widely with appropriate explanations and possible reasons for high and low levels of
spending.
The audience for this information should include:
• patient forums;
• practice-based commissioners;
• clinicians in hospital and community settings;
• specialist commissioning groups;
• local authority personnel, especially those responsible for local area agreements
(LAAs);
• local strategic partnerships;
7
• overview and scrutiny committees;
• local media.
What is the right answer? “There is no right answer for this one.”
Richard Gleave
As commissioners have to match local need to local resources, the situation for each PCT
will be different for each population in England. However, it is essential that
commissioners are aware of any variations in expenditure, and are able to explain the
reasons for outliers on particular programmes of spend, and have a plan to bring them
into line if there is no plausible explanation for the variation seen.
What will be the outcome of this annual population value review? For the first year, the main outcomes will be:
• a better understanding among the newly created commissioners of the distribution
of resources they have inherited;
• stimulation of discussions on each programme’s position with respect to PCTs
serving similar populations; • identification of opportunities to improve health and healthcare locally; • initiation of discussions with local authorities on matching health needs and
investment in health services for the local population. Topics for discussion about individual programme budgets could include:
• programme objectives;
• programme budgets (“inputs”);
• programme activities (“outputs”);
• programme achievements (“outcomes”).
Ultimately, the focus of discussion for the Annual Population Value Review is the
redeployment of resources to achieve better value outcomes to meet objectives.
Information that can be used to support detailed discussion about individual programmes
will be provided during the National Knowledge Weeks, which are being organised as
part of the EPOC Programme (see Annex 2). The focus of the National Knowledge
Weeks will be the principal health issues within each programme budget, providing:
• up-to-date evidence about relevant health problems;
• detailed information about prescribing and hospital utilisation trends and
variations.
Given the recent innovation of programme data collection, there may be variation in the
data. If there is lack of confidence in the financial estimate for a programme budget, the
discussion should still go ahead but be framed in terms of:
8
• admissions to hospital;
• prescriptions;
• staff;
• beds and bed-days;
• theatre sessions;
• similar tangible resources.
If nothing else, discuss programme objectives, such as meeting un-met needs and tackling
inequalities.
9
Section 1:
Taking the plunge into Programme Budgeting and Marginal Analysis (PBMA)
What is Programme Budgeting and Marginal Analysis (PBMA)? Programme budgeting is a technique that enables personnel in a health service, and those
who use the health service, to identify how much money has been invested in major
health programmes, with a view to influencing future investment. Marginal analysis is an
economic appraisal technique that evaluates incremental changes in costs and benefits
when resources in programmes are increased, decreased or deployed in different ways.
PBMA can be used within programmes of care or across services and programmes within
a health organisation.
The technique provides users with the capacity to identify:
• Where resources are currently being invested;
• The level of effectiveness of those investments;
• The most effective way of investing in health services in future in relation to the
needs of the population for which services are being commissioned.
Programme budgeting provides a rich source of information that will enable managers
and clinicians to work together to improve healthcare for the local population (see box
below). Although the best way to use the information generated by programme budgeting
is through a structured analytical technique particularly marginal analysis, information on
programme budgets can be used by anyone – it is not necessary to have skills in
economic appraisal.
Delivery of efficient (and in the case of the NHS, equitable) health care requires doctors
to take responsibility for resources and to consider the needs of populations while
managers need to become more outcome and patient centred. …programme budgeting
and marginal analysis has the potential to align the goals of doctors and managers and
create common ground between them.
Ruta et al. (2005)1
1 Ruta, D., Mitton, C., Bate, A. et al. (2005) Programme budgeting and marginal analysis: bridging the
divide between doctors and managers. British Medical Journal 330: 1501-1503.
10
What data and resources are available to undertake Programme Budgeting? As part of the National Programme Budgeting Project (see Annex 1), there are two sets of
data available:
1. Data on expenditure;
2. Data on outcomes.
Data on expenditure Programme budgeting expenditure data for the financial years 2003-04, 2004-05 and
2005-06 are published as per the previous configuration of 303 PCTs, and are available
as a spreadsheet (together with a range of supporting material) on the Department of
Health website, available at:
http://www.dh.gov.uk/programmebudgeting
The programme budgeting spreadsheet presents PCT (and SHA) level expenditure data,
programme by programme, in a variety of ways, as follows.
The PCT’s per-capita spend (using raw or weighted populations) in each of the
programme budget categories.
A comparison of the PCT’s spend in any programme budget category with that of:
o a cluster of similar PCTs;
o the SHA average;
o the England average.
Changes in expenditure over the 3 years.
Spider web charts, which show the programmes (and sub-programmes) around
the circumference of the web, the block of cluster PCTs as a shaded area in the
centre and superimposed on that a line representing the PCT in question – this
format enables any discordant areas of spend between the PCT in question and
comparable PCTs from the same cluster to be identified.
Expenditure distribution charts of each Programme Budget category, which show
the PCT position in the distribution as a gold square, other PCTs in the cluster
(i.e. comparable PCTs) as pink dots and all other PCTs as blue dots – this format
enables a PCT to identify whether it is an outlier for particular programmes of
spend.
Cancer networks, built up from their constituent PCTs, showing per capita Cancer
and other programme expenditure per network, between-years changes in
investment at network level and the change the cancer programme’s total share of
the total budget.
Cardiovascular disease networks, built up from their constituent PCTs, showing
per capita Cardiovascular and other programme expenditure per network,
between-years changes in investment at network level and the change the
cardiovascular programme’s total share of the total budget.
11
Data on outcomes The Department of Health has worked closely with the National Centre for Health
Outcomes Development (NCHOD) at the London School of Hygiene and Tropical
Medicine to link the programme budgeting expenditure data (described above) with
NCHOD’s compendium of health outcomes indicators.
To date, linked expenditure and outcomes data are available for 15 of the 23 Programmes
and allow users to compare at PCT level:
• cardiovascular disease expenditure and mortality from cardiovascular disease;
• cancer expenditure and cancer incidence.
The linked expenditure and outcomes data are available on the NCHOD website, but only
to users of the NHS net (note the NHS web address with nww prefix):
http://nww.nchod.nhs.uk
The data on the NCHOD website are presented using an interactive map base software,
and users may have to download the ‘SGV’ viewer to view this analysis – instructions on
how to do this are available on the NCHOD website.
To access the programme budgeting data, after logging onto the NCHOD website:
• click on ‘Compendium Indicators’ (on the left hand side);
• then click on ‘Programme Budgeting Atlas’.
A beige box will appear, which for 15 of the 23 programmes, offers analysis using either
the ‘nested rate’ or ‘correlation’ plots.
The ‘nested rate’ plot presents analysis for a single indicator (i.e. expenditure or
outcomes) as a single map of England. The software also presents a distribution plot of
the chosen indicator, assigning each PCT to the relevant Office of National Statistics
(ONS) cluster.
The ‘correlation’ plot presents analysis using two indicators, for example, expenditure
and mortality. The software presents a double map, and draws a correlation plot of the
two indicators, thereby allowing users, for example, to examine the relationship between
expenditure and outcomes. Individual PCTs can thus determine if their (e.g. high)
expenditure in a particular programme is accompanied by either high or low mortality.
DH and NCHOD will be continually updating the Programme Budgeting Atlases. The
next data release is due to include data (per programme per PCT) on:
admissions (elective and non-elective);
average length of stay;
bed-days;
Family Health Service data on the number of prescriptions dispensed and
prescription expenditure;
12
Quality and Outcomes Framework data (including disease prevalence).
How is the information collected? Information for the National Programme Budgeting Project is collected from two
different sources by two separate groups.
Information on expenditure is collected through the Financial Returns Exercise as
part of the statutory accounts process. Although these data are not currently
subject to audit, there are plans to do so in due course;
Information on outcomes is collected by the National Centre for Health Outcomes
Development (NCHOD), led by Professor Azim Lakhani.
What do I do now? Once you have accessed the data, there are two main types of assessment you need to
perform:
1. General, painting the big picture of the PCT’s investment across all the major
programmes in 2005/06 and comparing them with those of the cluster of
comparable PCTs and those of the average for England – see Section 2;
2. Specific, programme by programme, showing how the pattern of your PCT’s
expenditure across the individual programme budget categories compares with the
average for that of England and the average for that of PCTs in the same cluster –
see Section 3.
Additional resources to support commissioners There is a range of other tools and techniques that can be used to support commissioner
decisions, produced as part of the Commissioner Development Programme.
Some commissioners are already modelling possible cost pressures in all 23 programme
budget areas, which can then be used to discuss potential trade-offs, both between
programme budgets and within a single programme budget, for example, considering
shifting resources from acute care to health promotion and prevention.
13
Section 2
What tasks do I need to do for the general assessment of the whole budget? For the first task in the general assessment, use the proforma 2.1. For each programme
budget category, insert the following information into the proforma:
• Spend per 100,000 weighted population for your PCT (or its constituent PCTs if
you are in a newly created PCT) during 2005/06;
• The average spend per 100,000 weighted population for the “cluster” to which
your PCT belongs during 2005/06 – choose ‘Group’ from the expenditure
spreadsheet;
• The average spend per 100,000 weighted population for England during 2005/06. Interpreting the results – what does this tell us? This will help you to identify whether overall expenditure, and the spend by programme
budgeting category, for your PCT is similar to, or greater or less, than the spend for the
average for your cluster and the average for England. (You can note this in the comments
column on the far right-hand side of the proforma.)
For the second task in the general assessment, identify the main providers of services to
residents in your PCT during 2005/06. For instance, this list will probably include:
• all local hospitals, including tertiary care;
• the mental health trust;
• the community services;
• the GP prescribing budget;
• the ambulance trust;
• the voluntary sector;
• practice-based commissioning (PBC) provider services.
Then list the providers in order of spend.
Interpreting the results – what does this tell us? This list will disclose the relative size of each provider’s contribution to health services
for your population.
For the third task in the general assessment, identify the top 10 health programmes in
each of the major providers in the list you have just compiled. Look at the differences.
For example the cancer programme is likely to be near the top of the list in the district
general hospital, in the middle of the list for community services but not even in the top
10 in the GP prescribing budget. Circulatory disorders may be high on all three lists.
The pattern for mental health will be different again. Discuss and understand these
differences. Try and identify the networks and pathways these patterns reveal. .
14
Interpreting the results – what does this tell us? This shows on which programme categories you should focus your attention.
For the fourth task, identify the age breakdown as it applies to programme budget
categories. As this information is not required as part of the return to the centre yet, you
will need to look at local data, and there will be gaps. It should be possible to use the
number of PCT residents admitted to any hospital during 2005/06 for each programme
budgeting category.
Using the proforma set out at Proforma 2.2, fill in the cells in the matrix with financial
information if you have it, but also make notes.
For example, the first cell is about infection in the pre-school population.
• Is that population set to rise?
• What are your immunisation uptake rates?
• What notifications of disease have you seen?
• Which infections take these children into hospital?
Interpreting the results – what does this tell us? Once the matrix is annotated:
1. look across the rows to see what the issues are for each programme;
2. look down the columns to see what the issues are for each age-group.
Then consider what you know about demographic projections, for instance, if an age-
group is projected to rise, the programme expenditures will need to be anticipated and
planned in.
To help you with an analysis of quality outcomes, and to examine the interaction between
spend and outcome, use the matrix shown in Figure 2.1, which helps you to identify
programmes where there are:
Good outcomes for low spend;
Good outcomes for high spend;
Poor outcomes for low spend;
Poor outcomes for high spend.
15
Proforma 2.1 Programme Budget
category Spend per
100,000 weighted population for
your PCT
Spend per 100,000 weighted
population for cluster average
Spend per 100,000 weighted population for England average
Comments
1. Infectious
diseases
2. Cancers &
tumours
3. Blood disorders
4. Endocrine,
nutritional &
metabolic disorders
5. Mental health
problems
6. Learning
disability problems
7. Neurological
system problems
8. Eye/vision
problems
9. Hearing problems
10. Circulation
problems
11. Respiratory
system problems
12. Dental problems
13. Gastrointestinal
system problems
14. Skin problems
15. Musculoskeletal
system problems
16. Trauma &
injuries
17. Genitourinary
system disorders
18. Maternity &
reproductive health
19. Neonate
conditions
20. Poisoning and
adverse events
21. Healthy
individuals
22. Social care
needs
23. Other areas of
spend/conditions
Total
16
Proforma 2.2 Programme
Budget category 0-4
years 5-14 years
15-44 years
45-64 years
65-74 years
75-84 years
85+ years
Age-related issues for programme
1. Infectious
diseases
2. Cancers &
tumours
3. Blood disorders
4. Endocrine,
nutritional &
metabolic
disorders
5. Mental health
problems
6. Learning
disability
problems
7. Neurological
system problems
8. Eye/vision
problems
9. Hearing
problems
10. Circulation
problems
11. Respiratory
system problems
12. Dental
problems
13.
Gastrointestinal
system problems
14. Skin problems
15.
Musculoskeletal
system problems
16. Trauma &
injuries
17. Genitourinary
system disorders
18. Maternity &
reproductive
health
19. Neonate
conditions
20. Poisoning
21. Healthy
individuals
22. Social care
needs
23. Other areas of
spend/conditions
Issues affecting age-group
17
Figure 2.1
High outcome /low spend High outcome/high spend
Low outcome/low spend Low outcome/low spend
Outcome
Spend
High
Low
Low High
High outcome /low spend High outcome/high spend
Low outcome/low spend Low outcome/low spend
Outcome
Spend
High
Low
Low High
18
Section 3
What tasks do I need to do for the specific assessment of a programme budget for a single disease category?
Assess the spend for each programme budget category in relation to:
• the aims of the programme locally, including the aims within the main stages of
the care pathway – prevention, diagnosis and assessment, treatment, rehabilitation
and continuing care and terminal care; look at NICE guidance, targets, National
Service Frameworks, local patient feedback, and other guidance and feedback.
• any other health issues relevant to the programme locally.
Consider convening a marginal analysis advisory group for programme or sub-
programme budgets of particular interest or concern. The main steps for such an
initiative2 are:
• Determine the aim and scope of the priority-setting exercise, for example, the
whole of the musculoskeletal programme or rheumatoid arthritis alone
• Compile the most comprehensive programme budget (or sub-programme budget)
information you can
• Set up a marginal analysis advisory panel, for example, comprising managers,
clinicians from primary and secondary care, service users and an economist
• Determine the decision-making criteria, using evidence where available but group
opinion where it is lacking
• Identify options for redeploying resources by expanding some areas and reducing
others
• Appraise the costs and benefits of the options
• Consult, decide, and make it happen!
“Recent NHS reforms give doctors increased responsibility for the efficient and fair use
of resources. Programme budgeting and marginal analysis is one way to ensure the views
of all stakeholders are properly represented.” Ruta et al. (2005)3
2Adapted from Peacock, S., Richardson, J., Carter, R. and Edwards, E. (2007) Priority setting in health care
using multi-attribute utility theory and programme budgeting and marginal analysis (PBMA). Social
Science and Medicine 64: 897-910. 3 Ruta, D., Mitton, C., Bate, A. et al. (2005) Programme budgeting and marginal analysis: bridging the
divide between doctors and managers. British Medical Journal 330: 1501-1503.
19
There will be the opportunity to consider further detail later this year when knowledge
relevant to the principal health problems, organised at the level of the individual disease
within the ICD grouping (such as rheumatoid arthritis within the musculoskeletal disease
programme) will be sent to each PCT during the relevant national Knowledge Week – see
Annex 2 for information about the Annual Review of Evidence, Process, Outcome and
Configuration (EPOC) Programme.
20
Section 4
The future
What further information will be available to increase the usefulness of Programme Budgeting?
More detailed programme and sub-programme financial data The 2006/07 returns will contain more detail in some of the programmes, for example the
cancer programme will have around 10 sub-programmes based on the main cancer body
sites.
More reliable data It is anticipated that as pricing mechanisms such as “payment by results” mature, and as
people use the data more to support decisions, the quality of data returns will improve.
More outcome and output data The programme budget atlas produced jointly by NCHOD and DH will contain more data
next year.
Marginal analysis The rigour with which marginal analysis is conducted, within programmes and between
programmes, should improve with familiarity and as more experience is published.
21
Further reading
Brambleby, P. (1993) A purchaser’s guide to purchasing healthcare. Clinician in
Management 2(6): 3-6.
This paper is 14 years old. It called for programme budgeting as a framework for
commissioning, setting out the authority’s view on fair shares between programmes and
giving its officers operating parameters within which to pursue efficiency.
Brambleby, P. (1995) A survivor’s guide to programme budgeting. Health Policy 3:127-
145.
An account of experience in Hastings Health Authority.
Brambleby, P. (2004) The quiet revolution. ACCA, Health Service Review, pp. 5-7.
This paper was commissioned by ACCA and aimed chiefly at a finance audience.
Brambleby, P. (2005) Finance. [Letter] Health Service Journal, 7 April 2005, p. 20.
Brambleby, P. and Dixon, J. (2005) The HSJ Debate: Programme budgeting is better for
the health service than payment by results. Health Service Journal, 21 July 2005, pp. 18-
19.
Clapperton, A. (2004) The road to success, Healthcare Finance, February 2004, pp. 14-
15.
Enthoven, A. (1999) In pursuit of an improving National Health Service. Nuffield Trust,
London. pp. 32-39.
Gray, J.A.M. (2006) Better Value Healthcare. Offox Press, Oxford.
Kings Fund (2006) Local variations in NHS spending priorities. King’s Fund Briefing.
King’s Fund, London.
This recent paper, reporting the emerging findings of the English NHS programme
budget work, was widely reported in the national media.
Mitton, C. and Donaldson, D. (2001) Twenty-five years of programme budgeting and
marginal analysis in the health sector, 1974-1999. Journal of Health Services Research
and Policy 6: 239-248.
Mitton, C. and Donaldson, C. (2004) Priority Setting Toolkit: a guide to the use of
economics in healthcare decision making. BMJ Books/Blackwell, London.
22
Peacock, S., Richardson, J., Carter, R., and Edwards, E. (2007) Priority setting in health
care using multi-attribute utility theory and programme budgeting and marginal analysis
(PBMA). Social Science and Medicine 64: 897-910.
Ruta, D., Mitton, C., Bate, A. and Donaldson, C. (2005) Programme budgeting and
marginal analysis: bridging the divide between doctors and managers. British Medical
Journal 330:1501-3.
Smith, P. (2003) Clarity begins at home. Health Service Journal, 20 November 2003, pp.
10-11.
Brambleby, P. (2003) Collective good. [Letter] Health Service Journal, 18 December
2003, p. 26.
A response to Smith (2003)
Thalange, N., Gardner, C. and Reading, R. (2004) How is money spent on children’s
services? Child: Care, Health and Development 30(5): 503-505.
This paper is based on experience in Norfolk.
23
Annex 1
Background to Programme Budgeting
What is the National Programme Budgeting Project? The aims of the National Programme Budgeting Project in the NHS are:
to develop a primary source of information, which can be used by all bodies, to
give a greater understanding of “what we are getting for the money we invest in
the NHS”;
to map all NHS expenditure, including primary care services, to programmes of
care based on medical conditions.
The categories currently being used for Programme Budgeting in the NHS are shown in
Box A1. The first 20 categories correspond to chapters in the World Health
Organization’s International Classification of Disease (Version 10). In addition, there are
three further categories that have been introduced to capture remaining areas of spend
that do not fit easily into the first 20 categories. In future, these three categories may be
absorbed into the first 20.
Box A1: Programme Budget categories in the National Programme Budgeting Project 1. Infectious diseases
2. Cancers and tumours
3. Blood disorders
4. Endocrine, nutritional and metabolic problems
5. Mental Health problems
6. Learning disability problems
7. Neurological system problems
8. Eye/vision problems
9. Hearing problems
10. Circulation problems
11. Respiratory system problems
12. Dental problems
13. Gastrointestinal system problems
14. Skin problems
15. Musculoskeletal system problems (excludes trauma)
16. Trauma and injuries (includes burns)
17. Genitourinary system disorders (except infertility)
18. Maternity and reproductive health
19. Neonate conditions
20. Poisoning
21. Healthy individuals
22. Social care needs
23. Other areas of spend/conditions
24
Why is Programme Budgeting important now? Two important changes will begin to affect and influence the way healthcare is procured
and provided in the NHS:
1. The introduction of commissioning;
2. The end of a period of significant regular increase in NHS funding.
As the combination of these two changes alters the operating context for the provision of
health services in England, the relevance and usefulness of programme budgeting and
marginal analysis will be brought into focus. As the NHS moves towards financial
balance and attention is taken from issues such as waiting times, programme budgeting
and marginal analysis will play an increasing important role in maximising value for the
resources invested.
Traditionally, in the NHS, expenditure has been reported on the basis of inputs using
budget categories such as GP prescribing, hospital services and community services.
However, the classification of spend according to these categories has meant that it is not
possible to assess the outputs of the health service against financial investment.
Although reference costs, which focus on secondary and tertiary care, can help in part to
assess this, they do not cover primary care services upon which significant NHS
resources are expended.
As the focus of the NHS has been changing over the last 5-10 years with the introduction
of Local Delivery Plans, National Service Frameworks (NSFs) and Long Term Service
Agreements (LTSAs), it is important to concentrate on health service outcomes.
Programme Budgeting gives government, commissioners and providers the capacity to
generate information appropriate to and necessary for commissioning and managing
health services in this new paradigm.
The analysis of expenditure across primary, secondary and community care will provide
the capacity:
• To identify current patterns of service delivery for groups of patients and to
identify variations between providers and access to services by geographical area
• To map care pathways
• To agree the desired patterns of commissioning
• To monitor NHS expenditure against NSFs
• To identify different expenditure patterns within the country
Change in productivity = change in outputs/change in inputs Change in efficiency = change in outcomes/change in inputs
25
What is the history of Programme Budgeting? Alain Enthoven, an American academic and economist, implemented Programme
Budgeting when he was United States Assistant Secretary of Defence. He then moved
into healthcare management, and later was a proponent of an internal market (i.e.
“commissioning”) for the NHS. He maintains that effective commissioners of health
services need Programme Budgeting and Marginal Analysis.4
However, one of the authors (AJ) has tracked down a Department of Health Report from
1972, entitled “Planning Programme Budgeting System for the health and personal social
services”, in which it states:
“the main recommendations in our first report (April 1971) were that a
programme budget for health and personal social services should be developed mainly on
the basis of client groups and that its prime aims should be to assist with determining
priorities and with achieving the most cost-effective use of resources.”5
When was Programme Budgeting introduced into the NHS? In 2002, the Secretary of State for Health requested the collection of financial
information that identifies all primary care trust expenditure, including primary care
services, to programmes of care based on medical condition.
For the financial years 2003-04, 2004-05 and 2005-06, all PCTs in England submitted a
return to the Department of Health recording how their total expenditure was deployed
across the 23 Programme Budget categories shown in Box A1.
For the financial year 2004-05, the data on expenditure were also linked to data on
activity and outcomes in an interactive atlas produced in collaboration with NCHOD.
The National Programme Budget Project Board The Programme Budgeting Project Board was originally set up in 2003 to coordinate and
facilitate the development of the Programme Budgeting Project.
In 2005, the Board was re-formed and re-named the National Programme Budget Project
Board. The objectives of the Project Board are shown in Box A2.
4 Enthoven, A. (1999) In pursuit of an improving National Health Service. Nuffield Trust, London.
5 Department of Health (1972) Planning Programme Budgeting System for the Health and Personal Soial
Services. Second Report by the Project Team.
26
Box A2: Objectives of the National Programme Budget Project Board • To oversee the production of annual Programme Budget data and DH Resource
Accounts (Schedule 5) and ensure it meets National Audit Office (NAO),
Treasury and DH requirements
• To ensure the methodology of the project takes account of other DH initiatives
including Financial Flows and Patient Choice
• To recommend areas where existing data collection exercises could be reduced
• To ensure all stakeholders are consulted and kept fully informed of the progress
of this project
• To oversee the development of the Programme Budget Project for future
collection exercises, including:
o Non-admitted patient care reporting;
o Admitted patient care reporting – integration with system users service;
o Dis-aggregation of data – by age and primary/secondary care;
o SHA expenditure apportionment, e.g. WDC spend;
o Linking Programme Budgeting data to health outcomes;
o Engagement of specialist tsars, e.g. mental health or diabetes, with
Programme Budgeting Project
Key stakeholders of the National Programme Budget Board include:
• Department of Health
• National Health Service
However, other Government departments and agencies will also be interested in the
results of programme budgeting and marginal analysis in the NHS, including:
• National Audit Office
• Audit Commission
• Her Majesty’s Treasury
• Healthcare Commission
What are the benefits of Programme Budgeting for the NHS? The National Audit Office and the Audit Commission have identified the following
overall benefits of Programme Budgeting for the NHS:
Showing where total NHS funds have been spent in a way that is useful and
interesting to taxpayers;
Enabling expenditure on particular conditions to be assessed against National
Service Frameworks and health outcomes;
Providing consistent data to compare one NHS organisation’s expenditure with
that of another;
Assisting primary care trusts (PCTs) in planning the provision of services, thereby
providing support for more effective budgeting and commissioning;
Increasing transparency about the performance of PCTs and Strategic Health
authorities (SHAs)
27
What are the advantages of Programme Budgeting to individual NHS organisations? In November 2006, Richard Douglas, the Director of Finance at the Department of
Health highlighted that, by focussing on medical conditions rather than on input costs, it
is possible to make a direct link between the object of expenditure and the patient care it
delivers. Once expenditure is analysed in this way, it is then possible for PCTs to
investigate the level of health gain that can be obtained for the amount of money
invested, which
“will help to inform understanding about equity and how patterns of expenditure
map to the epidemiology of the local population”.6
The Director of Finance concludes that taking into account epidemiological factors and
differing local priorities, PCTs should be able:
• To understand their expenditure;
• To question their expenditure;
• To explore the possibilities of changing spending patterns among different
programmes of care.
How will Programme Budgeting be used in the long term? A database of NHS spend will be compiled over time which will give a detailed analysis
of PCT spending patterns. This database will be used to help:
• PCTs assess the health gain obtained from investment;
• PCTs address issues of equity in relation to patterns of expenditure and the
epidemiology of the local population;
• Healthcare Commission and other regulatory bodies in their scrutiny of the NHS.
6 Letter from Richard Douglas, Director of Finance, DH, to all SHAs. 8 December 2005.
28
Annex 2 The EPOC Programme
1. The EPOC Project – annual review of Evidence, Process, Outcome and
Configuration relating to the 50 biggest health conditions and problems that cause
80% of the burden of disease:
Stomach cancer
Bowel cancer
Heart failure
Chest pain & Coronary disease
Incontinence
Failure to cope in old age
Alzheimer's disease
Inflammatory bowel disease
Hepatitis and Liver failure
Disability
COPD (Bronchitis)
HIV & AIDS
Stroke
Skin cancer
Psoriasis
Eczema
Dysmenorrhoea and Menorrhagia
Depression
Schizophrenia
Drug and alcohol dependence
Breast cancer
Osteoporosis
Allergy
Renal failure
Antenatal and pregnancy care
Children’s problems
Oral health
Deafness and tinnitus
Asthma
TB
Lung Cancer
Glaucoma
Visual failure
Deafness
Stroke
Trauma
Headache
Spinal disease
Parkinson’s
Epilepsy
Prostate hypertrophy and cancer
Diabetes
29
Project description
Review packs will be put together for each Primary Care Trust (PCT) covering the 50
major causes of disease burden. These packs will comprise:
o new knowledge that has been published in the last year, co-ordinated by the
National Library for Health specialist libraries;
o prescribing data;
o hospital admission data;
o operating data where relevant;
o outcome data where available, for example, through audit projects;
o outcome tools and measures that could be used if none are being used at present.
PCTs will be required to carry out a formal review if more than two standard deviations
above or below the mean. They could be expected to give consideration if they were one
standard deviation above or below the mean, but a well-organised PCT should be able to
review each of these topics every year, because the mean may not be representative of
best value.
Deliverables
The focus of this review is to identify opportunities for increased value. By separating
the review from the financial year, clinicians, patients and commissioners will focus on
the steps that could be taken within existing resources to increase value, for example by
identifying interventions of high value that should be increased, and interventions of low
value that should be decreased. The identification of these interventions could, of
course, be used to bid for more resources or as a focus for service reduction, depending
upon the availability of resources, but the main focus is on value improvement by change
in service.
At the end of the review, commissioners and providers, with patient support, will have a
view of the activities that need to be increased or decreased to achieve better outcome.
At the end of the review, it would also be appropriate to identify outcomes of interest to
patients and to consider ways in which those could be measured, even on a sample of
patients, until Connecting for Health has delivered the Secondary Uses Service.
In addition, commissioners will be asked to describe the network of existing services and
communication between different parts of the service, for example between optometrists
and Ophthalmology Departments, or between one acute Trust and another, with a view to
laying the foundations for network strengthening or development.
30
© Crown Copyright
Produced by the NHS National Knowledge Service
February 2007
The text of this document may be
reproduced without formal permission
or charge for personal or in-house use.
First published February 2007.
If you require further copies of this title,
contact:
J A Muir Gray
Badenoch Building
University of Oxford Old Road Campus
Headington
Oxford OX3 7LF
www.nks.nhs.uk
Appendix 2.
Priority setting in health care using multi-attribute utility theory and programme budgeting and marginal analysis (PBMA)
ARTICLE IN PRESS
0277-9536/$ - se
doi:10.1016/j.so
�Correspondfax: +1604 675
E-mail addr
jeff.richardson@
r.carter@unime
Diana.Edwards1Stuart Peac
Research Schol
Social Science & Medicine 64 (2007) 897–910
www.elsevier.com/locate/socscimed
Priority setting in health care using multi-attribute utility theoryand programme budgeting and marginal analysis (PBMA)
Stuart J. Peacocka,b,�,1, Jeff R.J. Richardsonc, Rob Carterd, Diana Edwardse
aCentre for Health Economics Research in Cancer, Cancer Control Research, BC Cancer Agency,
675 West 10th Avenue, Vancouver, BC, Canada V5Z 1L3bDepartment of Health Care and Epidemiology, University of British Columbia, Canada
cCentre for Health Economics, Monash University, AustraliadProgram Evaluation Unit, University of Melbourne, Australia
ePfizer Australia, NSW, Australia
Available online 4 December 2006
Abstract
Programme budgeting and marginal analysis (PBMA) is becoming an increasingly popular tool in setting health service
priorities. This paper presents a novel multi-attribute utility (MAU) approach to setting health service priorities using
PBMA. This approach includes identifying the attributes of the MAU function; describing and scaling attributes;
quantifying trade-offs between attributes; and combining single conditional utility functions into the MAU function. We
illustrate the MAU approach using a PBMA case study in mental health services from the Community Health Sector in
metropolitan South Australia.
r 2006 Elsevier Ltd. All rights reserved.
Keywords: Priority setting; Programme budgeting; Marginal analysis; Decision analysis; Multi-attribute utility theory; Mental health;
Australia
Introduction
The development of frameworks to allow deci-sion-makers to manage scarce resources is one ofthe most important challenges facing health ser-vices. Managing resource scarcity involves makingchoices about which types and amounts of health
e front matter r 2006 Elsevier Ltd. All rights reserved
cscimed.2006.09.029
ing author. Tel.: +1604 675 8068;
8180.
esses: [email protected] (S.J. Peacock),
buseco.monash.edu.au (J.R.J. Richardson),
lb.edu.au (R. Carter),
@pfizer.com (D. Edwards).
ock is a Michael Smith Foundation for Health
ar.
care to provide for different individuals andpopulations from a given budget. Decision-ma-kers—managers and clinicians—therefore face thechallenge of prioritising between competing claimson scarce health service resources and implementingtheir choices.
In recent literature, economic approaches topriority setting have been criticised on the groundsthat they have only had limited success in practice(Alban, 1994; Carter, 2001; Hoffmann & von derSchulenburg, 2000; MacDonald, 2002). This hasbeen, at least in part, due to their failure toadequately capture the complex and multifacetednature of both objectives and constraints in healthservice decision-making (Carter, 2001; Jan, 2000;
.
ARTICLE IN PRESS
Table 1
Stages in a PBMA priority setting exercise
1. Determine the aim and scope of the priority-setting
exercise
Determine whether PBMA will be used to examine
changes in services within a given programme (micro/
within programme study design) or between
programmes (macro/between programme study design).
2. Compile a ‘program budget’
The resources and costs of programs may need to be
identified and quantified, which, when combined with
activity information, is the programme budget.
3. Form a ‘marginal analysis’ advisory panel
The panel is made up of key stakeholders (managers,
clinicians, consumers etc.) in the priority setting process.
4. Determine locally relevant decision-making criteria
To be elicited from the advisory panel (e.g. maximising
benefits, improving access and equity, reducing waiting
times etc.), with reference to national, regional and local
objectives, and specified objectives of the health system
and the community.
5. Identify options for (a) service growth (b) resource
release from gains in operational efficiency (c) resource
release from scaling back or ceasing some services
The programme budget, along with information on
decision-making objectives, evidence on benefits from
service, changes in local health care needs, and policy
guidance, are used to highlight options for investment
and disinvestment.
6. Evaluate investments and disinvestments
Evaluate in terms of costs and benefits and make
recommendations for (a) funding growth areas with new
resources (b) moving resources from 5(b) and 5(c) to 5
(a).
7. Validate results and reallocate resources
Re-examine and validate evidence and judgements used
in the process and reallocate resources according to
cost-benefit ratios and other decision-making criteria.
Source: adapted from Mitton and Donaldson (2004).
S.J. Peacock et al. / Social Science & Medicine 64 (2007) 897–910898
MacDonald, 2002). In response to this criticismeconomic approaches to priority setting are givinggreater attention to understanding the inherentcomplexity of the health services decision-makingenvironment (Peacock et al., 2006). In particular,developments in the programme budgeting andmarginal analysis (PBMA) framework have fo-cussed on better understanding decision-makers’objectives and utility functions, balancing improvedrigour against user friendliness, the importance of‘due process’, and the political and institutionalconstraints that decision-makers face in settingpriorities (Carter, 2001; Jan, 2000; Peacock, 1998;Mitton, Peacock, Donaldson, & Bate, 2003).
In this paper, we focus on eliciting and valuingattributes in decision-makers’ utility functions usinga novel multi-attribute utility (MAU) approach topriority setting in health services. We present anMAU approach to identifying, measuring andvaluing multiple attributes in health service deci-sion-makers’ utility functions, which is used toinform the marginal analysis phase of PBMA.
The PBMA framework
PBMA is a practical tool to assist decision-makers in setting priorities in health care and hasbeen used in over 70 priority setting exercises incountries such as Australia, Canada, New Zealandand the UK (Mitton, Peacock, Donaldson, & Bate,2003). It offers a pragmatic framework to aid healthservice decision-makers in setting priorities based onthree pivotal concepts, namely: the need to considerthe opportunity cost of activities; the need for ananalysis of marginal and not average costs andbenefits; and, the existence of a fixed budget whichimplies a need to contract some services if others areto be expanded (Mooney, Gerard, Donaldson, &Farrar, 1992). The seven stages in a PBMA studyare summarised in Table 1.
PBMA requires information about the benefitsfrom the services being studied. However, high-quality quantitative evidence is often not available(for an exception see Donaldson and Farrar (1993)).Reflecting a common view in the PBMA literature,Cohen (1995) and Peacock (1998) argue that muchcan be achieved even when only crude data areavailable. Consistent with this, some PBMA studieshave used an advisory panel to provide ‘bestestimates’ of the benefits from services—based onknowledge of available quantitative and qualitativeevidence and expert judgement. This approach has
been described as ‘options appraisal’ (Cohen, 1995).While the judgement of an advisory panel may becriticised on the grounds that it provides less reliableevidence than a randomised controlled trial ormeta-analysis, it may be justified by the dictum‘perfection is the enemy of the good’. We wouldargue that the structured framework for decision-making provided by PBMA is better than arbitraryprocesses and judgements, which may be the defaultoption.
The use of PBMA advisory panels has severalother advantages. First, there may be different typesof benefits from health programmes, such as health
ARTICLE IN PRESSS.J. Peacock et al. / Social Science & Medicine 64 (2007) 897–910 899
gains for patients, reductions in health inequalities,and improvements in community empowerment.That is, benefits may consist of multiple attributes.The panel can define these attributes, which are usedto evaluate programmes included in the PBMAanalysis. Second, the panel can determine therelative importance of different attributes. If asingle index of benefit is to be calculated for eachprogramme, it is necessary to combine informationon how well each programme performs under eachattribute. This requires that each programme isgiven a ‘score’ under each attribute, and thatattribute scores are weighted for their relativeimportance when they are combined. The resultingmeasure of benefit can be used to calculate cost-benefit ratios. Third, the panel can make judge-ments, which are well structured, explicit andtransparent, allowing panel members and (poten-tially) third parties the chance to scrutinise decisionsand how they were reached.
Methods for including an MAU assessment of
benefits in PBMA
The MAU approach we now describe uses decisionanalytic techniques to model and quantify attributesin a decision-maker’s utility function (Kenney &Raiffa, 1993).2 The MAU model combines multipleattributes, such as health, equity and empowerment,by eliciting importance (trade-off) weights for attri-butes from members of the PBMA advisory panel,and combining attribute ‘scores’ to calculate a singleindex of benefit. This approach involves the followingmethodological steps.
Methodological steps in the MAU approach
(I)
2Fol
include
tainty.
Identifying attributes in the MAU function. Theadvisory panel defines attributes, which arerelevant to the organisational context and theobjectives of decision-makers. The panelshould be allowed full discussion of themeaning of different attributes in order togain a clear and shared understanding of thecomponent parts of benefit in their decision-making context.
(II)
Describing attributes. The panel constructsmeasurement scales for each attribute, againstlowing Edwards (1977) we use the term utility function to
measures of benefits both under certainty and uncer-
which programmes are to be evaluated. To doso, the panel constructs descriptions for thebest and worst, and a number of intermediate,levels for each attribute. For example, the bestand worst levels for health might be ‘excellenthealth’ and ‘death’.
(III)
Scaling attribute levels. The different levelswithin attributes are ‘scaled’ by the panel; thatis their relative importance is determined on a0–100 scale. For example, on a health scale‘excellent health’ may receive a score of 100,‘death’ 0, and intermediate levels a scorebetween these. Scaling should use a recognisedscaling instrument such as a rating scale or atime trade-off instrument. In the decisionanalysis literature the resulting measurementscales are referred to as single conditionalutility functions.(IV)
Quantifying trade-offs between attributes. Theadvisory panel assesses the relative importanceof each attribute, as they are unlikely to be ofequal importance. Theoretically valid andreliable techniques should be used to derivemeaningful estimates of each attribute’s rela-tive importance.(V)
Evaluating programmes. The panel evaluateseach programme in terms of how well itperforms with respect to each attribute, by‘scoring’ each programme using the attributemeasurement scales. Scores should be basedon available quantitative and qualitativeevidence and technical judgements (wherenecessary) from the panel. The degree towhich judgement should be employed willvary between contexts depending on theavailability of relevant evidence, and thequality of that evidence.(VI)
Combining attribute scores. Panel scores foreach attribute are combined using the MAUmodel to calculate the combined benefit scoreof a programme. Benefit scores should bemeasured on a scale, which is easy to under-stand, and be intuitive and plausible.The programmes are then ranked according totheir combined benefit and the panel validatesresults through discussion and deliberation. If thepanel is dissatisfied with the implied ranking eachstage of the process is re-evaluated until they aresatisfied with the integrity of the results. Benefitsfrom the MAU model are used to construct cost-benefit ratios, with higher priority given to services
ARTICLE IN PRESSS.J. Peacock et al. / Social Science & Medicine 64 (2007) 897–910900
with a lower cost-benefit ratio. Resources should beallocated to competing services based on the cost-benefit ranking from the most efficient service untilresources are exhausted.
Choosing a functional form for the MAU model
The importance of each attribute in the MAUfunction may vary for one of two reasons, due to:the size of the importance weight elicited from thepanel; and, the type of function (e.g. additive,multiplicative etc.) which is selected for the MAUmodel. We now focus on different types of MAUfunctions and their implications for estimatingbenefits, an issue which has received relatively littleexplicit attention in the literature.
Any type of MAU or social welfare function(SWF) imposes particular (algebraic) propertieson the utility function (Dolan, 1998; von Winter-feldt & Edwards, 1986). In the MAU quality oflife literature, the use of additive, multiplicativeand multi-linear functions has been discussedby Feeny, Torrance, and Furlong (1996) andRichardson, Day, Peacock, and Iezzi (2004). Inthe SWF literature, Wagstaff (1991) explored theproperties of the linear exponential SWF and itsability to capture different distributive objec-tives. This form of the SWF contains parametersreflecting aversion to inequality in the distributionof health and the relative weight given to thetreatment of different individuals. Dolan (1998)presented a more flexible SWF, which permits awider range of prescriptions concerning the dis-tribution of health.
The properties of these different types of func-tions may or may not be appropriate for differentPBMA priority setting contexts. The advisory panelmay elect to use an importance-weighted average ofthe attributes (an additive function). However, thisimposes particular, and restrictive, properties on thecomputation of benefit: the effect of attributes isunchanging as the overall level of benefit changes;weights must be relatively small; and, they must sumto unity. For example, in the context of health stateutilities, the 15-dimensional (15D) MAU quality oflife instrument uses such an approach (Sintonen2001). The ‘average’ weight of each attribute in themodel is 1/15, and no one attribute can indepen-dently impact catastrophically on overall quality oflife. The result is that, for example, severe depres-sion in isolation cannot reduce quality of life to alevel corresponding with a ‘near suicidal’ health
state. Equally, the independent effect of extremepain on quality of life is small. Other examples ofadditive functions in the quality of life literatureinclude the Quality of Well-Being Scale, the EQ-5Dand the SF-6D (Furlong, Barr, Feeny, & Yandow,2005).
MAU theory suggests that when two or moreattributes can independently have a large impact onoverall benefit a multiplicative or multi-linear modelshould be used (von Winterfeldt & Edwards, 1986).These models allow extreme pain and severedepression, for example, to independently reducequality of life to zero. Examples of MAU quality oflife instruments that use multiplicative functionsinclude the health utilities index (HUI) (Feeny,Torrance, & Furlong, 1996) and the assessment ofquality of life (AQoL) (Richardson, Day, Peacock,& Iezzi, 2004).
When one attribute (or set of attributes) isconsidered to be of primary importance, and otherattributes of secondary importance, theory suggeststhat the MAU function should reflect the under-lying objectives hierarchy (von Winterfeldt &Edwards, 1986). Objectives hierarchies have re-ceived little attention in the health literature.However, empirical evidence supporting the exis-tence of hierarchical preferences for environmentalgoods is mounting (Spash, 2000). In such cases, itmay be appropriate to adopt a functional form,which permits only one attribute (or set ofattributes) to independently have a large impacton overall benefit. For example, the communitymay consider that improving the health of indivi-duals is the primary objective of health services, andthat providing programmes that are culturallyappropriate is a secondary objective. A programmethat provides a large health gain may independentlyproduce a large impact on overall benefit. However,a programme that is highly culturally appropriatemust also provide a positive health gain to impacton overall benefit. The MAU model should alsohave the property that preferences for health are notlexicographic (Tversky & Sattah, 1979).
Similarly, alternative models from the SWFliterature may or may not be appropriate indifferent priority setting contexts. For a SWF modelto be appropriate, the panel must consider thathealth gain and the distribution of health are theonly two objectives relevant to their decision-making context. If this condition is met, the panelmust then estimate of the aversion to inequalityparameter, which may take a wide range of values
ARTICLE IN PRESS
3The [(100–M)/P
Wi] term rescales weighted attribute scores so
that U is measured on a 0–100 scale (Kenney & Raiffa, 1993).
S.J. Peacock et al. / Social Science & Medicine 64 (2007) 897–910 901
reflecting a range of utilitarian and non-utilitarianperspectives.
The critical task is to select an MAU functionthat allows attributes to be combined in a way,which is consistent with the panel’s stated prefer-ences (which should, in turn, reflect communitypreferences). The need for such a choice is universal:a combination rule must have an algebraic form(even the simple utilitarian SWF has a particularalgebraic property, namely the additivity of utilities)and this does not depend upon the adoption ofeither welfarist or extra-welfarist objectives. BothWagstaff (1991) and Feeny, Torrance, & Furlong(1996) explicitly claim to be measuring ‘utility’ albeit
with a more complex equation for combining theattributes. The choice of an appropriate MAUfunction is essential if PBMA is to be consistentwith local decision-making objectives and organisa-tional context. Proper consideration of local deci-sion-making objectives and objectives hierarchies iscritical to the success of a PBMA study (Peacocket al., 2006). However, for this reason, the MAUfunction developed for one context may not begeneralisable to other contexts.
Methods for constructing a Community Health MAU
model
We now turn to methods for constructing anMAU model in the context of South AustralianCommunity Health Services (CHS). Before imple-menting the steps described above two methodolo-gical decisions had to be made.
The first concerned the form of the MAUfunction which was consistent with the local CHSdecision-making context. This context proved to beatypical in one important respect. The advisorypanel for the PBMA project considered that theprimary objective of South Australian CommunityHealth programmes is to improve individuals’health, with a secondary purpose to do so in away that achieves other stated objectives relating toequity and community health. As discussed above,many additive and multiplicative MAU functionsdo not incorporate this property, and SWF func-tions are not applicable because they only allowhealth and equity objectives to be considered.
For this reason, and in consultation with theadvisory panel, a second model was adopted whichis additive with respect to attributes other thanhealth, but incorporates a multiplicative relation-ship between health and other attributes (which we
call the ‘multiplicative weights for health model’).For a given service, this model takes the score forindividual health gain and weights it according tothe scores for all other attributes:
U ¼ UH ½1þW 1D1þ; � � � ;þW nDn�, (1)
where U is the combined utility (or benefit) score fora given service, UH is the utility for individualhealth, D 1,y,Dn are scores for the n otherattributes on their respective measurement scales,and W1 ,y,Wn are importance weights for those n
attributes. This model has the property that ifindividual health gain is zero, U is also zero. Aservice that provides large individual health gainsmay independently produce a large impact on U,but a service that scores highly on other attributesmust also provide improvements in individualhealth to impact on U. The term UH is given by
UH ¼M H, (2)
where (for a given service) H is the score forindividual health on its attribute measurement scaleand M is the importance weight for individualhealth. This model can be expanded to be useddirectly with data elicited from an advisory panel asshown in Eq. (3). In this equation, U lies between 0(worst utility) and 100 (best utility).3
U ¼H
100M þ
100�MPW i
� �W 1D1
100þ; � � � ;
�
þ100�MP
W i
� �W nDn
100
�. ð3Þ
The panel determines the relative importance ofeach attribute, yielding the values M and Wi, andthe scores for each attribute for each service beingconsidered (H and Di).
The second methodological decision concernedthe method for deriving the importance weights forattributes. A handful of published studies haveconsidered weighting multiple attributes withinPBMA (e.g. Cohen, 1995). These studies have usedan ‘options appraisal’ approach where weights aretypically assessed by asking respondents to distri-bute 100 points over attributes to reflect theirrelative importance (a constant-sum variant ofratio estimation). However, there are two poten-tially serious problems with this approach. Con-stant-sum ratio estimation procedures typicallyproduce flatter importance weight distributions
ARTICLE IN PRESSS.J. Peacock et al. / Social Science & Medicine 64 (2007) 897–910902
than ratio estimation (von Winterfeldt & Edwards,1986) which may lead to systematic under-estima-tion of trade-offs between attributes. And, directjudgments of importance may be insensitive to theranges of measurement scales used in assessing theperformance of alternative programmes (Gabrielli& von Winterfeldt, 1978).
Following common practice in the decisionanalysis literature a ‘swing weights’ method wasselected for weighting attributes. This methodovercomes many of the problems of constant-sumratio estimation; is relatively simple, transparentand easy to use; and produces weights which arepractically indistinguishable from indifferencemethods (von Winterfeldt & Edwards, 1986). Inthis approach respondents are asked how much anattribute contributes to overall utility relative toother attributes by comparing hypothetical healthprogrammes that ‘swing’ between the worst and bestlevels in each attribute. They then estimate thechange in utility that would result from changingeach attribute from its worst to best level using arating scale which has endpoints of 100 (allattributes at their best level) and 0 (all attributesat their worst level) (von Winterfeldt & Edwards,
C
Individual Health at best Community Health at worst Equity at worst
Individual Health at best Community Health at worst Equity at best
M M
(Worst
Fig. 1. Weighting attributes
1986). In this study two forms of the swing weightsmethod were used, termed the ‘bottom up method’and the ‘top down method’.
The bottom up method first asked each respon-dent to consider a state of the world in which nohealth programme exists for a hypothetical group ofindividuals. This state is represented by 0 (allattributes at their worst level) in Fig. 1. Eachrespondent is then asked to consider the introduc-tion of a hypothetical new health programme, whichprovides the best possible level of individual healthbut no improvements in community health orequity. That is, the new programme represents astate in which the individual health attribute is at itsbest level, but community health and equityattributes remain at their worst level. Using Fig. 1,this results in a swing up the scale from 0 to thepoint M (arrow A). The value on the rating scale ofthis new state indicates the relative importance ofthe individual health attribute.
As discussed above, it was agreed that services,which did not provide any health gain at theindividual level should receive an overall benefitscore of zero. Consequently, for attributes otherthan individual health, the starting state for the
(Best) 100
90
80
70
B
60
50
40
30
A20
10
0
Individual Health at best Community Health at worst Equity at worst
Individual Health at best Community Health at best Equity at worst
Individual Health at worst Community Health at worst Equity at worst
)
—bottom up method.
ARTICLE IN PRESSS.J. Peacock et al. / Social Science & Medicine 64 (2007) 897–910 903
bottom up method is not 0, but the state whereindividual health is at its best level and all otherattributes are at their worst level. That is, eachrespondent is asked to use their value for M in Fig.1 as the starting point for assessing the relativeimportance of community health and equity attri-butes.
For the community health attribute, each respon-dent is asked to consider the introduction of newhealth programme that represents a state in whichboth individual health and community healthattributes are at their best level, but equity is at itsworst level. In Fig. 1, this is the swing up the scalefrom the point M shown by arrow B, where thedistance of the swing up the scale from M indicatesthe relative importance of the community healthattribute. Similarly for the equity attribute, eachrespondent is asked to consider a new healthprogramme that represents a state in which boththe individual health and equity attributes are attheir best level, but community health is at its worstlevel. This is the swing up the scale from the point M
shown by arrow C, where the distance of the swingindicates the relative importance of the equityattribute.
E
Individual Health at best Community Health at best Equity at worst
Individual Health at best Community Health at best Equity at best
(W
Fig. 2. Weighting attribute
The top down method first asked each respondentto consider a health programme that resulted in astate where all attributes are at their best level,represented by the ‘best possible’ state (100) inFig. 2. Each respondent is then asked to considerthe replacement (or contraction) of the ‘bestpossible’ programme with a new programme, whichprovides the best levels of both individual healthand equity, but the worst level of community health.That is, each respondent is asked to consider aswing down the scale (arrow D in Fig. 2), where thedistance of the swing indicates the importance of thecommunity health attribute. The swing down thescale is a measure of the disutility each respondentplaces on a move from the community healthattribute at its best level to its worst level. Similarlyfor equity, each respondent is asked to consider thereplacement (or contraction) of the ‘best possible’programme with a new programme, which providesthe best levels of individual health and communityhealth, but the worst level of equity. That is, eachrespondent is asked to consider a swing down thescale (arrow E in Fig. 2), where the distance of theswing indicates the importance of the equityattribute.
(Best)
90
100
D80
70
60
50
40
30
20
10
0
Individual Health at best Community Health at worst Equity at best
Individual Health at best Community Health at best Equity at best
orst)
s—top down method.
ARTICLE IN PRESSS.J. Peacock et al. / Social Science & Medicine 64 (2007) 897–910904
Results from a mental health case study
In this section, we present results from the mentalhealth PBMA study in South Australian CHS as acase study application of our methods (see Peacockand Edwards (1997) and Peacock, Richardson, andCarter (1997)).
The advisory panel consisted of CHS mental healthservice managers and providers from four SouthAustralian CHS regions, service providers from otherprimary and mental health care agencies, finance anddata officers from each region, and representativesfrom the South Australian Health Commission andthe community (a total of 19 panel members). SouthAustralian CHS mental health services place signifi-cant emphasis on the promotion of mental health, theprevention of mental health problems, early and‘crisis’ intervention for mental health problems,advocacy, and community participation, as well asan emphasis upon community support and increasingaccess for ‘marginalised groups’. The marginalanalysis exercise took place over two consecutivedays. An independent facilitator was engaged for theexercise, assisted by health economists, prior to whichthe panel received training covering the background,aims, and methods of PBMA.
Identifying attributes in the MAU function
The first step in the marginal analysis exercise was todefine benefits from mental health services in thecontext of the study (the attributes of the MAUfunction) using a process of semi-structured groupdiscussion and deliberation. In defining attributes panelmembers were asked to consider local and regional/national level policy objectives, published evidence, andlocal expert knowledge. The facilitators guided debateto help ensure that two key assumptions of MAUtheory were adhered to: attributes were mutuallyexclusive (orthogonal) to avoid double counting ofthe same attribute; and attributes were collectivelycomprehensive to ensure all relevant aspects of thedecision-makers’ utility function were captured.
This task proved to be the most challenging partof marginal analysis. The exercise commenced witha general discussion, which identified three potentialattributes: individual health, community health, andequity. The panel was split into three groups (of six,six, and seven), with each group defining themeaning of a single attribute and reporting back.The panel then debated the definitions and clarifieddistinctions between attributes, in particular be-
tween the notions of health gain for individuals andcommunity health. The latter was defined in termsof community ownership and control of a healthprogramme and the sustainability of benefitsbeyond the lifetime that programme. Equity wasdefined in terms of the extent to which a healthprogramme is culturally appropriate, available,perceived to be accessible and addresses the needsof disadvantaged groups (see Table 2).
Describing attributes
Descriptions for each attribute’s best and worstlevels, as well as two or three intermediate levels, werethen constructed. Since the advisory panel would laterbe asked to score services in terms of the threeattributes, it was vital that each panel member had aclear and shared understanding of each attribute level.The panel deliberated over and refined the descrip-tions into final attribute levels (see Table 2).
Scaling attribute levels
‘Attribute worst’ and ‘attribute best’ levels wereplaced on a rating scale at 0 and 100 to define the end-points of the measurement scale for each attribute. Theconcepts of interval-scale properties were explainedand members asked to place each intermediate level onthe scale between 0 and 100. The average of panelmembers’ responses for each intermediate level wascalculated and used to calibrate the scale for eachattribute (see Table 2). These measurement scales formthe basis of single conditional utility functions, whichare combined in the MAU function.
The descriptions for each attribute demonstrate afurther important point about our approach. Theindividual health attribute seeks to measure the directhealth benefits that clients derive from the use of healthservices, i.e. benefit is measured at the individual level.However, whilst individuals benefit if a service is highlyequitable or provides ongoing community structuresfor health maintenance and promotion, benefits fromequity and community health are measured at theservice level, i.e. the impact the service has on specifieddisadvantaged groups or the community. Identifying,describing and scaling attributes took a full day ofdiscussion and deliberation.
Quantifying trade-offs between attributes
The relative importance of each attribute in theMAU function was assessed using the methods
ARTICLE IN PRESS
Table 2
Attribute levels and measurement scales
Individual health Position on
rating scaleaCommunity health Position on
rating scaleaEquity Position on
rating scalea
Individual has sense of
independence and well-
being; belonging/
acceptance; acquired
useful skills; able to
achieve their potential;
aware of social context
and of own needs;
responds positively to life’s
challenges (i.e. personal,
interpersonal and
environmental); able to
influence events around
them.
100 Community
knowledge, skills, and
support to take action
to deal with health
issues and their
collective health; to
select, manage and
control services and
planning/funding
system; benefit is
sustained and operates
over long term.
100 Highly culturally appropriate,
physically available, perceived
to be accessible, free at point
of use and addresses
circumstances which assist
disadvantaged groups.
100
Individual has sense of
belonging/acceptance;
occasionally feels
distressed/unable to
resolve issues alone, but
recognises need for help
and able to gain
assistance. Able to
respond to life’s challenges
but less able to influence
events around them.
76 Community in real
partnership with
planning/funding
system; with real input
to decision-making but
no control. Benefits go
beyond life of
immediate project, but
not sustained.
63 Culturally appropriate,
available, perceived to be
accessible, and addresses
some circumstances which
assist disadvantaged groups.
74
Individual has sense of
distress and isolation,
recognises need for help
and able to seek help.
Unable to respond to life’s
challenges in a positive
way without assistance.
43 Community
participation, but no
ownership or control;
limited influence on
decision-making.
Benefits limited to life
of the project.
36 Culturally appropriate,
available perceived to be
accessible, but only for
relatively advantaged groups.
29
Individual has sense of
distress and isolation and
recognises need for help.
Unable to respond to life’s
challenges in a positive
way without assistance,
and is unable to access
help.
20 Token community
participation; no
impact on decision-
making; no influence;
few choices. Benefits
dissolve during life of
project.
14
Individual in crisis and
unable to respond. At risk
to self/others; isolated and
unable to access help, yet
has acute mental health
needs.
0 Community with no
participation in
planning/provision; no
ownership and control;
plus divisive and
disenfranchised.
0 Culturally inappropriate, only
available and accessible to
relatively advantaged groups.
Does not consider special
needs and presents barriers to
disadvantaged groups.
0
aAverage of all panel member’s responses to rating scale questions.
S.J. Peacock et al. / Social Science & Medicine 64 (2007) 897–910 905
described above, where each respondent con-sidered the swings A (individual health), B (com-munity health) and C (equity) for the bottom
up method (Fig. 1), and D (community health)and E (equity) for the top down method(Fig. 2). These swings represent changes in utility
ARTICLE IN PRESSS.J. Peacock et al. / Social Science & Medicine 64 (2007) 897–910906
associated with moves between attributes worst andbest levels.
The mean of panel member’s responses for A wasused to calculate the importance weight(M ¼ 23:84) for individual health in the MAUmodel. Mean responses for B and C were used tocalculate the bottom up importance values forcommunity health and equity attributes, respec-tively. Similarly, mean responses for D and E wereused to calculate the top down importance valuesfor community health and equity. Descriptivestatistics are shown in Table 3.
To adjust for the potential impact of referencepoint effects, the mean of the importance valuesfrom the bottom up and top down methods wereused to calculate the importance weights (Wi) forcommunity health and equity attributes in theMAU model (see Table 4). Following discussionand deliberation over the results from both swingweights methods the panel agreed that final weights
Table 3
Descriptive statistics for bottom up and top down methods
Attribute n Mean s.d. Min Max
Bottom up method
Individual health (swing A, Fig. 1) 19 23.84 11.66 10 50
Community health (swing B, Fig. 1) 19 26.26 14.98 5 62
Equity (swing C, Fig. 1) 19 33.37 13.91 7 55
Top down method
Individual health n.a. n.a. n.a. n.a. n.a.
Community health (swing D, Fig. 2) 19 50.26 19.54 15 80
Equity (swing E, Fig. 2) 19 66.05 20.72 10 95
Table 4
Mean responses for attribute weights
Attribute Bottom up
methodaTop down
methodaAttribute
weightb
Individual health 23.84 n.a. 23.84
Community
health
26.26 50.26 38.26
Equity 33.37 66.05 49.71
aEntries in columns are the mean of panel member’s responses
for the swings A–E in Figs. 1 and 2 where swings represent
changes in utility associated with moves between attribute worst
and best levels.bAttribute weight for Individual Health is M in Eq. (3) from
the bottom up method. Attribute weights for community health
and equity (Wi in Eq. (3)) are the mean of their bottom up and
top down scores.
were intuitive, plausible and valid for the PBMAstudy.
Some care is needed to correctly compare resultsfrom the top down and bottom up methods. UsingFig. 2, D measures the change in utility resultingfrom a move from the ‘best possible’ state (1 0 0) tothe state ‘individual health at best, communityhealth at worst, equity at best’. Inspection of Fig. 1shows that the change in utility resulting from amove from the worst state (0) to the state ‘individualhealth at best, community health at worst, equity atbest’ is the sum of the two moves A and C. FromTable 3, the mean values were 50.26 for D, 23.84 forA and 33.37 for C. The sum of A and C is 57.21which is slightly larger than the value for D.Similarly, E in Fig. 2 measures the change in utilityresulting from a move from the ‘best possible’ state(1 0 0) to the state ‘individual health at best,community health at best, equity at worst’. In Fig.1 the change in utility resulting from a move fromthe worst state (0) to the state ‘individual health atbest, community health at best, equity at worst’ isthe sum of the two moves A and B. Using Table 3,the mean values were 66.05 for E, 23.84 for A and26.26 for B. The sum of A and B is 50.10, which isslightly lower than the value for E.
Evaluating programmes
Panel members scored each service beingevaluated using the attribute measurement scales.Members were not confined to choosing one ofthe attribute levels described in Table 2: they weretold that descriptions were markers on the scale toaid them in evaluating services (to maintain theinterval property of the conditional utility func-tions).
Combining attribute scores
For the mental health study, Eq. (3) simplified to:
U ¼H
100
� M þ100�M
W C þW E
� �W CC
100þ
100�M
W C þW E
� �W EE
100
� �ð4Þ
where the attribute scores (on a 0–100 scale) foreach service being evaluated are represented by H
(individual health), C (community health), and E
(equity); and importance the weights for communityhealth and equity are represented by WC and WE,respectively. Entering the values for M, WC and WE
ARTICLE IN PRESSS.J. Peacock et al. / Social Science & Medicine 64 (2007) 897–910 907
from Table 4 yields the calibrated mental healthMAU model:
U ¼H
10023:84þ 33:12
C
100þ 43:03
E
100
� �. (5)
A worked example of calibrating the MAUmodeland calculating utility scores for services is given inAppendix A. Services in the case study were rankedaccording to their utility score and followingdiscussion the panel was satisfied with the consis-tency of the ranking.
Discussion
The MAU approach to marginal analysis de-scribed in this paper has extended the optionsappraisal methodology of earlier PBMA studies.Our MAU approach is based on the notion thatbenefits from health programmes are multifaceted,and extend beyond health gains for individuals. Thechallenge for the analyst who wishes to estimatecost-benefit ratios for programme options is how tocombine preferences for multiple types of benefitsinto a single (cardinal) utility measure in asystematic and transparent manner. We believeour MAU approach offers some insights on howto meet this challenge and raises a number of issuesfor discussion and future research.
The initial task of eliciting attributes fromadvisory panels is demanding, but this is to beexpected. Defining measures of health outcomes is acomplex and demanding task in its own right.Defining measures of other types of benefits fromhealth programmes (such as improving access tohealth care for disadvantaged groups) places furtherdemands on panels. However, the process ofdeliberation and values clarification undertaken ineliciting attributes in the MAU approach, we wouldargue, provides valuable insights for the priority-setting process, precisely because panel members arechallenged to explicitly define (and defend) conceptsof benefit. Of course, some decision-makers mightprefer a less-demanding process. However, there islikely to be a trade-off between the demands of thetask and increased potential for measures of benefitsto be poorly specified and/or understood.
Some PBMA studies have failed to elicit im-portance weights for attributes, and have assignedunitary weights in the absence of data. Such anapproach is questionable. To avoid this problem,the importance of attribute weighting was outlined
at a workshop prior to marginal analysis, in thepreliminary questionnaire, and at the 2-day exercise.Our MAU approach uses a swing weights methodto explicitly estimate the relative importance of thedifferent attributes, adjusted for potential referencepoint effects. A prerequisite for most priority-setting exercises is that the methods can be used ina timely manner for assisting decision-makers. Tothis end swing weights appear to represent a robustand relatively easy to use methodology, which canyield immediate results.
There are four caveats. First, two PBMA panelsin later studies reported having some diffi-culty following the logic of swing weights andchose to use weights based on simple ratio estima-tion techniques instead (Edwards, Peacock, &Carter, 1998). Second, it is not yet clear whetherdecision-makers would favour more techni-cally complex, time intensive, weighting methods,such as willingness to pay and discrete choiceexperiments. Deciding the optimal method forattribute weighting represents an important re-search topic in the economics of prioritysetting. Third, we found evidence of referencepoint effects. The disutility of a move from equityat its best to its worst level was greater than theutility of a move in the opposite direction:respondents placed greater importance on equityin the context of reductions to services than in thecontext of expansions to services. This suggeststhat decision-makers may have different attri-bute weights for service reductions and expan-sions. This study is the first to report such a finding,which may explain why some PBMA panelshave refused to consider service reductions.Fourth, resource allocation recommendationsare based on the cost-benefit ratios, but the use ofratios involves implicit assumptions about perfectdivisibilities for all programmes and constantreturns to scale (Gafni & Birch, 2006). Decision-makers are dealing with increments, not margins,since most programmes cannot be designed toprovide individuals with a single unit of improve-ment in benefit.
The measurement of MAU may be carried out inone of two ways. In the ‘holistic’ or compositeapproach, vignettes are used to describe a set ofhypothetical scenarios in terms of different levels ofall attributes, and utilities for scenarios are elicitedusing a scaling instrument. Typically, this approachthen requires estimation of regression model toobtain the parameters for the MAU model. The
ARTICLE IN PRESSS.J. Peacock et al. / Social Science & Medicine 64 (2007) 897–910908
second, ‘decomposed’, approach was adopted inthis paper. It requires that utilities are estimated foreach attribute in isolation, and overall utility iscalculated by scaling an appropriate MAU func-tion. Both approaches have strengths and weak-nesses. Holistic measurement permits a description,which is tailored to a scenario (e.g. a specific healthservice). Unique aspects of the service, its context,its consequences, and the process of health caredelivery may all be included in the vignette.However, in the MAU quality of life literature,the validation of vignettes has seldom (if ever) beencarried out, and regression modelling requires datafrom large surveys. In contrast, the decomposedMAU approach may be unable to capture some ofthe nuances of alternative services. However, in thispaper, following common practice in decisionanalysis, validity and consistency of responses wasestablished through panel discussion and delibera-tion. Further, the advisory panel consisted of 19members, which was too small to allow the use ofregression techniques.
Combining utility functions for single attributesinto the MAU function as described heretakes account of the fundamental importanceof the improvements in health for individuals inmost (if not all) health programmes. The multi-plicative weights for the MAU functional formavoids a major weakness of the simple additiveMAU function: that programmes which do notoffer improvements in health for individuals canscore highly if they perform well in terms of otherattributes. This problem appears to have goneunnoticed in the PBMA literature. Critically, the‘multiplicative weights for health’ model wasnot imposed on the analysis by researchers. Rather,the panel selected this function when they wereoffered it as an option in preference to otherfunctional forms. We are not suggesting that thefunctional form we have proposed is the (univer-sally applicable) MAU functional form for mar-ginal analysis. Legitimate questions about thechoice of function might include: what is the effectof assuming that other attributes are includedusing a multiplicative interaction with indi-vidual health gain compared to other approaches?And, does this assumption under or over-statebenefits from other attributes? In the absenceof a gold standard against which MAU modelscan be judged, these questions are difficult toanswer. The important point is that MAU theoryand methods used here have been largely over-
looked in the literature. We believe that they shouldbe part of the ongoing priority-setting researchagenda.
Acknowledgements
The research presented in this paper was fundedby a grant from the Faculty of Business andEconomics, Monash University and by the SouthAustralian Health Commission (for the mentalhealth PBMA case study). We would like to thankthe South Australian PBMA committees for theirinvaluable efforts, and Gavin Mooney, ColinGreen, Steve Birch and two anonymous refereesfor their very useful comments on drafts of thispaper. The views expressed in this paper are those ofthe authors, and not the funding agencies or SouthAustralian health services.
Appendix A. A worked example of calibrating the
MAU model and calculating utility scores
A. Calibrating the mental health MAU model
The mental health MAU model (Eq. (4)) is givenby
U ¼H
100M þ
100�M
W C þW E
� �W CC
100þ
100�M
W C þW E
� �W EE
100
� �,
where the utility score for a given service isrepresented by U; the importance weights forindividual health, community health and equityare given by M, WC and WE, respectively; and theattribute scores for each service being evaluated arerepresented by H (individual health), C (communityhealth), and E (equity).
(i)
Calculate the constant [(100–M)/(WC+WE)]from the attribute weights in Table 4.½ð100�MÞ=ðW C þW EÞ� ¼ ð100� 23:84Þ=ð38:26þ 49:71Þ
¼ 0:8657.
(ii)
Multiply the attribute weights for communityhealth and equity by this constant.½ð100�MÞ=ðW C þW EÞ�W C ¼ 0:8657� 38:26 ¼ 33:12,
½ð100�MÞ=ðWC þWEÞ�WE ¼ 0:8657� 49:71 ¼ 43:03.
ARTICLE IN PRESSS.J. Peacock et al. / Social Science & Medicine 64 (2007) 897–910 909
This gives the calibrated mental health MAU
(iii) model (where utilities lie in the 0–100 range).U ¼H
10023:84þ 33:12
C
100þ 43:03
E
100
� �.
B. Evaluating services and calculating utility scores
Two services (X and Y) are evaluated as partof a mental health priority setting exercise. X
provides relatively small health gains for indi-viduals who have limited ownership and con-trol of the service, but it targets disadvantagedgroups. Y provides large health gains for indi-viduals who have greater ownership and control ofthe service, but it targets relatively advantagedgroups.
(i)
Elicit the advisory panel’s scores for how well Xand Y perform under each attribute using themeasurement scales in Table 2. For example:
Attribute scores Service X Service Y
Individualhealth (H)
30 90
Communityhealth (C)
40 85
Equity (E) 80 50
(ii)
Enter the attribute scores for X and Y into thecalibrated MAU model to obtain the overallutility (or benefit) scores.UðX Þ ¼30
10023:84þ 33:12
40
100þ 43:03
80
100
� �¼ 21:45,
UðY Þ ¼90
10023:84þ 33:12
85
100þ 43:03
50
100
� �¼ 66:16.
(iii)
Combine the overall scores for X and Y withcost data to produce cost-benefit ratios for usein PBMA.References
Alban, A. (1994). The role of economic appraisal in Denmark.
Social Science & Medicine, 38, 1647–1652.
Carter, R. (2001). Priority setting in health: Processes and
mechanisms. Expert paper prepared on invitation from the
Commonwealth Secretariat for the 13th Commonwealth
health ministers meeting, Christchurch, New Zealand, 25–29
November 2001.
Cohen, D. (1995). Messages from Mid Glamorgan: A multi-
programme experiment with marginal analysis. Health Policy,
33, 147–155.
Dolan, P. (1998). The measurement of individual utility and
social welfare. Journal of Health Economics, 17, 39–52.
Donaldson, C., & Farrar, S. (1993). Needs assessment—
Developing an economics approach. Health Policy, 25,
141–152.
Edwards, W. (1977). How to use multiattribute utility measure-
ment for social decision-making. IEEE Transactions on
Systems, Man, and Cybernetics, SMC-7, 326–340.
Edwards, D., Peacock, S., & Carter, R. (1998). Setting
priorities in South Australian community health III: Regional
applications of program budgeting and marginal ana-
lysis. Centre for Health Program Evaluation, Monash
University.
Feeny, D., Torrance, G., & Furlong, W. (1996). Health utilities
index. In B. Spilker (Ed.), Quality of life and pharmacoeco-
nomics in clinical trials. Philadelphia Lippencott Raven
Publishers.
Furlong, W., Barr, R. D., Feeny, D., & Yandow, S. (2005).
Patient-focused measures of functional health status and
health-related quality of life in pediatric orthopedics: A case
study in measurement selection. Health and Quality of Life
Outcomes, 3, 3.
Gabrielli, W., & von Winterfeldt, D. (1978). Are importance
weights sensitive to the range of alternatives in multiattribute
utility measurement? Research report 78–6, University of
Southern California, Social Science Research Institute.
Gafni, A., & Birch, S. (2006). Incremental cost-effectiveness
ratios (ICERs): The silence of the lambda. Social Science &
Medicine, 62, 2091–2100.
Hoffmann, C., & von der Schulenburg, J. M. G. (2000). The
influence of economic evaluation studies on decision making.
A European survey. Health Policy, 52, 179–192.
Jan, S. (2000). Institutional considerations in priority setting:
Transactions costs perspective on PBMA. Health Economics,
9, 631–641.
Kenney, R. L., & Raiffa, H. (1993). Decisions with multiple
objectives. Cambridge: Cambridge University Press.
MacDonald, R. (2002). Using health economics in health services:
Rationing rationally?. Houston: Open University Press.
Mitton, C., & Donaldson, C. (2004). Priority setting Toolkit: A
guide to the use of economics in healthcare decision making.
London: BMJ Books.
Mitton, C., Peacock, S., Donaldson, C., & Bate, A. (2003). Using
PBMA in health care priority setting: Description, challenges
and experience. Applied Health Economics and Health Policy,
2, 121–134.
Mooney, G., Gerard, K., Donaldson, C., & Farrar, S. (1992).
Priority setting in purchasing: Some practical guidelines
(Research Paper 6). Scotland: National Association of Health
Authorities and Trusts.
Peacock, S. (1998). An evaluation of programme budgeting
and marginal analysis applied in South Australian hos-
pitals. Centre for Health Programme Evaluation, Monash
University.
Peacock, S., Edwards, D. (1997). Setting priorities in South
Australian community health I: The mental health program
budget. Centre for Health Program Evaluation, Monash
University.
Peacock, S., Richardson, J., & Carter, R. (1997). Setting priorities
in South Australian community health II: Marginal analysis of
mental health services. Centre for Health Programme Evalua-
tion, Monash University.
ARTICLE IN PRESSS.J. Peacock et al. / Social Science & Medicine 64 (2007) 897–910910
Peacock, S., Ruta, D., Mitton, C., Donaldson, C., Bate, A., &
Murtagh, M. (2006). Using economics to set pragmatic and
ethical priorities. British Medical Journal, 332, 482–485.
Richardson, J., Day, N., Peacock, S., & Iezzi, A. (2004).
Measurement of quality of life for economic evaluation and
the assessment of quality of life (AQoL) mark II instrument.
Australian Economic Review, 37, 62–88.
Sintonen, H. (2001). The 15D instrument of health-related
quality of life: Properties and applications. Annals of
Medicine, 33(5), 328–336.
Spash, C. (2000). Ecosystems, contingent valuation and ethics:
The case of wetland re-creation. Ecological Economics, 34,
195–215.
Tversky, A., & Sattah, S. (1979). Preference trees. Psychological
Review, 86, 542–573.
von Winterfeldt, D., & Edwards, W. (1986). Decision analysis
and behavioural research. New York: Cambridge University
Press.
Wagstaff, A. (1991). QALYs and the equity efficiency trade-off.
Journal of Health Economics, 10(1), 21–42.
Appendix 3.
Programme Budgeting and Marginal Analysis: Bridging the divide between doctors and managers
doi:10.1136/bmj.330.7506.1501 2005;330;1501-1503 BMJ
Danny Ruta, Craig Mitton, Angela Bate and Cam Donaldson
managersbridging the divide between doctors and Programme budgeting and marginal analysis:
http://bmj.com/cgi/content/full/330/7506/1501Updated information and services can be found at:
These include:
References
http://bmj.com/cgi/content/full/330/7506/1501#otherarticles3 online articles that cite this article can be accessed at:
http://bmj.com/cgi/content/full/330/7506/1501#BIBLThis article cites 9 articles, 3 of which can be accessed free at:
Rapid responses
http://bmj.com/cgi/eletter-submit/330/7506/1501You can respond to this article at:
http://bmj.com/cgi/content/full/330/7506/1501#responsesfree at: 3 rapid responses have been posted to this article, which you can access for
serviceEmail alerting
box at the top left of the article Receive free email alerts when new articles cite this article - sign up in the
Topic collections
(309 articles) Resource allocation (including rationing) � (388 articles) Health Economics �
Articles on similar topics can be found in the following collections
Notes
To order reprints follow the "Request Permissions" link in the navigation box
http://resources.bmj.com/bmj/subscribers go to: BMJTo subscribe to
on 15 November 2007 bmj.comDownloaded from
Education and debate
Programme budgeting and marginal analysis: bridgingthe divide between doctors and managersDanny Ruta, Craig Mitton, Angela Bate, Cam Donaldson
Recent NHS reforms give doctors increased responsibility for efficient and fair use of resources.Programme budgeting and marginal analysis is one way to ensure the views of all stakeholders areproperly represented
Tensions between doctors and managers and thedifferences between medical and managerial cultureshave existed since the earliest provision of organisedhealth care.1 In a resource allocation context, doctorsare caricatured as taking the role of patient advocatewhile managers take the corporate, strategic view.Delivery of efficient (and in the case of the NHS, equi-table) health care requires doctors to take responsibil-ity for resources and to consider the needs ofpopulations while managers need to become moreoutcome and patient centred. One economicapproach, called programme budgeting and marginalanalysis, has the potential to align the goals of doctorsand managers and create common ground betweenthem. We describe how the approach works and why itshould be more widely used.
Economic principlesProgramme budgeting and marginal analysis is anapproach to commissioning and redesign of servicesthat can accommodate both medical and managerialcultures and the widest constituency of professional,patient, and public values within a single decision mak-ing framework. It allows for the complexities of healthcare while adhering to the two key economic conceptsof opportunity cost and the margin. When having tomake choices within limited resources, certain oppor-tunities will be taken up while others must be forgone.The benefits associated with forgone opportunities areopportunity costs. Thus, we need to know the costs andbenefits of various healthcare activities, and this is bestexamined at the margin—that is, the benefit gainedfrom an extra unit of resources or benefit lost fromhaving one unit less. If the marginal benefit per poundspent from programme A is greater than that for B,resources should be taken from B and given to A.
This process of reallocation should continue untilthe ratios of marginal benefit to marginal cost for theprogrammes are equal, maximising total patientbenefit across the two programmes. The opportunitycost of funding one more hip replacement, forexample, could be the benefit forgone by not using thatresource to fund renal dialysis. Thus, the application ofeconomics becomes about the balance of services, not
introduction or elimination of services. Such marginalanalysis is central in making the most of resourcesavailable.
Five questionsThe approach starts by examining how resources arecurrently spent before focusing on benefits and costsof changes to the spending pattern.2 It can be used atmicro levels (within programmes of care) or at a macrolevel (across services and programmes within a singlehealth organisation). At its core, the approach can beoperationalised by asking five questions aboutresource use (box 1).
The first two questions relate to programme budg-eting, and the other three to marginal analysis. Theunderlying premise of programme budgeting is thatwe cannot know where we are going if we do not knowwhere we are. All primary care trusts now have to col-lect programme budgeting information as part of thestatutory accounts process. What they are not yetrequired to do is proceed with the marginal analysis.
An advisory panel is usually formed to examine thecosts and benefits of proposed changes in services anduse this information to improve benefit overall. The
School ofPopulation andHealth Sciences,University ofNewcastle,Newcastle uponTyne NE2 4AADanny Rutasenior lecturer inepidemiology andpublic healthAngela Bateresearch associate inhealth economicsCam Donaldsonhealth foundationchair in healtheconomics
Centre forHealthcareInnovation andImprovement,Research Institutefor Children’s andWomen’s Health,University of BritishColumbia,Vancouver, CanadaV6H 3V4Craig Mittonassistant professor
Correspondence to:D Ruta [email protected]
BMJ 2005;330:1501–3
1501BMJ VOLUME 330 25 JUNE 2005 bmj.com
on 15 November 2007 bmj.comDownloaded from
panel is charged with making recommendations in linewith predefined criteria.
If the budget is fixed, opportunity cost is accountedfor by recognising that the items for service growth canbe funded only by taking resources from elsewhere.Resources can be obtained from elsewhere by beingmore technically efficient (changing practice to achievethe same health outcome at less cost) or moreallocatively efficient (treating entirely different condi-tions to achieve a greater health outcome at the samecost). The analysis can be done at the margin byconsidering the amounts of different services provided.Although in reality quantitative data on marginal ben-efits are often lacking, it is the way of thinkingunderpinning the framework that is important.
Of course, governments tend to add real resourcesto health organisation budgets each year. But theincreased funds are unlikely to cover all proposedgrowth areas. Scarcity still exists, and the principles ofprogramme budgeting and marginal analysis stillapply. In effect, although sounding extreme, the wholebudget is available for consideration for re-allocation.
Who decides and how?Careful consideration must be given to the make up ofthe advisory panel and to the various stakeholdergroups whose views and advice will be sought. The keyis to obtain representation3–5 without rendering theprocess unmanageable.6 The composition of the panelwill depend on the questions under consideration andthe scope of the exercise, but it is likely to comprise amix of clinical staff and managers and perhaps patientsor members of the public. Information analysts andfinancial staff are also key resources to providesupport.
Whenever possible, local knowledge should besupplemented with evidence from sources such as eco-nomic evaluations, effectiveness studies, needs assess-ments, national and local policy documents, andsurveys of healthcare professionals and the public.5 6 Inthe end, however, it is the members of the advisorypanel who decide whether to recommend thatresources should be shifted. When evidence is lacking,group members may base recommendations on theirexpert opinion.7
It is also important to conduct a final round of con-sultations with a wider group of relevant stakeholders.
This tests the validity of the recommendations andmakes it more likely that they will be accepted. Box 2outlines the formal stages of the process. A practicaltoolkit is now available describing these stages in moredetail.8
Barriers to useAlthough programme budgeting and marginal analy-sis is not without challenges,9 the framework has beenused in over 60 health organisations in Australia, NewZealand, Canada, and the United Kingdom. A system-atic review showed that use was sustained in over halfof the 80 cases where the approach has beenimplemented. Given this, it is hard to understand whygreater use has not occurred, particularly in bodies likeNHS primary care trusts. Perhaps its use has been dis-couraged by the poor uptake of results of traditionaleconomic evaluations at the local level in the NHS.10
However, programme budgeting and marginal analy-sis is different from economic evaluation. Althoughbased on the same principles, it uses these principles tocreate a management process into which results fromstandard economic evaluations and other evidence canbe incorporated. Indeed, such a process could be seenas the missing piece in the jigsaw of reform, providingdefensible mechanisms to help primary care trustsremain within budget while prioritising betweennational guidance and local needs.
The approach requires an acceptance of resourcescarcity and the need to manage it. Another importantbarrier to its effective use may stem from reluctance bydoctors to accept loss of funding if their services arejudged to have lower marginal benefit. Financial incen-tives, whereby clinicians are empowered to reinvest aportion of resources released directly back into theirservices, have been shown to encourage participation.4
Box 1: Five questions about resource use
What are the total resources available?
On which services are these resources currently spent?
What services are candidates for receiving more ornew resources (and what are the costs and potentialbenefits of putting resources into such growth areas)?
Can any existing services be provided as effectively, butwith fewer resources, so releasing resources to funditems on the growth list?
If some growth areas still cannot be funded, are thereany services which should receive fewer resources, oreven be stopped, because greater benefit would bereached by funding the growth option as opposed tothe existing service?
Box 2: Seven stages in setting priorities• Determine the aim and scope of the exercise• Compile a programme budget (map of currentactivity and expenditure)• Form marginal analysis advisory panel andstakeholder advisory groups• Determine locally relevant decision making criteriawith input from decision makers and stakeholders (egservice providers, patients, public)• Advisory panel identifies options in terms of:Areas for service growthAreas for resource release through producing samelevel of output (or outcomes) but with fewer resourcesAreas for resource release through scaling back orstopping some services• Advisory panel makes recommendations in termsof:Funding growth areas with new resourcesDecisions to move resources released throughincreased productivity to areas ofgrowthTrade-off decisions to move resources from oneservice to another if relative value is deemed greater• Validity checks with additional stakeholders andfinal decisions to inform budget planning process
Education and debate
1502 BMJ VOLUME 330 25 JUNE 2005 bmj.com
on 15 November 2007 bmj.comDownloaded from
Improving the doctor-managerrelationshipA successful partnership between medicine andmanagement is widely believed to require joint leader-ship and alignment of goals.11 12 To accomplish aconvergence of cultures Ham suggests we need to“Harness the energies of clinicians and reformers inthe quest for improvements in performance thatbenefit patients.”11 The programme budgeting andmarginal analysis process has the potential to do this,providing a practical framework to facilitate jointworking in several ways.
The approach requires and values equally the con-tributions of doctors and managers. For example,different models of medical practice1 each play a legiti-mate part at different stages in the process. A reflectivemodel, drawing on tacit knowledge borne of individualclinical experience, is invaluable in formulating the cri-teria for assessing candidates for increased anddecreased funding, to identify these candidates, and toassess subjectively the benefits gained or lost from pro-posed shifts in resource allocation. At the same time,doctors bring essential critical appraisal skills to theevaluation of investment and disinvestment optionsand for integration of clinical evidence from systematicreviews. Managers, in addition to providing more obvi-ous organisational, operational, financial, and strategicmanagement skills, can ensure success at critical stagesof the process through cooperation, negotiation,delegation, teamwork, and persuasion.12 Managers willalso ensure that the local and national policies exert anappropriate level of influence on final priorities.Consideration of policies is no less important thanclinical evidence if the process is to lead to real changein delivery of services.
Other advantages of programme budgeting andmarginal analysis include transparency and inclusivity.Contextual information, evidence, and subjective judg-ment are explicitly presented, evaluated, and recorded.This makes it more difficult for any professional groupto defend (or reject) a stance simply throughobfuscation or unsubstantiated assertion. It is alsolikely to minimise legal intrusion into public policymaking.13 In addition, the perspectives of doctors andmanagers are both mediated and illuminated by arange of other viewpoints garnered from patient, pub-lic, and professional groups.
Perhaps the most important benefits for thedoctor-manager relationship would come throughinterdisciplinary education. Joint participation at eachstage of the process has the potential to lead to ashared understanding of each other’s cultures. The netresult may be a shared appreciation of opportunitycost, the need to focus on resources and healthoutcomes and to balance clinical autonomy with finan-cial responsibility. Sustainable publicly funded health-care systems depend on a mature recognition of theneed to manage scarcity. Programme budgeting andmarginal analysis can help achieve this preciselybecause it bridges clinical and strategic decisionmaking.
Contributors and sources: CD is an experienced healtheconomist with a long research interest in priority setting. DRand CM have extensive experience implementing programmebudgeting and marginal analysis (PBMA) as health services
researchers . Both CD and CM have recently completed a majorreview of PBMA studies over the last 25 years. This article is asynthesis of their personal experiences, the results of the review,and the preliminary findings of a PhD study by AB.Competing interests: None declared.
1 Davies HT, Harrison S. Trends in doctor-manager relationships. BMJ2003;326:646-9.
2 Donaldson C, Farrar S. Needs assessment: developing an economicapproach. Health Policy 1993;25:95-108.
3 Cohen D. Marginal analysis in practice: an alternative to needsassessment for contracting health care. BMJ 1994;309:781-4.
4 Lockett T, Rafferty J, Richards J. The strengths and limitations ofprogramme budgeting. In: Lockett T, ed. Priority setting in action. Oxford:Radcliffe Medical Press, 1995.
5 Ruta DA, Donaldson C, Gilray I. Economics, public health and healthcare purchasing: the Tayside experience of programme budgeting andmarginal analysis. J Health Services Res Policy 1996;1:185-93.
6 Craig N, Parkin D, Gerard K. Clearing the fog on the Tyne: programmebudgeting in Newcastle and North Tyneside Health Authority. HealthPolicy 1995;33:107-25.
7 Peacock S. Program budgeting and marginal analysis: options for health sectorreform. Melbourne: Centre for Health Program Evaluation, Monash Uni-versity, 1997.
8 Donaldson C, Mitton C. Priority setting toolkit: a guide to the use of economicsin health care decision making. London: BMJ Books, 2004.
9 Mitton C, Peacock S, Donaldson C, Bate A. Using PBMA in health carepriority setting: description, challenges and experience. Appl Health EconHealth Policy 2003;2:121-34.
10 McDonald R. Using health economics in health services: rationing rationally?Buckingham: Open University Press, 2002.
11 Ham C. Improving the performance of health services: the role of clini-cal leadership. Lancet 2003;361:1978-80.
12 Crosson FJ. Improving the doctor-manager relationship. KaiserPermanente: a propensity for partnership. BMJ 2003;326:654.
13 Greschner D, Lewis S. Autonomy and evidence-based decision-making:Medicare in the courts. Canadian Bar Rev 2003;82:501-33.
(Accepted 6 May 2005)
Summary points
Programme budgeting and marginal analysis hasthe potential to align the goals of doctors andmanagers
It is an economic approach to priority setting thatadheres to the two key economic concepts ofopportunity cost and the margin
The method requires and values equally thecontributions of doctors and managers
Contextual information, evidence, and subjectivejudgment are explicitly presented, evaluated, andrecorded
The approach fosters a shared appreciation of theneed to focus on resources and health outcomesand the need to balance clinical autonomy withfinancial responsibility
Endpiece
DiscoveryDiscovery consists of seeing what everybody hasseen and thinking what nobody has thought.
Albert von Szent-Gyorgy (1893-1986), Hungarianborn American biochemist (Nobel prize 1937)
Fred Charatan, retired geriatric physician, Florida
Education and debate
1503BMJ VOLUME 330 25 JUNE 2005 bmj.com
on 15 November 2007 bmj.comDownloaded from
Appendix 4.
Manager’s Faculty Annual Survey (2006)
Walker & Cate (2006)
1
Manager’s Faculty Annual Survey (2006) Sarah Walker & Tim Cate
Sarah Walker, Trainee Clinical Psychologist, University of Newcastle Upon Tyne Tim Cate, Associate Director of Psychology, Tees, Esk & Wear Valleys NHS Trust Introduction The DCP Manager’s Faculty Survey has been conducted annually, with this year
being its fifth year of assessing psychological services within the NHS. The survey
was again distributed to members of the DCP Managers Faculty and was conducted
electronically. The survey assessed various areas of services including service
configuration, vacancy factors for Clinical Psychology posts, distribution of CP posts
across the Agenda for Change bandings, waiting times, and benchmarking of services
against the criteria set out in the DoH report Organising and Developing Psychological Therapies (2004). Results were compared to previous year’s results
(Walker & Cate, 2006; Walker et al, 2005) in order to gauge any changes that may
have taken place within the last twelve months.
Respondents The number of respondents had again increased slightly to 86 services (83 in 2005, 71
in 2004, 68 in 2003, 60 in 2002), with 51 of the respondents indicating that they had
completed the survey for their trust in 2005. Respondents were asked to indicate
which specialities their service encompassed, which indicated that the survey was
representative of clinicians across a wide range of specialities within psychological
services in the NHS.
Table 1: Type of Services Responding
Type of Service No. of Services
Adult Mental Health 30
Child & Family 27
Forensic 11
Health &/or Medical 23
Learning Disabilities 28
Older Adults Mental Health 22
Addictive Difficulties 4
Eating Disorders 4
Neuropsychology 19
Primary Care Mental Health 17
Psychodynamic Psychotherapy 15
CBT 15
Miscellaneous 2
Walker & Cate (2006)
2
Vacancy Factor Respondents were asked to indicate the number of WTE psychology posts that were
currently occupied, vacant, frozen or filled by short-term temps. In addition,
respondents were asked to record their position 12 months ago, and to predict how
their service may look in 12 months time. Out of the 64 services that provided
responses to this section, only 19 services were able to complete all sections. The
figures shown in brackets in Table 2 indicate the number of services completing that
column.
Table 2: Summary of Vacancy Factor data (n=64)
Sum % Mean Range Last Year (74) 529.3 - 7.2 0.4 – 42.0
Present (76) 616.1 - 8.1 0.1 – 44.8 Total WTE Psychology Next Year (68) 589.5 - 8.7 0.2 - 46.0
Last Year (58) 25.1 4.7 0.4 0.2 – 3.0
Present (64) 54.3 8.8 0.8 0.3 – 5.3 Posts WTE
Vacant Next Year (48) 7.1 1.2 0.1 0.1 – 2.0
Last Year (48) 10.4 2.0 0.2 0.2 – 2.7
Present (55) 28.4 4.6 0.5 0.4 – 5.0 Posts WTE
Frozen Next Year (42) 6.5 1.1 0.2 0.2 – 2.5
Last Year (42) 9.3 1.8 0.2 0.2 – 2.0
Present (48) 20.4 3.3 0.4 0.4 – 6.4 Posts Filled by ST Assistants Next Year (40) 6.5 1.1 0.2 0.2 – 2.0
Last Year (40) 70.7 13.4 1.8 0.4 – 18.0
Present (48) 106.6 17.3 2.2 0.4 – 19.0 Total WTE
Posts Needed Next Year (39) 90.0 15.3 2.3 0.2 – 20.0
The figures in Table 2 indicate that (for the services completing this section) the
number of WTE psychology staff has increased when compared to their position 12
months ago, by an average of 0.9 WTE (7.2 to 8.1). It is predicted that, on average,
this will be maintained in the next 12 months (8.7). The percentage of WTE posts
vacant in these services appears to have increased from 4.7% to 8.8%, however the
forecast for the coming year is that this will drop, with a figure of 1.2% predicted for
the number of posts expected to be vacant in 12 months time. This is in contrast to the
predictions made by last year’s respondents who anticipated a vacancy factor of only
0.01% by this point in time (Walker & Cate, 2005).
The percentage of posts frozen has increased slightly within these services from the
figures they report from the previous year (2.0% to 4.6%), however, this is expected
to decrease again over the next 12 months (1.1%). The number of posts filled by
short-term assistants has also increased somewhat, from 1.8% to 3.3%, although
predictions for the coming 12 months indicate that services expect this to decrease
again (1.1%). The total number of WTE posts needed has increased slightly over the
last 12 months, with the average number of posts needed rising from 1.8 to 2.2.
Somewhat surprisingly, the overall picture does not appear to have changed
dramatically from the results of previous years surveys, despite the major changes
which have taken place and indeed are still ongoing in the NHS.
Walker & Cate (2006)
3
Agenda for Change Respondents were asked to indicate the WTE staff in each of 9 categories of staff
within their service.
Table 3: Number of WTE staff in each profession
Profession No. of Staff % Clinical Psychologist 802.8 59.2
Counselling Psychologist 69.9 5.2
Health Psychologist 12.6 0.9
Forensic Psychologist 49.0 3.6
Adult Psychotherapist 62.3 4.6
Child Psychotherapist 21.5 1.6
Counsellors 88.5 6.5
Assistant Psychologist 169.8 12.5
Others* 80.2 5.9
* Including Occupational Therapists, Graduate Mental Health Workers, Associate Psychologists and Psychological Therapists
A total of 15 forecast retirements were indicated over the next 12 months. 51 out of
86 services indicated that they expect changes to their service configuration to take
place over the next year. Many such changes were related to proposed service
reconfigurations, often as a result of trust mergers and changes in commissioning of
services. Eight services indicated that they expected to lose clinical psychology posts
as a result of the forthcoming changes, however, ten services indicated that they
expected at least one post to be created to accommodate changes.
Table 4: Percentage of staff in each AfC banding for each profession Agenda for Change Banding Profession 4 5 6 7 8a 8b 8c 8d 9 Clinical - - - 18.3 20.6 20.5 19.4 18.7 2.5
Counselling - - 8.1 34.9 31.1 7.2 13.9 4.8 -
Health - - - 26.9 25.7 17.5 23.4 6.4 -
Forensic - - - 15.0 16.2 29.0 21.3 18.6 -
Adult Psychotherapist - - - 27.3 35.9 11.5 8.2 17.0 -
Child Psychotherapist - - - 28.6 33.3 19.0 14.3 4.8 -
Counsellors - 13.3 34.6 45.9 5.6 0.7 - - -
Assistant 34.6 65.4 - - - - - - -
Others* 14.4 - 29.4 36.0 16.3 2.2 1.7 - -
Of the 86 services included in this year’s survey, 23 services had at least one member
of staff in the process of appealing against their Agenda for Change banding. Six
services reported that they had not yet been fully assimilated to the AfC system. At
the same point last year, 46 out of 83 services had not been fully assimilated, and 43
services had staff appealing against their banding. Clearly a large amount of work has
been completed in the last twelve months to reduce these figures, and it is hoped that
the remaining appeals will be resolved before next year’s survey.
Walker & Cate (2006)
4
Waiting Times Respondents were asked to provide figures for the average waiting time for the
different services within their department. Estimates were given for the wait from
referral to initial assessment, and from initial assessment to intervention.
Table 5: Waiting time in weeks for psychological services from referral to initial assessment, and from initial assessment to intervention
WT (weeks) Referral to Assessment
WT (weeks): Assessment to Intervention Service Type n
Range Average Range Average
Primary Care 12 4 – 100 20* 0 – 52 12
Adult Mental Health 25 0 – 156 22 0 – 52 12
Older Adult MH 16 0 - 40 8 0 – 20 3
Child & Family 13 0 – 52 14 0 – 43 4
Learning Disabilities 23 0 – 52 11 0 – 44 4
CAMHS 13 0 – 39 9 0 – 43 7
Psychodynamic
Psychotherapy
8 0 – 26 10 0 - 104 53
CBT 9 0 - 24 9 0 – 64 29
Neuropsychology 16 0 – 100 22 0 – 24 4
Addictive Difficulties 3 0 – 13 5 0 - 32 8
Eating Disorders 5 0 – 13 5 0 – 32 7
Health Psychology 17 0 – 26 10 0 – 26 2
Forensic Psychology 8 0 – 8 4 0 – 32 5
Other 6 0 -156 36 0 0 *Would be 13.2 without service reporting 100 There appears to be a large variation between services in terms of waiting times for
assessment and treatment. Although it is pleasing and encouraging to see that some
services are able to see patients within a week of referral, such services are the
exception rather than the norm, as is reflected in the average waiting times shown.
Many services are still exceeding the target of 18 weeks from referral to intervention. This may reflect the strain being put on services by an increasing amount of referrals
to psychological services, and further highlights the need for services to be given the
capacity to expand in order to tackle waiting list problems effectively.
Walker & Cate (2006)
5
Table 6: Average waiting times in 2004, 2005 & 2006
Average WT (weeks) Referral to Assessment
Average WT (weeks): Assessment to Intervention Service Type
2004 2005 2006 2004 2005 2006 Primary Care 23 28 20 8 7 12
Adult Mental Health 24 16 22 12 19 12
Older Adult MH 11 11 8 2 11 3
Child & Family 34 23 14 3 37 4
Learning Disabilities 17 11 11 8 7 4
CAMHS 18 9 9 2 13 7
Psychodynamic
Psychotherapy
20 17 10 21 64 53
Neuropsychology 20 21 22 5 6 4
Health Psychology 15 20 10 6 6 2
Forensic Psychology 6 6 4 3 6 5
When compared to previous year’s figures, it appears that on average waiting times
from referral to assessment have continued to decrease, or at least maintain previous
decreases in most services. Only Neuropsychology services have failed to decrease
waiting times over the last three years, reflecting the constant demands on this limited
service.
Average waiting times from assessment to intervention also appear to becoming more
acceptable, with decreases on last years long waiting times in Adult Mental Health,
Older Adults, and Child & Family services. Only Primary Care services show an
increase in waiting times. However, it must be noted that waiting times for
psychodynamic psychotherapy, although less than those reported in 2005, are still just
over one year from assessment to intervention.
Overall, it appears that patients are waiting longer for assessment than the wait from
assessment to intervention, and that the overall waiting time continues to drop. There
is, however, still work to be done to reduce this further and keep waiting times to a
minimum.
Although the national picture on average is encouraging, it must be noted that some
services are still reporting waiting times of up to 156 weeks in Adult Mental Health,
100 weeks in Primary Care and 52 weeks in Learning Disabilities and Child & Family
services. These services are the exception however, and many services are reporting
waiting times of less than one month across the specialities, which must be
commended. Progress to reduce waiting times is slow, but it is happening and further
initiatives are required for all services to be able to meet national targets.
Walker & Cate (2006)
6
Benchmarking
Respondents were asked to grade their service against the ten benchmarks set out in
the DoH report (2004) using the following levels:
Level 1: Not present at all
Level 2: Minimal evidence of the feature
Level 3: Making significant progress
Level 4: Present to a notable degree
Level 5: Present to an extent that warrants beacon status
Table 7: Percentages of respondents scoring at each level for each benchmark (n=59)
Level 1 Level 2 Level 3 Level 4 Level 5 Average Targeting those with greatest
need
1.4 16.7 37.0 35.0 9.7 3.35
Multidisciplinary &
Multi professional
0 4.3 18.9 29.0 47.8 4.20
Clear training strategy
0 9.7 11.1 59.7 19.4 3.89
Single point of entry
0 22.2 16.7 41.7 19.4 3.58
Involve Service users & carers
2.7 34.2 53.4 6.8 2.7 2.73
Tiered psych network
3.2 30.2 36.5 19.0 11.1 3.05
Manage WL effectively
2.9 30.0 31.4 20.0 15.7 3.16
Routine audit & research
0 12.5 50.0 25.0 12.5 3.38
Clear & defined leadership
structure
0 1.4 34.2 56.2 8.2 3.71
Well integrated into NHS
0 5.6 32.4 32.4 29.6 3.86
The data gathered indicates that the majority of services are meeting standards in
terms of being multidisciplinary & multi-professional, training strategies, leadership
structure and integration. There appears to be wide variation in the ability of services
to meet criteria for having a single point of entry and effectively managing waiting
lists. This may also account for the variations in waiting times demonstrated earlier,
and reflects the disparity in service configurations both across and within specialities.
Walker & Cate (2006)
7
Table 8: Comparing average results from 2004 (n=59), 2005 (n=59) and 2006 (n=73) 2004 2005 2006
Targeting those with greatest need 3.27 3.34 3.35
Multidisciplinary & multi professional 4.07 4.00 4.20
Clear training strategy 3.61 3.62 3.89
Single point of entry 3.38 3.53 3.58
Involve Service users & carers 2.59 2.62 2.73
Tiered psych network 3.08 2.77 3.05
Manage WL effectively 2.95 2.98 3.16
Routine audit & research 3.24 3.24 3.38
Clear & defined leadership structure 3.76 3.66 3.71
Well integrated into NHS 3.70 3.68 3.86
As there have been no major fluctuations in average scores reported, it appears that
standards achieved in previous years are being maintained, an important point as it
shows that efforts to achieve the standards set out by the DoH (2004) have not
diminished in the last year.
With the exception of involvement of services users and carers, all the standards
investigated are achieving an average rating above 3, indicating that in general,
services are progressing satisfactorily towards achieving the standards set out in
Organising and Delivering Psychological Therapies. Involving service users and
carers has consistently been difficult to achieve with fewer than 10% of services
reporting their involvement in management level service decisions and input into
improving access to services. Services which were achieving these high levels of
involvement came from a range of specialities including learning disabilities,
addictive difficulties, forensic, health and CAMHS, indicating that service user
involvement is possible regardless of the speciality.
On a positive note, almost 65% of services are reporting that service users are
involved in at least an advisory capacity, a notable achievement. Further work may
need to be done to look at why services fail to regularly achieve the higher levels in
this category and make services aware of the strategies used by those services that are
able to achieve level 4 or 5 in this standard.
Walker & Cate (2006)
8
Summary Of particular interest in this year’s survey was the impact Agenda for Change and
reconfiguration of services in the NHS has had on Clinical Psychology. In terms of
jobs, it was somewhat surprising and pleasing to report that the number of CP posts is
not starting to diminish; in contrast services were reporting on average an increase in
the number of CP posts vacant, and although there had been an increase in the number
of posts frozen, this was expected to decrease again over the next twelve months.
Many services forecast service reconfigurations over the coming year, and although
some predicted the loss of CP posts, slightly more services predicted the development
of new posts or growth in existing ones. Most services are now fully assimilated to the
AfC payscales, with a marked reduction in the number of outstanding appeals since
the 2005 report. When taken collectively, these results paint a reassuring picture for
clinical psychology for the coming months.
It appears that work continues to progress towards meeting DoH targets for services,
such as waiting times, gains have been made which should be commended, but
equally there is still a lot of work to be done in terms of reducing waiting times and
meeting other criteria for services such as the inclusion of service users and carers in
service development. Perhaps services which are able to meet level five on the
benchmarking section of the survey should be encouraged to use their ‘beacon’ status
to share their ideas and successes with other services in order to help all services
achieve the DoH targets for psychological therapies (2004).
The broad range of services covered in this year’s survey suggests a representative
sample of psychology in the NHS currently has been provided and examined. As the
survey continues to grow year on year, it is hoped that more and more respondents
will provide information, in order to encompass a greater number of trusts and
services. We would like to thank all those who took part in this year’s survey, and
encourage you to continue to contribute in future years.
Walker & Cate (2006)
9
References
Department of Health (2004). Organising and Delivering Psychological Therapies. London: DoH.
Walker, S., Cate, T., Gray, I., Paxton, R. & Ball, T. (2005). Organising and Delivering
Psychological Therapies: How great is the challenge? Clinical Psychology, 50, 45-53.
Walker, S. & Cate, T. (2006). Managers’ Faculty annual survey 2005. Clinical Psychology Forum, 168, 37-44.
Appendix 5.
Mental Health Observatory Brief: Psychological therapy staff
What are psychological therapies for? Modern mental health services cannot function without adequate psychological therapy resources. Recent NICE guidelines (NICE 2002-2006) identify these as key elements of treatment for anxiety and panic disorders, depression, eating disorders, obsessive-compulsive disorder, post-traumatic stress disorder and schizophrenia. For mild depression, anxiety and panic disorders and most eating disorders, psychological therapies are the principal recommended treatments. They also have a role in the treatment of bipolar disorders.
For commoner condit ions, s impler psychological therapies are appropriate. In some cases Cognitive Behaviour Therapy (CBT) for less complicated depression and anxiety disorders can be provided by a computer instead of a therapist. For more severe disorders, a range of specialised techniques is required.
The importance and cost effectiveness of CBT specifically for depression and anxiety disorders has recently been highlighted by Layard (2004). These disorders are common and frequently impede people’s ability to function at home or work. They are particularly amenable to this simple and comparatively cheap treatment.
Psychological therapy staff Key resource – Wide variations in availability. Gyles Glover, Rebecca Lee and Richard Dean
How many therapists are needed? Lavender and Paxton estimated the numbers of clinical psychologists needed for local services on the basis of recommended service models and provision in a number of well functioning services. Their estimates covered primary, local secondary care, including some services that would probably often be shared between neighbouring districts, and national specialist services. Omitting a few components not relating to services for mentally-ill people, their work suggests that, for an average district, 18.8 clinical psychologists and 4.4 assistant psychologists would be required per 100,000 working age adults. Socially deprived areas might be expected to need more while more comfortable areas would need less.
Assistant psychologists are commonly employed in secondary care settings. Not formally qualified in clinical psychology, they are often used to provide simple therapies under supervision and to assist service users with the operation of computer-administered CBT. In 2000, the government set up a scheme to train 1000 graduate primary care mental health workers to provide similar functions in primary care settings. In addition to this other groups, including, psychotherapists and counsellors are needed.
Total Primary Secondary Tertiary Other
Qualified Clinical Psychologists 2156 3% 69% 17% 11%
Psychotherapists 544 4% 36% 55% 5%
Counsellors 1392 27% 54% 5% 14%
Assistant Psychologists 313 4% 47% 31% 19%
Graduate Workers 711 78% 19% 2% 1%
Total 5116
Table 1. National numbers of staff (whole time equivalents - WTEs) providing psychological therapies, and proportions working in different types of NHS setting.
Mental Health Observatory Briefs
April 2007
Issue 1
1. A full listing of the types of service included in each of these four groups can be found on the accompanying website.
2. Population figures have been weighted (increased or decreased) to allow for the fact that mental health problems are commoner in some areas using was the AREA index. This is the system currently used by the Department of Health for allocating money for mental health care.
What do the figures show? In the adult mental health service mapping of March 2006, a total of 5116 whole time equivalent (wte) staff involved in psychological therapies were reported working in units run by the NHS. Table 1 shows the numbers by broad staff group and the level of the service in which they were working. The number of qualified clinical psychologists is below half the estimated requirement. They work mainly in secondary care settings (for example community mental health teams). Graduate workers are mainly found in primary care (at GP health centres) and psychotherapists in specialist psychotherapy units. The majority of
Introduction Psychological therapies in mental health care are effective, popular with service users and, for some types of mental illness, have been shown to have more enduring benefits than drug treatments. Recent work by the Office for National Statistics has shown that between 1993 and 2000, the proportion of people suffering with neurotic disorders receiving any drug treatment doubled from 10% to 20%, and the proportion receiving antidepressants nearly trebled (from 6% to 16%). However the proportions of those receiving psychological therapies remained constant at around 7% (3% receiving psychotherapy, 3% counselling and 1% behavioural and cognitive therapies) (Brugha et al 2004).
Ten years ago, Parry (1996) showed that provision varied considerably around the country. The National Service Framework for Mental Health (DH 1999) drew attention to evidence that members of ethnic minorities had less access. In his update on the NSF – Five Years On, the National Director for Mental Health announced a new programme to address the long waiting lists existing in many places for psychological therapies (Appleby 2004).
This brief presents the most recent data (March 2006) from mental health service mapping about the availability of staff to provide psychological treatments for working-age adults with mental health problems. The aim is to show the extent to which this varies around England. National and new strategic health authority figures are shown here; an accompanying spreadsheet details the pattern in each region.
Strategic Health Authority
Qualified clinical Psychologists
Psycho-therapists Counsellors Assistant
Psychologists Graduate Workers
East of England 5.7 1.4 2.9 0.9 1.1 East Midlands 5.9 1.5 2.7 0.9 3.2 Yorkshire and the Humber 5.1 2.0 5.5 1.0 2.3
West Midlands 7.3 1.1 4.0 1.5 2.3 South East Coast 7.5 2.7 3.5 0.8 1.9 North East 5.9 2.1 5.1 0.8 2.8 North West 4.8 1.5 6.1 1.1 3.7
South Central 8.3 2.4 4.7 0.7 1.4
South West 8.5 1.0 5.0 0.8 2.5 London 10.2 2.2 4.4 1.1 1.6 England 7.0 1.8 4.5 1.0 2.3
Table 2. Numbers of psychological therapy staff by discipline, per 100k population weighted for need (ordered by their total).
More local figures can be found on our website. In reading these, remember that some services are shared between neighbouring districts.
www.nepho.org.uk/mho/psychologicaltherapists
counsellors reported appeared to be in secondary care settings. This is surprising as they are more usually associated with primary care work, where the numbers look implausibly low. Where counsellors are employed directly by GP practices they may be less reliably reported. About 10% of the total workforce identified, mostly clinical psychologists and counsellors, were operating in a range of other settings, from inpatient wards and acute home treatment teams to mother and baby facilities and homeless mental health services.
Substantial numbers of both counsellors and psychotherapists work outside the NHS, funded through charitable sources, directly by clients or in other ways. Mapping of these is very incomplete and is therefore not reported here.
Table 2 and figures 1 to 5 shows staff numbers in relation to population size. In each case the range between new strategic health authorities is considerable with the best provided areas having 35% more counsellors, 45% more qualified psychologists and 50% more psychotherapists than the national total. The least provided have 39%, 32% and 44% below respectively. There is some suggestion of substitution. London has the highest provision of qualified psychologists and more than average psychotherapists, but relatively few graduate workers. The north-west, with the highest provision of graduate workers, has the lowest number of clinical psychologists and fewer than average psychotherapists.
2
Key questions:
Service users and representative groups:
Are our services adequate for our local population and how do they compare with others?
Are services provided in pleasant and convenient locations?
Commissioners:
Is the number and range of therapists we are providing adequate to service the requirements of NICE treatment guidelines?
Do we have an appropriate quota of graduate workers for an efficient skill mix, and are supervision arrangements adequate for them?
Providers:
Is the skill mix right?
Are services provided in a range of non-stigmatising locations convenient for people's homes?
Strategic Health Authorities:
Do the figures suggest staff availability for our region is adequate, and -what strategic steps are we taking to ensure it is?
Are the figures accurate? Data come from the annual reporting system set up to monitor the National Service Framework. Reporting requirements have been broadly stable for five years and the figures were signed-off as accurate by local NHS Trust chief executives.
However, we have anecdotal reports that some services have been missed. It seems likely that this reflects limited understanding and awareness of these services by Local Implementation Team managers, itself a
Discussion The total number of staff available appears to be well below what is required. The variation between regions, particularly in clinical psychologist provision, is so large as to indicate that major interventions to expand the numbers of available qualified staff would be needed to achieve anything like uniform national access to adequate levels of services.
In any area, it is important to provide both sufficient numbers and an appropriate mix of skill levels. Graduate workers and assistant psychologists are considerably cheaper than clinical and consultant psychologists, however they require supervision and are not capable of providing for people with more complex problems.
Mental Health Observatory Wolfson Research Institute, Durham University, Queens Campus, University Boulevard, Stockton on Tees, TS17 6BH
problem. If you think the figures do not represent your area accurately, look at the detail on the website. At present this is at www.amhmapping.org.uk/reports. Select option 4, Reporting autumn 2004 and spring 2006 and look for the tables with names starting ‘DMHB1’, selecting the year Spring 2006. Click on the button to get the report and look at the row covering your area. Click on the area's name and a more detailed presentation will appear. Repeat this until you see the individual services. If the service is missing, or inaccurately reported, tell its manager and ask them to make sure it is corrected in this year's mapping which should be happening through April and May 2007.
Figures 1 to 5. Difference between regional and overall national staff provision. Bars are shown above and below the national figure. (Strategic health authorities are ranked by total provision.)
0 0.5 1 1.5 2 2.5 3 3.5 4
East of England
East Midlands
Yorkshire and the Humber
West Midlands
South East Coast
North East
North West
South Central
South West
London
wte staff per 100k need weighted-population
5. Graduate Workers (1.3 per 100k working age adults nationally)
0 0.5 1 1.5 2 2.5 3
East of England
East Midlands
Yorkshire and the Humber
West Midlands
South East Coast
North East
North West
South Central
South West
London
wte staff per 100k need weighted-population
2. Psychotherapists (1.8 per 100k working age adults nationally)
For more detailed information, visit the Mental Health Observatory website
www.mentalhealthobservatory.org.uk
0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8
East of England
East Midlands
Yorkshire and the Humber
West Midlands
South East Coast
North East
North West
South Central
South West
London
wte staff per 100k need weighted-population
4. Assistant Psychologists (1.05 per 100k working age adults nationally)
0 2 4 6 8 10 12
East of England
East Midlands
Yorkshire and the Humber
West Midlands
South East Coast
North East
North West
South Central
South West
London
wte staff per 100k need weighted-population
1. Qualified clinical psychologists (7.0 per 100k working age adults nationally)
0 1 2 3 4 5 6
East of England
East Midlands
Yorkshire and the Humber
West Midlands
South East Coast
North East
North West
South Central
South West
London
wte staff per 100k need weighted-population
3. Counsellors (4.5 per 100k working age adults nationally)
3
References · Appleby, L. (2004). The National Service Framework for Mental Health-five
years on., Department of Health, London.
· Brugha TS ; Bebbington PE ; Singleton N ; Melzer D ; Jenkins R ; Lewis G; Farrell M ; Bhugra D ; Lee A ; Meltzer H. (2004) Trends in service use and treatment for mental disorders in adults throughout Great Britain. British Journal of Psychiatry 185: 378-384.
· DH (1999). National service framework for mental health: modern standards and service models. London, National Health Service Executive, Department of Health.
· Lavender, T. and Paxton, R. (2004). Estimating the Applied Psychology Demand in Adult Mental Health. British Psychological Society. St. Andrew's House, 48 Princess Road East, Leicester. ISBN 1 85433 411 5.
· Layard, R. E. (2004). The case for psychological treatment centres., London School of Economics.
· NICE 2002-2006 All the guidance quoted in this paragraph can be found online at: http://www.nice.org.uk/guidance/topic/behavioural
· Parry, G. D. (1996). NHS psychotherapy services in England: A strategic review., Department of Health, London.
Acknowledgements: The authors are grateful to Di Barnes and Steve Bradley of the Durham Mapping service for access to the data, and to Mike Slade and James Seward for comments.
Mapping service types included in the categories ‘Primary’, ‘Secondary’ and ‘Tertiary’ care. Table 1 distinguishes three care ‘levels’ at which psychological therapies would normally be found. The categorisation of service types for these levels is set out below, showing the total number of whole time staff reported nationally.
Primary care. These are services which would normally be located in the GP surgery and which, while often funded through the local PCT, can be accessed without referral through the local psychiatric services. Service Type Qualified clinical
psychologists Psychotherapists Counsellors Assistant
psychologists Graduate workers
Primary care mental health service 59 13 133 11 329 GP Counselling Service 14 7 245 3 2 Graduate Primary Care Worker 0 0 0 0 224 Secondary care. These are services to which individuals are normally referred by their GP or a social worker. Some have self referral routes, but in any case an initial assessment is usually undertaken to determine whether this level of mental health care is needed. These services would be provided in every National Service Framework local implementation team (LIT). Service Type Qualified clinical
psychologists Psychotherapists Counsellors Assistant
psychologists Graduate workers
Psychological Therapies and Counselling Services (Statutory sector) 803 143 664 86 76 Community Mental Health Teams 547 42 66 21 68 Early Intervention in Psychosis Service (commonly shared between several LITs)
81 4 2 34 0
Psychiatric Outpatient Care 48 7 6 6 0 Mental Health Crisis Intervention Service (direct access psychological therapy services available in a few places, not to be confused with crisis resolution/home treatment teams for acute psychiatric illness)
0 1 18 0 0
Tertiary care. These provide more specialised care, usually on the basis of referral from a secondary mental health services. Some of these services are commonly shared between two or more LITs. In all cases, psychological interventions are key components of the role. Service Type Qualified clinical
psychologists Psychotherapists Counsellors Assistant
psychologists Graduate workers
Specialist Psychotherapy Service 61 222 17 10 0 Other community and/or hospital professional team/specialist 61 23 40 16 8 Assertive Outreach Team 63 4 0 11 1 Regional medium secure unit 59 2 1 9 0 Local Medium Secure Service 51 3 0 17 0 Local Low Secure Service – High Dependency Unit 40 6 2 21 2 Personality Disorder Service 15 35 4 4 0 Local Psychiatric Intensive Care Unit 14 0 1 5 0 NHS 24-hour nurse staffed care 9 0 0 3 0 Other settings Psychological therapy staff are also found in a wide range of other settings. All of the following included psychological therapy staff in least one location. They have been grouped together here as they are not places to which individuals would normally be referred for psychological therapies.
Service Type Qualified clinical psychologists
Psychotherapists Counsellors Assistant psychologists
Graduate workers
Acute Inpatient Unit/ Ward 67 12 2 30 0 Advice and Information Service 2 2 69 0 0 Residential Rehabilitation Unit 26 2 0 11 0 Rehabilitation or Continuing Care Team 32 1 1 4 0 Crisis Resolution Team 30 1 1 6 0 Home/Community Support Service 3 6 20 0 0 Self-help and Mutual Aid Group 0 0 27 0 0 Carers Support Service 0 0 27 0 0 NHS Day Care Facility 14 2 5 3 0 Staff-facilitated Support Group 3 1 17 1 0 Community Forensic Services 16 0 0 1 0 Psychiatric liaison service 14 1 0 0 1 Prison Psychiatric Inreach Service 9 0 4 0 1 Mental Health Promotion Initiative 1 0 4 0 3 Criminal Justice Liaison and Diversion Service 5 0 0 1 0 Mother and Baby Facility 2 1 1 1 0 Gateway Worker 0 0 0 0 4 Carers Support Group 0 0 4 0 0 Service User Group/Forum 0 0 3 0 0 Advocacy Service 0 0 3 0 0 Short-term Breaks / Respite Care Service 0 0 3 0 0 Homeless Mental Health Service 2 0 1 0 0 Peri-natal Mental Illness Service 3 0 0 0 0 Crisis Accommodation 1 0 1 0 0
Annex 1.
Appendix 6.
Service change proforma
Appendix 6.
Service change proforma
Appendix 7.
Functional Somatic Symptoms in A and E (example of bid)
Functional Somatic Symptoms in A&E Executive Summary Due to the Governments recent focus on targets within A&E departments, greater scrutiny has taken place as to the type of patient who uses this NHS service. It has been concluded that a small proportion of patients attending A&E account for a large percentage of healthcare utilisation within the A&E department. This is also the case for other NHS services such as outpatient clinics and GP surgeries.
Included within these figures are repeat attenders who have no medical diagnosis or physical disease. These patients make catastrophic misinterpretations of their bodily sensations, believing that they indicate a physical disease, and therefore need investigating by their GP, A&E or other hospital clinics. Such patients are referred to as having Functional Somatic Symptoms (FSS), somatisization, hypochondriasis or health anxiety. In order to determine the extent of the problem within the Hillingdon borough, the Research and Development department at the Hospital funded an A&E based study. Results showed that over a six month period, 100 patients with no medical diagnosis attended A&E 595 times. 60% of patients were admitted to hospital at least once, for an average of 3 days, with a total of 439 days spent in hospital. Over 80% of patients breached the A&E 4 hour waiting target. Attendance at GP surgeries was not routinely monitored in the study, but other studies have shown that such patients attend their GP’s on average 11 times a year. This indicates in the region of 2,200 visits were made by patients with no medical diagnosis to Hillingdon GPs over the last year. The annual cost to the Hospital to assess, investigate and admit patients with FSS totals £189,854. The annual cost to the GP to assess and investigate patients with FSS totals £44,000. The total annual cost of FSS to both PCT and Hospital is £233,854 The cost effectiveness of cognitive behavioural therapy provided by clinical psychology has been proven. It is proposed that a full time clinical psychologist be employed specifically for assessing and treating patients with FSS, at a cost of £39,097 pa. Presented by: Dr Simon Dupont, Consultant Clinical Psychologist
Introduction By far the majority of patients attending their GP’s have a diagnosable condition which is treated successfully within the practice. A minority need secondary health care due to their illness, and are referred to hospital for either in- or out-patient treatment. A third group of patients have no medical diagnosable condition yet utilise the health care system repeatedly and are referred to as having Functional Somatic Symptoms (FSS). Functional Somatic Symptoms (FSS) are bodily sensations which do not result from physical disease but which patients respond to as if they do (Sharpe et al. 1992). FSS are typically characterized as unexplained pain, non-cardiac chest pain or abdominal disturbances and are associated with high rates of physical and psychiatric illness as well as social problems (Karlsson et al. 1997). FSS are generally understood to be caused by a catastrophic misinterpretation of bodily sensations (Mayou et al. 1995). GP surgeries, A&E departments and outpatient clinics have on average 40% of patients who have FSS (Mayou & Sharpe 1997, Williams et al. 2001, Murphy et al. 1999). As a group they are heavy users of the health service and cost the NHS millions of pound every year. Recent studies have shown the efficacy of psychological treatments amongst patients with FSS, with a resultant reduction in the patients’ distress, health care attendance record and associated costs (Mayou & Sharpe 1997, Lidbeck 1997, Hellman et al. 1990, Warwick et al. 1996, Clark et al, 1998, Bourman & Visser 1998, Speckens et al.1995). Before any such treatment could be implemented within Hillingdon, it was important to obtain detailed information as to the extend of the FSS situation in the Borough. Present situation In order to determine the extent of the problem in Hillingdon Hospital, a study was carried out specifically within the A&E department. All patients who had attended A&E four or more times in six months were investigated to see whether a diagnosis was made, and if not what care-pathway such patients followed. Results from the study show that in the 6 month period (Oct 02 to Apr 03), 26,967 patients attended A&E, of which 350 patients attended A&E four or more times. The majority of patients (37%) were medically diagnosed, and others were excluded from the study due to; a psychiatric history (13%); a drug / alcohol problem (4.5%); pregnancy (5.5%); NFA (3%) or; had died (8%). This resulted in 100 patients who had attended A&E four or more times in six months who had not received a medical diagnosis, and who could be classified has having FSS. It is important to keep in mind that this group excluded patients with an overt psychiatric illness / psychiatric history.
Care pathways for patients with FSS On average, the 100 patients with FSS made 6 visits to A&E. The total number of visits during the 6 months was 595. The results of this were:
• 60 % of patients were admitted to hospital at least once • 119 visits lead to hospital admission • 449 visits lead to discharge home / GP/ did not wait • 27 visits lead to outpatient appointment • 83 patients breeched the 4 hour A&E waiting time target
Each hospital admission lasted on average 3 days with a total of 439 days spent in hospital. In summary, during a 12 month period, 1190 A&E visits were made by 200 patients with no diagnosable condition, of whom 60% were admitted to hospital. Over of patients breeched the 4 hour A&E waiting target. Financial Implications for a full year 1190 visits to A&E, costing a minimum of £37 each £ 44,030 54 visits resulted in outpatient appointment, costing £56 each £ 3,024 238 visits resulted in hospital admission for approximately three days, costing £200 per day £142,800 Total Cost to Hospital of patients with FSS for one year £189,854 Impact of patients with FSS on GP practices Previous studies have showed that frequent attenders in A&E visit their GP on average 11 times during a year (Williams et al. 2001). Extrapolating from this data it can be assumed that in the Hillingdon borough 2,200 visits to the GP were made by patients with FSS. Using GP unit costs of £20 per consultation (PSSRU 2003), this equates to £44,000 per year excluding investigation costs. Total annual cost of FSS to both PCT and Hospital £233,854 If patients with FSS could be identified early in their trajectory through the health care system, they could be targeted for intervention to avert excessive costs and maladaptive utilisation which otherwise ensue.
Cost effectiveness of treatments The most effective treatment used for patients with FSS is Cognitive Behaviour Therapy (CBT) which aims to address patients thoughts, beliefs and underlying assumptions. This is particularly pertinent as FSS results from catastrophic misinterpretation of bodily sensations. Several randomised trials have shown CBT is both acceptable to patients with FSS and more effective than conventional medical care (Mayou & Sharpe 1997, Lidbeck 1997, Hellman et al. 1990, Warwick et al. 1996, Clark et al, 1998, Bourman & Visser 1998, Speckens et al.1995). CBT is a brief, structured psychological treatment offered either in a group or individual setting. On average, 8 to 10 sessions are needed, although interventions as minimal as 5 sessions are effective, with benefits sustained at 12 months (Kroenke & Swindle 2000). Smith et al. (1995) found a reduction in medical costs of over 30% if patients with medically unexplained symptoms were dealt with using more psychologically orientated treatments. Matalon et al. (2002) found the average yearly costs of frequent attenders was $4035 per person which reduced to $1161 following short term intervention. These costs included reductions in emergency room visits, hospital admissions and decreasing the number of tests performed. Clinical Psychology Proposal As part of the above study, a number of patients with FSS were invited to discuss their situation with a clinical psychologist. The majority of interviewees acknowledged their mental rather than physical state had the greater influence over their health seeking behaviour. When asked directly, 80% stated that a psychological treatment would reduce their attendance at A&E. It is proposed that a clinical psychology service be set up to assess and treat patients attending A&E with FSS. The most effective system for such a service would be in close cooperation with the health care staff at A&E. Following exclusion of other diagnoses, A&E staff could inform the proposed clinical psychologist, who could participate in a joint discussion with the patient and medical staff. This would allay any fears regarding a physical cause, and enable the patient to make a smooth transition from a physical to a psychological focus.
Based on the annual numbers of patients with FSS at Hillingdon Hospital, the following service would be needed: Assessment 4 patients (on average) per week: 2 hours per week Individual Treatment 200 patients per year 9 sessions per patient (on average) 1800 hours per year: 36 hours per week Taking into account the necessary liaison with A&E staff, the mental health liaison service and GP’s, along with supervision and research, the total input required would amount to one full time A Grade clinical psychologist (at spine point 35) Total costs (including on-costs) £39,097 References
Bouman TK, & Visser S (1998): Cognitive and behavioural treatment of hypochondriasis. Psychother Psychosom, 67:214-221.
Clark DM, Salkovskis PM, Hackman A, Wells A, Fennel (1998): Two psychological treatments for hypochondriasis. A randomised controlled trial. British Journal of Psychiatry;173:218-225. Hellman CJC, Budd M, Borysenko J, McClelland DC, Benson H (1990): A study of the effectiveness of two group behavioral medicine interventions for patients with psychosomatic complaints. Behav Med, 16:165-173. Karlsson, H., Lehtinen, V. & Joukamaa, M. (1997). Frequent attender profiles: different clinical subgroups among frequent attender patients in primary care. Journal of Psychosomatic Research, Vol 42, 157-166 Kroenke, K and Swindle, R (2000). Cognitive-behavioural therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychotherapy and Psychosomatics 69(4): 205-15. Lidbeck J (1997): Group therapy for somatization disorders in general practice: Effectiveness of a short cognitive-behavioural treatment model. Acta Psychiatr Scand 96:14-24.
Matalon,A., Nahmani,T., Rabin,S. and Hart,J (2002) A short-term intervention in a multidisciplinary referral clinic for primary care frequent attenders. Family Practice. Vol. 19 (3). pp. 251-256.
Mayou, R., Bass.,C. and Sharpe. M. (1995). Treatment of functional somatic symptoms. Oxford: Oxford University Press. Mayou, R. and Sharpe, M. (1997). Treating medically unexplained physical symptoms: Effective interventions are available. British Medical Journal. Vol. 315. pp. 561-562.
Murphy, A.W., Leonard, C., Plunkett, P.K., Brazier, H., Conroy, R., Lynam, F & Bury, G. (1999). Characteristics of attenders and their attendances at an urban accident and emergency department over a one year period. Journal of Accident & Emergency Medicine, Vol (16), 425-427.
Personal Social Services Research Unit (2003). Unit Costs of Health and Social Care. www.pssru.ac.uk
Smith, G., Rost, K, and Kashner, T. (1995). A trial of the effect of a standardised psychiatric consultation on health outcomes and costs in somatizing patients. Archives of General Psychiatry. Vol 52. pp.238-243.
Sharpe, M., Peveler, R. & Mayou, R. (1992). The psychological treatment of patients with functional somatic symptoms: A practical guide. Journal of Psychosomatic Research, Vol 36 (6), 515-529.
Speckens, A., Van Hemert,A., Spinhoven, P., and Hawton, K (1995). Cognitive behavioural therapy for medically unexplained physical symptoms:a randomised controlled trial. British Medical Journal. Vol. 311. pp 1328-1332.
Warwick MCH, Clark DM, Cobb AM, Salkovskis PM (1996): A controlled trial of cognitive behavioural treatment of hypochondriasis. Brithish Journal of Psychiatry 169:189-195. Williams, E.R.L, Guthrie, E., Mackway-Jones, K., James, M., Tomenson, B., Eastham, J & McNally, D. (2001). Psychiatric status, somatisation, and health care utilization of frequent attenders at the emergency department. A comparison with routine attenders. Journal of Psychosomatic Research, Vol (50) 161-167.
Appendix 8.
Handling uncertainty in economic evaluations of healthcare interventions
1999;319;635-638 BMJ Andrew H Briggs and Alastair M Gray
interventionshealthcareuncertainty in economic evaluations of
Methods in health service research: Handling
http://bmj.com/cgi/content/full/319/7210/635Updated information and services can be found at:
These include:
References
http://bmj.com/cgi/content/full/319/7210/635#otherarticles8 online articles that cite this article can be accessed at:
http://bmj.com/cgi/content/full/319/7210/635#BIBLThis article cites 9 articles, 2 of which can be accessed free at:
Rapid responses http://bmj.com/cgi/eletter-submit/319/7210/635
You can respond to this article at:
serviceEmail alerting
the top left of the article Receive free email alerts when new articles cite this article - sign up in the box at
Notes
To order reprints follow the "Request Permissions" link in the navigation box
http://resources.bmj.com/bmj/subscribers go to: BMJTo subscribe to
on 15 November 2007 bmj.comDownloaded from
24 Hansson L, Lindholm LH, Niskanen L, Lanke J, Hedner T, Niklason A, etal. Effect of angiotensin-converting enzyme inhibition compared withconventional therapy on cardiovascular morbidity and mortality inhypertension: the captopril prevention project (CAPPP). Lancet 1999;353:611-5.
25 SHEP Cooperative Research Group. Prevention of stroke by antihyper-tensive drug treatment in older persons with isolated systolichypertension. Final results of the systolic hypertension in the elderly pro-gram (SHEP). JAMA 1991;265:3255-64.
26 Thijs L, Fagard R, Lijnen P, Staessen J, Van Hoof R, Amery A. Ameta-analysis of outcome trials in elderly hypertensives. J Hypertens1992;10:1103-9.
27 Messerli FH, Grossman E, Goldbourt U. Are ß-blockers efficacious asfirst-line therapy for hypertension in the elderly? A systematic review.JAMA 1998;279:1903-7.
28 Medical Research Council’s General Practice Research Framework.Thrombosis prevention trial: randomised trial of low-intensity oralanticoagulation with warfarin and low-dose aspirin in the primaryprevention of ischaemic heart disease in men at increased risk. Lancet1998;351:233-41.
29 Downs JR, Clearfield M, Weis S, Whitney E, Shapiro DR, Beere PA, et al.Primary prevention of acute coronary events with lovastatin in men andwomen with average cholesterol levels. Results of AFCAPS/TexCAPS.JAMA 1998;279:1615-22.
(Accepted 11 August 1999)
AppendixMaterial for patientsx Patient information booklet: “Understanding HighBlood Pressure”x Fact sheets:
Selfhelp measuresAntihypertensive drugs
Blood pressure measurementReducing dietary saltBlood pressure and kidney disease
x Diet sheet: “Healthy Eating”Available from the British Hypertension Society Infor-mation Service, Blood Pressure Unit, St George’s Hos-pital Medical School, Cranmer Terrace, London SW170RE (tel: 0181 725 3412; fax: 0181 725 2959;www.bhsinfo.hyp.ac.uk (for information service);website: www.bhs.hyp.ac.uk)
Material for doctorsx Blood Pressure Measurement—Recommendations of theBritish Hypertension Society. 3rd edition, 1997. (Edited byE O’Brien et al; price £4.95.)x BHS/BMJ. Recommendations for Blood PressureMeasurement. CD Rom, price £58.75.Available from BMJ Publications or the BMJ Book-shop, BMA House, London WC1H 9JR (tel: 0171 3836244; fax: 0171 383 6455; [email protected]).x The Joint British Societies’ Cardiac Risk Assessorcomputer program and copies of the Joint BritishSocieties coronary heart disease risk assessment chartcan be downloaded from the British HypertensionSociety website (www.bhs.hyp.ac.uk).
Methods in health service researchHandling uncertainty in economic evaluations ofhealthcare interventionsAndrew H Briggs, Alastair M Gray
The constant introduction of new health technologies,coupled with limited healthcare resources, hasengendered a growing interest in economic evaluationas a way of guiding decision makers towards interven-tions that are likely to offer maximum health gain. Inparticular, cost effectiveness analyses—which compareinterventions in terms of the extra or incremental costper unit of health outcome obtained—have becomeincreasingly familiar in many medical and health serv-ice journals.
Considerable uncertainty exists in regard to valideconomic evaluations. Firstly, several aspects of theunderlying methodological framework are still beingdebated among health economists. Secondly, there isoften considerable uncertainty surrounding the data,the assumptions that may have been used, and how tohandle and express this uncertainty. In the absence ofdata at the patient level sensitivity analysis is commonlyused; however, a number of alternative methods ofsensitivity analysis exist, with different implications forthe interval estimates generated (see box). Finally, thereis a substantial amount of subjectivity in presentingand interpreting the results of economic evaluations.
The aim of this paper is to give an overview ofthe handling of uncertainty in economic evaluationsof healthcare interventions.3 It examines how ana-lysts have handled uncertainty in economic evalua-
tion, assembled data on the distribution and varianceof healthcare costs, and proposed guidelines toimprove current practice. It is intended as a con-tribution towards the development of agreed guide-lines for analysts, reviewers, editors, and decisionmakers.4-7
Summary points
Economic evaluations are beset by uncertaintyconcerning methodology and data
A review of 492 articles published up toDecember 1996 found that a fifth did not attemptany analysis to examine uncertainty
Only 5% of these studies reported some measureof cost variance
Closer adherence to published guidelines wouldgreatly improve the current position
Use of a methodological reference case willimprove comparability
Education and debate
This is the lastof four articles
Health EconomicsResearch Centre,Institute of HealthSciences, Universityof Oxford, OxfordOX3 7LFAndrew H Briggstraining fellowAlastair M GrayreaderCorrespondence to:A H [email protected] editor:Nick Black
BMJ 1999;319:635–8
635BMJ VOLUME 319 4 SEPTEMBER 1999 www.bmj.com
on 15 November 2007 bmj.comDownloaded from
Nature of the evidenceA structured review examined the methods used tohandle uncertainty in the empirical literature, and thiswas supplemented by a review of methodological arti-cles on the specific topic of confidence interval estima-tion for cost effectiveness ratios. The first step in theempirical review was a search of the literature to iden-tify published economic evaluations that reportedresults in terms of cost per life year or cost per qualityadjusted life year (QALY). This form of study was cho-sen as the results of these studies are commonlyconsidered to be sufficiently comparable to be groupedtogether and reported in cost effectiveness leaguetables.
Searches were conducted for all such studiespublished up to the end of 1996 using Medline,CINAHL, Econlit, Embase, the Social Science CitationIndex, and the economic evaluation databases of theCentre for Reviews and Dissemination at York Univer-sity and the Office of Health Economics andInternational Federation of Pharmaceutical Manufac-turers’ Association. Articles identified as meeting thesearch criteria were reviewed by using a form designedto collect summary information on each study, includ-ing the disease area, type of intervention, nature of thedata, nature of the results, study design, and the meth-ods used to handle uncertainty. This information wasentered as keywords into a database to allow interroga-tion and cross referencing of the database by category.
This overall dataset was then used to focus on twospecific areas of interest, using subsets of articles toperform more detailed reviews. Firstly, all British stud-ies were identified and reviewed in detail, and
information on the baseline results, the methodsunderlying those results, the range of results represent-ing uncertainty, and the number of previouslypublished results quoted for purposes of comparisonwere entered on to a relational database. By matchingresults by the methods used in a retrospective applica-tion of a methodological “reference case” (box),5 a sub-set of results with improved comparability wasidentified, and a rank ordering of these results was thenattempted. Where a range of values accompanied thebaseline results, the implications of this uncertainty forthe rank ordering was also examined.
Secondly, all studies that reported cost data at thepatient level were identified and reviewed in detail withrespect to how they had reported the distribution andvariance of healthcare costs. Thirdly, and in parallelwith the structured review, five datasets of patient levelcost data were obtained and examined to show how thehealthcare costs in those data were distributed and toelucidate issues surrounding the analysis and presenta-tion of differences in healthcare cost.
Economic analyses are not simply concerned withcosts, but also with effects, with the incremental costeffectiveness ratio being the outcome of interest inmost economic evaluations. Unfortunately, ratio statis-tics pose particular problems for standard statisticalmethods. The review examines a number of proposedmethods that have appeared in the recent literature forestimating confidence limits for cost effectiveness ratios(when patient level data are available).
FindingsTrends in economic evaluationsA total of 492 articles published up to December 1996were found to match the search criteria and were fullyreviewed. The review found an exponential rate ofincrease in published economic evaluations over timeand an increasing proportion reporting cost perQALY results. Analysis of the articles in terms of themethod used by analysts to handle uncertainty showsthat the vast majority of studies (just over 70%) usedone way sensitivity analysis methods to quantify uncer-tainty (see box 1). Of some concern is that almost 20%of studies did not attempt any analysis to examineuncertainty, although there is weak evidence to showthat this situation has improved over time.
Box 1: Sensitivity analysis
Sensitivity analysis involves systematically examiningthe influence of uncertainties in the variables andassumptions employed in an evaluation on theestimated results. It encompasses at least threealternative approaches.1
• One way sensitivity analysis systematically examinesthe impact of each variable in the study by varying itacross a plausible range of values while holding allother variables in the analysis constant at their “bestestimate” or baseline value.• Extreme scenario analysis involves setting eachvariable to simultaneously take the most optimistic(pessimistic) value from the point of view of theintervention under evaluation in order to generate abest (worst) case scenario.
Of course, in real life the components of anevaluation do not vary in isolation nor are theyperfectly correlated, hence it is likely that one waysensitivity analysis will underestimate, and extremescenario analysis overestimate, the uncertaintyassociated with the results of economic evaluation.• Probabilistic sensitivity analysis, which is based on alarge number of Monte Carlo simulations, examinesthe effect on the results of an evaluation when theunderlying variables are allowed to varysimultaneously across a plausible range according topredefined distributions. These probabilistic analysesare likely to produce results that lie between theranges implied by one way sensitivity analysis andextreme scenario analysis, and therefore may producea more realistic estimate of uncertainty.2
The “reference case”
The Panel on Cost-Effectiveness in Health andMedicine, an expert committee convened by the USPublic Health Service in 1993, proposed that allpublished cost effectiveness studies contain at least oneset of results based on a standardised act of methodsand conventions—a reference case analysis—whichwould aid comparability between studies. The featuresof this reference case were set out in detail in thepanel’s report.5
The current review used this concept retrospectively,selecting for comparison a subset of results whichconformed to the following conditions:• An incremental analysis was undertaken;• A health service perspective was employed; and• Both costs and health outcomes were discounted atthe UK Treasury approved rate of 6% per annum.
Education and debate
636 BMJ VOLUME 319 4 SEPTEMBER 1999 www.bmj.com
on 15 November 2007 bmj.comDownloaded from
Handling of uncertaintyOf the 492 studies, 60 reported results for the UnitedKingdom. From these, 548 baseline results wereextracted for different subgroups. The importance ofseparate baselines for different subgroups of patients isshown in the results of an evaluation of an implantablecardioverter defibrillator where the average cost perlife year saved across the whole patient group—£57 000—masks important differences betweenpatients with different clinical characteristics.8 Forpatients with a low ejection fraction and induciblearrhythmia that is not controlled by drugs, the costeffectiveness of the device is £22 000 per year of lifesaved. By contrast, the use of the device in patients withhigh ejection fraction and inducible arrhythmia that iscontrolled by drugs is associated with an incrementalcost effectiveness of around £700 000 per year of lifesaved.
The 548 baseline results used no fewer than 106different methodological scenarios, and consequentlya “reference case” methodological scenario wasapplied retrospectively to each article; this resulted in atotal of 333 methodologically comparable baselineresults. These results were converted to a common costbase year and ranked to give a comprehensive “leaguetable” of results for the United Kingdom. Of the 333results, 61 reported an associated range of high andlow values to represent uncertainty. Alternativerankings based on the high or low values from thisrange showed that there could be considerable disrup-tion to the ranked order based on the baseline pointestimates only. This is illustrated by figure 1, whichshows the rank ordering of these 61 results by theirbaseline values and by the highest value from theirrange. This analysis of UK studies reporting the rangesof sensitivity analyses raises the further concern thatthe median number of variables included in the sensi-tivity analysis was just two. Therefore, the ranges of
values shown in figure 1 are likely to be less than if acomprehensive analysis of all uncertain variables hadbeen conducted. Clearly, this would further increasethe potential for the rank order to vary depending onthe value chosen from the overall range.
Cost data at patient levelOf the 492 studies on the database, only 53 had patientlevel cost data and just 25 of these reported somemeasure of cost variance. Eleven reported only ranges,which are of limited usefulness in quantifying variance.Five articles gave a standard error, seven a standarddeviation, and only four studies ( < 1%) had calculated95% confidence intervals for cost.
In the five datasets of cost at the patient level, analy-sis indicated that many cost data were substantiallyskewed in their distribution. This may cause problemsfor parametric statistical tests for the equality of twomeans. One method for dealing with this is totransform the data to an alternative scale ofmeasurement—for example by means of log, squareroot, or reciprocal transformations. However, ouranalysis of these data indicated that although atransformation may modestly improve the statisticalsignificance of observed cost differences or may reducethe sample size requirements to detect a specifieddifference, it is difficult to give the results of atransformed or back transformed scale a meaningfuleconomic interpretation, especially if we intend to usethe cost information as part of a cost effectiveness ratio.It would be appropriate to use non-parametricbootstrapping to test whether the sample size of astudy’s cost data is sufficient for the central limittheorem to hold, and to base analyses on mean valuesfrom untransformed data.
Estimating confidence intervals for costeffectiveness ratiosFinally, our review identified a number of differentmethods for estimating confidence intervals for costeffectiveness ratios that have appeared in the recentliterature,9-14 and we applied each of these methods toone of the five datasets listed above.15 These differentmethods produced very different intervals. Examina-tion of their statistical properties and evidence fromrecent Monte Carlo simulation studies14 16 suggests thatmany of these methods may not perform well in somecircumstances. The parametric method based onFieller’s theorem and the non-parametric approach of
Cost
effe
ctiv
enes
s (£
)
0 1
2 7 16 24 26 37 44 59 60 61
3 4 5 6 8 9 10 11 12 13 14 15 17 1819
20 21 22 23 25
27
28 2930
3132 33
34
35 36
38
3940
41 42 43 45 46 47 48 49
50 51 52 53
54
55
56 5758
100 000
150 000
200 000
250 000
300 000
350 000
400 000
50 000
Rank order
Cost
effe
ctiv
enes
s (£
)
0 1
2 7 1624 37 4459 60 61
3 45 689 1011 12 1314 15 171819
20 2122 2325
27
28 2930
31 3334
35 36
38
3940
42 43 45 46 47 48 49
50 51 52 53
54
55
565758
100 000
150 000
200 000
250 000
300 000
350 000
400 000
50 000
26
3241
Fig 1 Alternative rank orderings of 61 British cost effectivenessresults by baseline value (above) and highest sensitivity analysisvalue (below)
Initial cost effectiveness and cost utility studies: 368
Studies reporting patient-level cost data: 41
Studies reporting some measure of cost variance: 20
Standarderror 3
Standarddeviation 3
95%confidence
interval3
Range6
2
1Inter-
quartilerange
2
Fig 2 The handling of cost variance by studies reporting patient levelcost data
Education and debate
637BMJ VOLUME 319 4 SEPTEMBER 1999 www.bmj.com
on 15 November 2007 bmj.comDownloaded from
bootstrapping have been shown to produce consist-ently the best results in terms of the number of times,in repeated sampling, the true population parameter iscontained within the interval.14 16
RecommendationsUncertainty in economic evaluation is often handledinconsistently and unsatisfactorily. Recently publishedguidelines should improve this situation, but weemphasise the following:x Ensure that the potential implications of uncer-tainty for the results are considered in all analyses;x When reporting cost and cost effectiveness infor-mation, make more use of descriptive statistics. Intervalestimates should accompany each point estimatepresented;x Sensitivity analyses should be comprehensive intheir inclusion of all variables;x Cost and cost effectiveness data are often skewed.Significance tests may be more powerful on atransformed scale, but confidence interval should bereported on the original scale. Even when data areskewed, economic analyses should be based on meansof distributions;x Where patient level data on both cost and effect areavailable, the parametric approach based on Fieller’stheorem or the non-parametric approach of boot-strapping should be used to estimate a confidenceinterval for the cost effectiveness ratio;x When comparing results between studies, ensurethat they are representative;x Using a methodological reference case whenpresenting results will increase the comparability ofresults between studies.
This article is adapted from Health Services Research Methods:A Guide to Best Practice, edited by Nick Black, John Brazier, RayFitzpatrick, and Barnaby Reeves, published by BMJ Books.
Competing interests: None declared.
1 Briggs AH. Handling uncertainty in the results of economic evaluation.London: Office of Health Economics,1995. (OHE briefing paper No 32.)
2 Manning WG, Fryback DG, Weinstein MC. Reflecting uncertainty in cost-effectiveness analysis. In: Gold MR, Siegel JE, Russell LB, Weinstein MC,eds. Cost-effectiveness in health and medicine. New York: Oxford UniversityPress, 1996:247-75.
3 Briggs AH, Gray AM. Handling uncertainty when performing economicevaluations of health care interventions: a systematic review with specialreference to the variance and distributional form of cost data. HealthTechnol Assess 1999;3(2).
4 Drummond MF, Jefferson TO. Guidelines for authors and peer reviewersof economic submissions to the BMJ. BMJ 1996;313:275-83.
5 Gold MR, Siegel JE, Russell LB, Weinstein MC, eds. Cost-effectiveness inhealth and medicine. New York: Oxford University Press, 1996.
6 Canadian Coordinating Office for Health Technology Assessment.Guidelines for the economic evaluation of pharmaceuticals: Canada. 2nd ed.Ottawa: CCOHTA, 1997.
7 Drummond MF, O’Brien B, Stoddart GL, Torrance GW. Methods for theeconomic evaluation of health care programmes. 2nd ed. Oxford: Oxford Uni-versity Press, 1997.
8 Anderson MH, Camm AJ. Implications for present and futureapplications of the implantable cardioverter-defibrillator resulting fromthe use of a simple model of cost efficacy. Br Heart J 1993;69:83-92.
9 O’Brien BJ, Drummond MF, Labelle RJ, Willan A. In search of power andsignificance: issues in the design and analysis of stochastic cost-effectiveness studies in health care. Med Care 1994;32:150-63.
10 Wakker P, Klaassen M. Confidence intervals for cost-effectiveness ratios.Health Econ 1995;4:373-82.
11 Van Hout BA, Al MJ, Gordon GS, Rutten FF. Costs, effects and C/E-ratiosalongside a clinical trial. Health Econ 1994;3:309-19.
12 Chaudhary MA, Stearns SC. Estimating confidence intervals forcost-effectiveness ratios: an example from a randomized trial. Stat Med1996;15:1447-58.
13 Briggs AH, Wonderling DE, Mooney CZ. Pulling cost-effectiveness analy-sis up by its bootstraps: a non-parametric approach to confidence inter-val estimation. Health Econ 1997;6:327-40.
14 Polsky D, Glick HA, Willke R, Schulman K. Confidence intervals for cost-effectiveness ratios: a comparison of four methods. Health Econ1997;6:243-52.
15 Fenn P, McGuire A, Phillips V, Backhouse M, Jones D. The analysis of cen-sored treatment cost data in economic evaluation. Med Care1995;33:851-63.
16 Briggs AH, Mooney CZ, Wonderling DE. Constructing confidence inter-vals around cost-effectiveness ratios: an evaluation of parametric andnon-parametric methods using Monte Carlo simulation. Stat Med (inpress).
How the defibrillator saved a patient’s life
Initially it was quite a struggle just getting the partners to agreethat purchasing a defibrillator would benefit the practice. We didnot even have to pay as the Friends of the Health Centre kindlyraised the money.
The equipment was installed in the nurses’ treatment room andgradually gathered dust. “Does the defibrillator work?” and “I betthe batteries aren’t charged” were some of the jocular commentsfrom the partners.
We had a couple of attempts at resuscitation, the equipmentworked well, but unfortunately the patient did not survive. It wasdecided to hold a training day on resuscitation for the nurses. Thealarms sounded, I rushed to the treatment room only to find thatit was a mock emergency.
In the middle of a busy afternoon surgery the same day thealarm went off again and there was an urgent telephone call. WhenI arrived several partners and nursing staff were in the middle offull cardiopulmonary resuscitation. The patient had been sentdown from the doctor’s surgery to the treatment room for anelectrocardiogram as he had chest pain and had collapsed. Thetracing showed ventricular fibrillation. Bring out the defibrillator!Charge to 200 deliver shock! It’s just like ER! Unfortunately, thepatient was unstable; there were further episodes of ventricularfibrillation and further defibrillation. As a former medical registrarit started to flood back. We need lignocaine, but what is the dose? Itwas like the blind leading the blind.
Four cardioversions later the ambulance arrived. Was he stableenough to transfer to our local hospital? It was decided that Ishould accompany the patient in the ambulance; this was just aswell as he had two further arrests in the ambulance requiringdefibrillation. An emergency stop as a bus pulled out in front ofus hurled the patient forward into my lap. But he survived, and ashe was only 40 with two children he was eternally grateful.
What have we learnt? Clearly, we need more training inresuscitation. We now have a very persuasive argument for thepartner who said that we did not need a defibrillator as theambulance always carries one. Our Friends of the Health Centreare now saving to buy us a better model that can record thecardiac rhythm through the paddles.
Alexander Williams, general practitioner, Exeter
We welcome articles up to 600 words on topics such as Amemorable patient, A paper that changed my practice, My mostunfortunate mistake, or any other piece conveying instruction,pathos, or humour. If possible the article should be supplied on adisk. Permission is needed from the patient or a relative if anidentifiable patient is referred to. We also welcome contributionsfor “Endpieces,” consisting of quotations of up to 80 words (butmost are considerably shorter) from any source, ancient ormodern, which have appealed to the reader.
Education and debate
638 BMJ VOLUME 319 4 SEPTEMBER 1999 www.bmj.com
on 15 November 2007 bmj.comDownloaded from
Appendix 9.
Examples of Excellence, achievement and innovation in the psychology services of NHS Argyll and Clyde
Examples of Excellence, Achievement and Innovation in the Psychology Services of NHS Argyll & Clyde
Services to Adults with Mental Health Problems Dissemination of Psychological Knowledge and Skills
Senior psychologists in Renfrewshire have been co-founders, with other professional colleagues, of the now Argyll and Clyde wide Psychological Therapies and Interventions Group (PTIG). This is a multidisciplinary group of senior mental health specialists in psychological therapies. The group’s remit is to support the development and clinical governance of enhanced skills in psychological therapies and psychosocial interventions among other staff.
There have been a number of initiatives that psychologists in Renfrewshire have
led, or co-led with other colleagues, aimed at disseminating knowledge of psychological therapies among other mental health disciplines.
For instance, for several years the Adult Psychology Department in Renfrewshire
has worked closely with colleagues from the Psychotherapy Department at Dykebar Hospital to run a multi-disciplinary psychological therapies journal club/ case discussion forum on a monthly basis.
These two services have also jointly staged a number of training seminars for a
range of disciplines, including junior and consultant psychiatrists. Moreover, the departments also co-operate closely in the provision of supervision in psychological therapies for SHOs and SPRs in psychiatry.
More recently, the Inverclyde Psychology Department has started hosting a
regular Psychological Therapy Journal Club since April 2005. This has become an effective multi-professional forum for discussions on issues related to psychological interventions and therapies.
Contributions to Multi-Disciplinary Working in AMH
Over the past four years the consultant clinical psychologist in the Inverclyde Community Mental Health and Resource Team has made important contributions to the management of the Team as well as to its clinical services. Besides playing a key role as a senior member of the Team Management Co-ordinating Group, she has overall responsibility for the groupwork of the Team.
Argyll psychologists have also, over time, played leading roles in facilitating multi-
disciplinary service initiatives. These have included an art therapy project, an improved care pathway for mothers with post-natal depression and new approaches to the delivery of psychotherapies across Argyll and Bute.
Innovative Practices in AMH Clinical Work
An example of innovative clinical practice is the work of the Inverclyde CMHRT psychologist in developing and auditing a psychosocial family intervention group
programme for patients suffering from schizophrenia. This ongoing programme has proved to be popular with families and has become an important resource for the training of team members in psychological approaches.
In Argyll, the nature of the extensive rural geography has led clinical
psychologists to alter their practice by incorporating occasional ‘telemedicine’ exchanges with patients on the islands. More commonly, they have employed extended telephone follow-up patient consultations to monitor patient progress, ensure adherence to treatment plans and resolve difficulties with the latter.
Services to People with Learning Disabilities
Service-Related
Establishment of Autistic Spectrum Disorders (ASD) clinical psychology service extending between child and adult services and including adults with autism and Asperger’s syndrome. As well as facilitating more integrative approaches with mainstream services, this innovative service refocused attention upon specialist services that extend through the Learning Disability boundary to include non-LD patients.
Set up NHS Argyll & Clyde wide LD clinical psychology community forensic
service. This enabled specialist service input to this group, particularly in the area of risk assessment and court advisement. It simultaneously took a considerable pressure off the generic services, which previously dealt with these referrals.
The Head of LD Psychology undertook a lead role in piloting the initial joint Community Learning Disability Team between NHS and Renfrewshire Social Work and thereafter in establishing the three current CLDTs. This included a research project that led to a publication comparing the community services in Renfrewshire with those in Lothian. Clinical
Developed Self-Report Depression Scale for adults with mild and moderate learning disability that is now in use internationally.
Completed assessments of the Quality of Life of long stay LD, MH and Elderly
inpatients across Renfrewshire and Inverclyde. This major clinical project, undertaken in 2003, prepared the way for improved care standards for inpatients that could also be implemented in a cost-effective way.
Services to Children & Adolescents
In the late 1990s Child and Adolescent Psychology Services in Renfrewshire and
Inverclyde were at the forefront of developing the Autistic Spectrum Disorder Assessment Service. Until recently this was a uniquely psychology service but has now become a multi-disciplinary service that psychology continues to contribute to as a key discipline.
In recent years C&A Psychology staff have established close liaison links with
paediatric services and psychology continues to be the only mental health discipline to provide regular input to these services. In particular, staff have regular ongoing involvement with the Cystic Fibrosis Team and the Diabetes Team.
In 2001 clinical psychologists became the first staff in the CAMHS to gain a
recognised qualification in family therapy and subsequently developed a Family Therapy assessment and treatment service that continues to this day. In association with this, the lead consultant psychologist offers clinical supervision to trainees and to those from other disciplines who wish to develop their skills in this area of clinical work.
Neuropsychological Services Inverclyde
Over the past 4 years, colleagues in Inverclyde have successfully developed Ravenscraig Neuropsychology into a well-respected specialist service in high demand locally. Neuropsychology input to both Adult Mental Health, as well as Older People Mental Health, has proven to be invaluable to these two specialties. Medical and psychiatric colleagues enormously value the expert diagnostic skills of the local consultant clinical neuropsychologist, particularly in relation to assessment of very complex neurological or neuropsychiatric cases.
Another aspect of the achievement of the Inverclyde Neuropsychology Service is
the major research study conducted by the consultant neuropsychologist into the population of head-injured patients in Inverclyde. This ongoing project has yielded very significant results which are likely to have important implications for service development, not only locally but also area-wide and possibly nationally.
Lomond and Argyll
Another consultant clinical psychologist specialising in neuropsychology from the Lomond Psychology Department has played a leading role in establishing and developing the Lomond and West Dunbartonshire Brain Injury Team. This service was nominated for, and reached the finals of, the NHS/Daily Record Scottish Health Awards of 2004. This is a Joint Futures service that is jointly funded by NHSGG, NHSA&C, West Dunbartonshire Council and Argyll & Bute Council.
Related to the above, a new post of assistant psychologist, to provide a variety of
functions (assessment, designing interventions, research and training) within the areas of traumatic brain injury and alcohol related brain damage, has just been established. This unique post will be hosted within Social Services and will
provide a stepping stone for psychology graduates seeking entry into doctoral courses in clinical psychology.
The consultant clinical neuropsychologist from the Lomond Department enjoyed
recent success in obtaining, jointly with a consultant psychiatrist colleague, a CSO research grant to conduct a RCT investigating the value of aromatherapy in the management of disruptive behaviour among elderly patients with dementia. The results indicated significant effects and these were published in two articles in respected international peer reviewed journals, one of which is cited in the Cochrane Review. Outline permission has also been given for further funding for a multi-centre trial.
Physical Health Psychology
A unique initiative within NHS A&C that has the potential to positively influence CHD healthcare across NHS Scotland is the ‘Heart in Mind’ project, led by a clinical psychologist attached to the Cardiac Rehabilitation team in the Royal Alexandra Hospital, Paisley. This project is jointly sponsored and supported by Health Scotland and Have-a-Heart Paisley. It entails the development and evaluation of a training programme and associated training materials to teach all professional groups with a role in cardiac care to incorporate psychological understanding, assessment and interventions in their day-to-day work.
One of the Argyll psychologists has also recently been involved in an innovative
project providing psychology input to a Rehabilitation Group for patients with Chronic Obstructive Pulmonary Disease (COPD). A physiotherapist and nurse specialist set up this currently time-limited service. Funding is being sought to continue to provide the service.
Appendix 10.
Briefing about the economic impact of Early Intervention Services Worcestershire Early Intervention Service Evaluation Summary
Worcestershire Early Intervention Service Evaluation Summary
October 2006
The early intervention service in Worcestershire provides support and care for 14 to 35
year olds who have experienced a first episode of psychosis within the past year and
who live within the County of Worcestershire. The service also carefully monitors those
with suspected psychosis. The service offers open access. Individuals or family members
can self refer for advice and support. Inappropriate referrals are signposted on to
other more appropriate agencies.
The service offers recovery based interventions to individuals and families in their home
or a place of their choice. Support may include information about psychosis, medication
and specialist psychological support and counselling for the young person and their
family. The service also offers regular fun social and leisure activities to boost
confidence and encourage individuals to mix and socialise. The service links with a range
of statutory and non statutory agencies including Connexions, youth services, drug and
alcohol services, housing, local schools and colleges, and work projects to assist the
individual in returning to education or work and in addressing other needs. The service
works closely with their three local CAMHS teams, has a strong transition protocol and
has a jointly appointed dedicated worker to support the under 18 years. Since 1st
October 2006, the team also links with a Countywide research driven early detection
team (EDIE2) offering Cognitive Behavioural Therapy intervention to individuals who are
deemed either at high risk or who are suspected first episode cases.
The team receives regular positive feedback from individuals and families via annual EI
service satisfaction audit questionnaire sent to individuals and their carers. Recent
comments include:
‘The support, care, help, guidance and counselling has been excellent for my son,
my wife and myself in understanding this health condition’
‘We feel that the care (our relative) has received from the EIS has been excellent
and we can find no fault at all in it, only professional, quality care from everyone’
‘The service has been absolutely brilliant- a ‘life saver’ for both of us.The team is
wonderful and absolutely essential’
‘I am highly impressed and extremely grateful for the treatment and care my son
has received from the EIS. Their care has been second to none’
The service has been successful in engaging individuals with the service and in reducing
the need for hospital admission, use of the Mental Health Act, substance use and suicide
attempts while also helping many individuals return to school, college or work or pursue
plans to travel or move to independent accommodation. Formal evaluation data from
service audit of case notes and medical records and routine user and carer satisfaction
returns are reported below together with appropriate comparative data where this is
available.
Impact on service delivery
National
Available
research
and audit
data
Worcestershire
Pre EIS
Baseline Audit
Data 2000
(based on 3
year cohort
data from
1997-1999
Worcestershire
EIS Audit
Data
2006
(based on 3
year cohort
data from
2003-2006)
Total number of patients contributing
to data
_______ 30 clients
15 carers
77
Total never having a hospital
admission
20% 13% 42.7%
(n = 75)
Percentage admitted to hospital for
first episode
80% 73% 41.4%
(Prior to or as
entry point to
EIS, n = 75)
Percentage admitted for first episode
using MHA
50% 59% 27%
(Prior to or as
entry point to
EIS, n = 74)
Hospital admissions for further
episodes
N/A 50%
30% 2
episodes
20% 3+
episodes
27.6%
6.6% 2
admissions
3.9% 3
admissions
(n = 76)
Percentage admissions using MHA for
further episodes
N/A N/A 9.5%
(n = 74)
Percentage engaged with services 50% (at
12
months)
97% 100%
Mean
engagement
rating 39
(scores above
33 indicate
good
engagement)
79.2% well
engaged
20.8% poorly
engaged
(n = 77)
Percentage with case manager
allocated
N/A 33% 100%
(n = 77)
Percentage aware of crisis contact
details / arrangements
N/A 63% 90% service
users
91.7% carers
(n= 22)
Care planning
20% aware of
CPA
13% had seen
copy of their
care plan
60% involved in
planning care
100% users and
carers aware of
CPA
100% users and
91.7% relatives
had seen copy
of care plan
80% users and
66.7% carers
involved in
planning care
(n = 22)
Family involvement
49% carers
given
management
advice
56% satisfied
with help
received
62% felt
listened to and
understood
100% offered
family support
or formal
family
intervention
71.4% satisfied
with help
received
91.7% felt
case manager
had discussed
and understood
their views
(n = 22)
Medication and treatment
40% given
information
about
medication and
50% about
potential side
effects
35% involved in
decisions about
medication
90% given
information
about
medication and
100% about
potential side
effects
85.7% involved
in decisions
about
medication
(n = 22)
Information about psychosis
67% reported
given little or
no information
about
psychosis
70% users and
75% carers
reported having
had enough
information
about psychosis
(n =22)
DUP
Mean
range
DUP:
12-18
months
Median DUP
2004: 5 months
2005: 6 months
2006: TBC
Social activities
52% satisfied
with social
activities
organised by
the service
83.3% users
and 87.5%
relatives
satisfied with
social activities
provided by EI
(n = 22)
Impact on outcomes
National audit data Worcs EIS 2006
Unemployed 45.7%
(n = 70)
Employed 8-18% (rates for
people with SMI-all
people with MH
problems)
25.7%
(n = 70)
Education 28.6%
(n = 70)
Satisfaction with help to find/return to
education/employment
10% satisfied with
help in finding
employment (pre EIS
audit)
71.4% users and
77.8% carers satisfied
with help offered
(n = 22)
Completed suicides 10% 0%
(n = 77)
Attempted suicides 48% 21.9%
(n = 73)
Homelessness
13.3%
86.6% had no days
homeless
(n = 70)
Cannabis Usage
On entry to EIS:
49.3% none
20% daily
Current usage:
64.3% none
8.6% daily
(n = 70)
Overall service satisfaction
55% users and 56%
carers
mostly/extremely
satisfied (Worcs pre
EIS audit data
2000):
100% users and carers
mostly/extremely
satisfied
(n = 22)
Discharge outcomes (n=19 to date)
Discharge destination %
GP 36.8%
CMHT 10.5%
Recovery service 5.2%
AO 10.5%
Private hospital 5.2%
Moved out of area (eg. returned to University or family home) 31.5%
Evaluation summary
To date, the impressive reduction in hospital admissions (first and subsequent), use of
the Mental Health Act, suicide rates and cannabis usage, the high levels of engagement
(with 0% of users lost to follow up) combined with high levels of user and carer
satisfaction with the care and interventions received and 54.3% employment /
occupation rates for service users demonstrates considerable value for money. An annual
audit cycle has been set in place to continually listen to and learn from users and carers
of the service to address unmet needs and identify more effective ways of helping to
deliver early intervention and further improve the service
Acknowledgements
Thanks are due to Liam Atwal, Faiza Anwar and Helen Lowe, Psychology assistants and
Emma Cotes, Clinical Psychologist who collected and analysed the data that formed the
basis for this evaluation summary and all the Early Intervention staff team for the
support and information they provided in the course of data collection.
Jo Smith,
Worcestershire Early Intervention Clinical Development Lead
Tony Gillam,
Early intervention Team Manager
October 2006
Contact details:
Jo Smith, Early Intervention Clinical Development Lead (E-mail: [email protected]) or
Tony Gillam, Early Intervention Team Manager (E-mail: [email protected])
Worcestershire Early Intervention Service
1, Britannia Court, Moor Street, Worcester, Worcestershire WR1 3DB
Tel: 01905 681787
Appendix 11.
What added value can clinical psychology bring to a specialist mental health trust?
Subject: Added Value of Clinical Psychology doc. Dear Tim A number of clinical psychology colleagues and I have put together a document (attached) to help inform our efforts to influence and enable senior managers and commissioners to utilise clinical psychology skills more effectively. The main impetus for this initiative has, of course, been the significant challenges facing the profession both locally and nationally. I am aware that the Division of Clinical Psychology is currently developing a marketing strategy and I hope our local document may be of some interest in this regard. Although the contents of the document are largely structured around the local FT business plan, I suspect that the arguments made are of relevance to other mental health trusts. Please feel free to use any aspect of the document as part of the national initiative to "sell" clinical psychology skills. Best wishes Gary L. Sidley Professional Lead for Psychology (Salford) Bolton, Salford & Trafford NHS Mental Health Trust
2
June 2007
WHAT ADDED
VALUE CAN CLINICAL
PSYCHOLOGY BRING TO A SPECIALIST
MENTAL HEALTH TRUST?
3
1. Purpose of this document?
The primary aim of this document is to increase awareness among senior
managers and commissioners of the range of contributions clinical psychologists
can make towards delivery of a high quality, specialist mental health service. It
is hoped the information will be helpful and timely, particularly in light of the
imminent transition to Foundation Trust status.
2. What is a clinical psychologist?
A clinical psychologist is an expert in applying the science of psychology to
health and social care settings. Psychology focuses on the factors that influence
how people (service-users, staff, carers) feel, think and behave. As such, it is a
very versatile science that is ideally suited to addressing the wide range of
“people” problems faced by a large mental health Trust, with regards to both
service delivery and organisational issues.
The core training of a clinical psychologist is lengthy and intensive. A newly
qualified clinical psychologist will have successfully completed a psychology
degree (3 years), undertaken relevant experience as an assistant psychologist
(typically at least 2 years), and then gone on to achieve a post graduate degree in
clinical psychology (3 years) incorporating both intensive academic study and a
wide range of supervised clinical placements. Thus, the minimum period
required to achieve the core qualification, a Doctorate, is 8 years of full time
study and training, an entry route that is comparable in length and depth to that
of medical practitioners.
3. Current context?
Despite a range of national policy directives indicating the need for expanding
the availability of psychological interventions (e.g. Mental Health Ten Years On: Progress on Mental Health Care Reform, Appleby, 2007), the clinical
psychology profession within the Trust has experienced significant loss of
resource over the last couple of years. Furthermore, ongoing pressures continue
in the form of year-on-year Cost Improvement Programmes. Recently the
Agenda for Change (AfC) process, although broadly re-affirming the status quo
for clinical psychology salaries, has resulted in the perception that the “going
rate” for clinical psychology is relatively expensive (particularly as medical
colleagues were excluded from the AfC review). Collectively these influences
may result in further reductions in clinical psychology posts being seen as
convenient and effective short-term cost-saving measures. Under these
circumstances it is important and timely to highlight the likely longer-term
detrimental effects upon the quality and productivity of mental health service
provision of further erosion of the specialist clinical psychology resource.
What follows is a summary of the main distinctive “added value” contributions
that clinical psychology can make within a specialist mental health Trust. To aid
clarity, it will be structured around the stated corporate objectives and
intentions.
WHAT DOES CLINICAL PSYCHOLOGY ADD TO MENTAL HEALTH SERVICES?
Theme Corporate objective/intention
Clinical Psychology skills that will help
meet this objective/intention
Relevant examples of application within a
specialist mental health service
Existing examples of relevant Clinical Psychology-led
innovation within the Trust
Risks of not having sufficient clinical
psychology expertise within the Trust
C O M P L E X I T Y
To focus core business on COMPLEX MENTAL HEALTH NEEDS (Foundation Trust – Integrated Business Plan, 2007) To emphasise “EXPERTISE” AND “CLINICAL CAPABILTIY” as basis for market expansion (Foundation Trust – Integrated Business Plan, 2007) To comply with “PERSONALITY DISORDERS – NO LONGER A DIAGNOSIS OF EXCLUSION” (NIMHE, 2003)
Formulation of complex problems by drawing flexibly on a range of psychological models and theories (an independent &
comprehensive review of
clinical psychology services
in Britain, [MAS, 1988]
concluded that clinical
psychologists were the only
professional group able to
perform this role)
1. Individual therapy with
complex/ “hard to treat”
presentations/ability
to work “off- piste”
with problems that
typically do not
respond to first-
line medical and
talking therapy
intervention;
2. Providing framework for
guiding multi-
disciplinary team
communication and
corresponding
intervention
/management;
3. Providing framework for
positive risk-taking/
risk-management;
4. Neuropsychological
assessment.
RAPID
PSYCHOLOGICAL
ASSESSMENT &
FORMULATION
CLINIC WITHIN
SALFORD’S
COMMUNITY
MENTAL HEALTH
TEAMS
EFFECTIVE WORKING
WITH CLIENTS WITH
SIGNIFICANT LEVELS
OF PSYCHOLOGICAL,
PHYSICAL AND
SOCIAL CO-
MORBIDITY
(SALFORD OLDER
PEOPLE PRIMARY
CARE PSYCHOLOGY)
BOLTON’S “174” DAY
SERVICE FOR PEOPLE
WITH PERSONALITY
DISORDERS
1. Ineffective services due
to over-reliance on first-
line interventions;
2. Failure to win contracts
for working with
severe/complex metal
health problems;
3. Litigation on basis of
clinical governance
deficiencies.
5
Theme Corporate objective/intention
Clinical Psychology skills that will help
meet this objective/intention
Relevant examples of application within a
specialist mental health service
Existing examples of relevant Clinical Psychology-led
innovation within the Trust
Risks of not having sufficient clinical
psychology expertise within the Trust
H U M A N I S I N G
To promote RECOVERY, SOCIAL INCLUSION & REDUCE INEQUALITIES (A strategic intention within the Trust’s Annual Report, 2006; Mental Health & Social Exclusion, Social Exclusion Unit 2004); BST Care Programme Approach, 2006; Everybody’s Business, CSIP, 2005)
Normalising framework for embedding people’s problems (psychology is fundamentally
about the science of “normal”
behaviour and emotion – as
such there is an inherent
expectation that everyone can
change, and that the
mechanisms for change for
people with mental health
problems will be no different
from those that influence each
and every human being)
Depth and breadth of knowledge/expertise to challenge traditional, overly biological models of service-delivery (typically clinical
psychologists are the lone
voice in raising concerns
about such practices)
Understanding of interpersonal dynamics and the inherent power imbalance in service-user/mental health worker interactions
1. Non-stigmatising service
provision;
2. Empowering service-users;
3. A service that does not
exclude people on the basis
of dubious and unreliable
psychiatric diagnoses;
4. Minimising prejudice/
promoting equity through
compassionate formulations
of people’s problems;
POSITIVE
PSYCHOLOGY &
MENTAL HEALTH
WORKSHOPS IN
COLLABORATION
WITH BOLTON’S
PATIENT’S COUNCIL
(funding acquired from the
PCT to support 10 further
workshops)
THE IMPACT & EDIT
SERVICES (precursors to
the early intervention
service) OFFERING
NORMALISING WAYS
OF MAKING SENSE OF
PSYCHOTIC
EXPERIENCES
THE RECOVERY
ORIENTATED MODEL
OF CARE WITHIN THE
HIGH DEPENDENCY
UNIT (A DIRECT
CONSEQUENCE OF A
CLINICAL
PSYCHOLOGY-
FACILITATED AWAY
DAY)
1. A less humanistic service
treating service-users as
“illnesses” rather than as
people.
2. Arbitrary exclusion of
some high risk groups
with complex problems.
3. Services that stigmatise
rather than enable.
6
Theme Corporate objective/intention
Clinical Psychology skills that will help
meet this objective/intention
Relevant examples of application within a
specialist mental health service
Existing examples of relevant Clinical Psychology-led
innovation within the Trust
Risks of not having sufficient clinical
psychology expertise within the Trust
I N N O V A T I O N
Income generation from SERVICE EXPANSION/ DEVELOPMENT Continuous SERVICE IMPROVEMENT A FOCUS ON QUALITY as much as quantity Income generation through HIGH PROFILE RESEARCHERS (All highlighted within the Foundation Trust – Integrated Business Plan, 2007)
Research expertise The core training uniquely
equips all clinical
psychologists with a
research doctorate
1. Service-innovation;
2. Service evaluation and the
development of
measurable outcomes;
3. Evidence-based practice
THE “IMPACT” TEAMS
(WITHIN TRAFFORD &
SALFORD) AS
PRECURSORS TO
EARLY
INTERVENTION
SERVICES [commended
by the Health Care
Commission]
CLINICAL AUDIT OF
OLDER PEOPLE’S
PRIMARY CARE
PSYCHOLOGY
SERVICE
SERVICE-USER/
EMPLOYEE
RESEARCHER ROLES
LINKED WITH THE
EARLY
INTERVENTION
SERVICE
THE DEVELOPMENT
OF THE “EDIT”
SERVICE FOLLOWING
RESEARCH TO
DEMONSTRATE THAT
PSYCHOLOGICAL
INTERVENTION CAN
PREVENT SOME HIGH
RISK INDIVIDUALS
A sterile service, lacking
innovatory ideas and
therefore unable to compete
within the mental health
market
7
I N N O V A T I O N
(Cont’d)
FROM BECOMING
PSYCHOTIC
THE DEVELOPMENT
AND RAPID
EXPANSION OF THE
PRIMARY CARE
PSYCHOLOGY
SERVICES IN
SALFORD AND
TRAFFORD (services
that closely resemble
those currently being
recommended by Lord
Layard
THE COGNTIVE
THERAPY TRAINING
CENTRE (SALFORD)
(led by a clinical
psychologist and
potentially a major source
of Trust income)
PERINATAL PROJECT
(SALFORD PRIMARY
CARE PSYCHOLOGY)
– recently achieved award
for “Innovative Service
Delivery”
8
Theme Corporate objective/intention
Clinical Psychology skills that will help
meet this objective/intention
Relevant examples of application within a
specialist mental health service
Existing examples of relevant Clinical Psychology-led
innovation within the Trust
Risks of not having sufficient clinical
psychology expertise within the Trust
S K I L L I N G
O T H E R S
To improve ACCESS TO PSYCHOLOGICAL THERAPIES (A commissioning priority, Organising and Delivering Psychological Therapies, 2004; We Need to Talk, 2006)
Expert therapists/ change-agents
1. Supervision of a range of
other staff groups in the
appropriate provision of
psychological
interventions;
2. In-house training of a
range of other staff in
appropriate levels of
psychological
intervention;
3. Developing, supporting
and informing stepped-
care models of provision
to ensure compliance with
governance and
effectiveness agendas
ASYLUM SEEKERS’
SERVICE in
collaboration with the
Horizon Centre GP
practice.
A NOVEL TRAINING
PROGRAMME FOR
MULTI-DISCIPLINARY
STAFF WITHIN
REHABILITATION
SERVICES
INCORPORATING
MOTIVATIONAL
APPROACHES
1. Little or no access to
specialist psychological
services;
2. Psychological
interventions offered by
inadequately
trained/supervised staff
leading to ineffective
delivery and risk of
litigation
9
Theme Corporate objective/intention
Clinical Psychology skills that will help
meet this objective/intention
Relevant examples of application within a
specialist mental health service
Existing examples of relevant Clinical Psychology-led
innovation within the Trust
Risks of not having sufficient clinical
psychology expertise within the Trust
V E R S A T I L I T Y
Competitive advantage from FLEXIBILITY OF SKILLS (Foundation Trust – Integrated Business Plan, 2007)
Unique core competency to work with any age group or speciality
1. Ability to work (on basis
of core training) across
traditional service
boundaries
“IMPACT” SERVICE/
EARLY
INTERVENTION
SERVICES WORKING
WITH 14 – 35 YEARS
AGE GROUP
CLINICAL
PSYCHOLOGISTS
HOLDING JOINT
POSTS ACROSS
PRIMARY AND
SECONDARY CARE
CLINICAL
PSYCHOLOGISTS
HOLDING JOINT
POSTS ACROSS
ADULTS OF WORKING
AGE AND OLDER
ADULTS
1. Lack of joined-up
services with
impermeable interfaces;
2. Unhelpful
competitiveness between
specialities.
10
Theme Corporate objective/intention
Clinical Psychology skills that will help
meet this objective/intention
Relevant examples of application within a
specialist mental health service
Existing examples of relevant Clinical Psychology-led
innovation within the Trust
Risks of not having sufficient clinical
psychology expertise within the Trust
P S Y C H O L O G I C A L L Y
I N F O R M E D
S E R V I C E S
Each service user to expect that EVERY INTERACTION IS THERAPEUTIC (Strategic intention within the Trust’s Annual Report, 2006)
Expertise in non-drug interventions as a result of
extensive/comprehensive
core training, allowing the
flexible use of a range of
models of human
development and social
psychology to inform the
moment by moment
management and
interactions with service
users.
1. Clinical leadership of
multi-disciplinary teams;
2. Formulation sharing with
other professions (see
above);
3. Clinical supervision of
other staff (see above);
4. In-house training of other
staff;
CLINICAL
SUPERVISION TO
STAFF ON THE
CONDITIONS
MANAGEMENT
PROGRAMME
(RECENT
SUCCESSFUL BID IN
PARTNERSHIP WITH
THE DEPARTMENT OF
WORKS & PENSIONS)
PROMOTING
PSYCHOLOGICAL
APPROACHES TO THE
FEAR OF FALLING IN
A PHYSICAL HEALTH
CARE TEAM (PSIGE
Newsletter, No. 96,
November 2006)
CLINICAL
SUPERVISION OF
NON-PSYCHOLOGISTS
WITHIN SALFORD’S
COMMUNITY
MENTAL HEALTH
TEAMS
1. Residential/inpatient
settings that provide
little more than custodial
care;
2. Poor quality milieus that
lack therapeutic
sophistication,
dominated by
exclusively “medication
and support” models of
service provision;
3. Inconsistent practices in
the management of
service-users.
11
Theme Corporate objective/intention
Clinical Psychology skills that will help
meet this objective/intention
Relevant examples of application within a
specialist mental health service
Existing examples of relevant Clinical Psychology-led
innovation within the Trust
Risks of not having sufficient clinical
psychology expertise within the Trust
M O T I V A T I O N
To nurture and maintain STAFF MOTIVATION (Strategic intention within the Trust’s Annual Report, 2006)
Expert skill/knowledge around the factors that motivate people High level communication skills so as to be able to
match the style of
communication to the target
group
Expertise in group dynamics Expertise as change enablers
1. Team-building initiatives;
2. Conflict resolution;
3. Provision of staff support
groups.
4. Provision of stress
management programmes
(for teams and
individuals).
NORTH WEST MULTI-
PROFESSIONAL SHA
MENTOR SCHEME
NORTH WEST
CLINICAL
PSYCHOLOGY CPD
SCHEME
COMMUNITY GROUP
FACILITATORS
SUPERVISION FORUM
WITHIN THE HIGH
DEPENDENCY
SERVICE
TRAINING
INITIATIVES FOR
CPNs/ OTs/SUPPORT
WORKERS WITHIN
SALFORD SERVICES
EXPLICIT PROCESS
FOR STAFF SUPPORT
FOLLOWING SERIOUS
INCIDENTS ON THE
MEADOWBROOK
INPATIENT UNIT
1. High levels of staff
sickness and
absenteeism;
2. High staff turn-over,
with associated high
recruitment costs;
3. An unhappy,
unproductive workforce;
4. High cost of
commissioning external
experts to provide stress
management courses.
Appendix 12.
Psychological services in the NHS
Psychological Services in the NHS
1. The extent of need for psychological services?
9% NHS expenditure mental health problems.
4-13% population suffers from mental health problems at any point in time.
10% of people with mental health problems suffer from psychotic disorders,
another 10% suffer from dementia. The remaining 80% suffer from anxiety,
depression and other acute or chronic problems. This group includes –
personality disorders, eating disorders, harmful drinking and drug taking.
In a substantial number of cases psychological problems are in the context of
physical disorders, requiring liaison work with physicians and surgeons.
On average GPs detect 6 out of 10 cases of mental health problems and 1 in 10 of
these are referred to specialist services.
Following major disasters incidence of severe psychological morbidity increases
sharply for at least 2 years.
The need for psychological services need to take into account sociodemographic
features including:
o Unemployment rates
o Number of single parent families
Commissioners and service planners need to consider the contribution
psychological services can make to:
o Crisis intervention and suicide prevention
o Management of major behavioural problems, including depression,
anxiety, obsessions, eating problems and alcohol/drug abuse
o Reactions to trauma, chronic health problems or disability
o Relationship problems, including sexual problems and family adjustment
to major mental issues
o Need for mental health promotion and prevention.
2. The contribution of Clinical and Counsel l ing Psychologists to
organising and del ivering psychological services
Clinical and counselling psychologists are trained to apply scientific knowledge
about human behaviour to alleviate psychological problems. As well as offering
psychological interventions of proven efficacy, they are committed to enhancing
the work of other professionals, developing new services and evaluating
objectively interventions.
2
Specialist skills include:
o Direct intervention in the form of assessment and treatment for
individuals, families and groups.
o Clinical consultancy in terms of training and supervision.
o Psychological consultancy in developing and evaluating services, teaching,
prevention and health promotion as well as research.
3. Context of Psychologists' work
Clinical Psychologists work largely in health and social care settings including
hospitals, health centres, community mental health and learning disability teams,
child and adolescent mental health services and social services.
Clinical Psychologists usually work as part of a team with, for example, social
workers, medical practitioners and other health professionals. Most clinical
psychologists work in the National Health Service, which has a clearly defined
career structure.
4. Qualifications and Training of Clinical Psychologists
Obtain Graduate Basis for Registration (GBR) by completing an accredited degree
course in psychology.
Complete a minimum of 1-2 years relevant work experience, usually as an
assistant psychologist within the NHS, however care assistant and related research
experience is acceptable.
Complete professional training via the Doctorate in Clinical Psychology funded
by the NHS.
Post graduate training takes 3 years full time.
Ivan Burchess
January 2007
Appendix 13.
National Advisory Group on Mental Health, Safety & Well-Being towards Proactive Policy: Five Universal Psychological Principles
1
National Advisory Group1 on Mental Health, Safety & Well-Being Towards Proactive Policy: Five Universal Psychological Principles
Summary of the Five Principles
1. Human well-being depends on universal psychological needs as well as physical and social
needs
2. A psychologically-informed generic policy framework is badly needed to promote
psychologically safe mental health services (over and above the growing guidance on specific
psychological treatments)
3. Attachment theory provides a universal evidence-base that has not yet been harnessed.
4. In mental health it is primarily relationships that can kill and cure, so all our staff must be
trained and supported psychologically to promote therapeutic responses to service users
5. Choosing between medical and psychological approaches is a false choice. Mental distress
always has a psychological meaning and context. Any response to distress (including medical)
conveys a psychological attitude and impact. Psychological standards for all interventions are
therefore required.
Principle One: Human health and well-being depends on psychological (mind) as well as biological (body) and social factors. Fundamental psychological needs are:
(a) To have a secure and stable attachment to at least one significant other person who knows us
well and on whom we can trust and depend (ATTACHMENT & TRUST)
(b) To have our attempts to communicate recognised and attended to by at least one other
available person who is motivated to understand the meaning behind them (EMPATHIC
COMMUNICATION & RELATIONSHIP)
(c) To belong to a family or other care-giving social group/system and to have a recognised and
respected identity and position within that group (IDENTITY & BELONGING)
(d) To have secure, clear and consistent social boundaries and rules within which to live which
are enforced in a firm, fair and containing manner (CONTAINMENT, SECURITY &
DISCIPLINE)
(e) To have a sense of hope, belief, meaning, value and purposeful occupation in relationship to
self and others (ESTEEM, BELIEF & PURPOSE)
(f) To develop understanding and influence over ourselves and the environment in which we live
(SELF-DETERMINATION)
(g) To develop our capacity to tolerate frustration and fully experience pleasure (RESILIENCE &
HAPPINESS)
(h) To learn reciprocal respect, regard and responsibility towards others (RESPECT &
RESPONSIBILITY)
These needs can be observed and extracted as themes from a wide spectrum of psychosocial
research, knowledge, writing and experience over the last five decades and more. Any family,
school, nursery, hospital, clinic, organisation, institution, community or society can be
measured in terms of how far it meets or fails to meet these standards. These standards could
be said to provide a psychosocial definition and measure of civilisation and humanity itself.
Within public mental health and care services, no single profession, brand of therapy or care
model has any monopoly on supplying these psychological needs. Within society as a whole,
the increasing fragmentation of family life and the demise of a coherent religious or spiritual
framework for community life have led to a net decline in meeting some of these standards
despite an increase in economic prosperity. The “holy trinity” of “health (bio-), wealth
(social) and happiness (psycho-)” is in fact a bio-psycho-social trinity. As our democratic
society evolves and matures as a secular entity, it is beginning to refocus more on the
psychological and spiritual dimension, the “happiness and well-being” dimension. The above
psychological principles provide a scientific basis for secular care services that also connects
1 National Advisory Group are Susie Orbach, Andrew Samuels, Valerie Sinason, Lucy Johnstone,
Martin Seager, Glenda Fredman, Ross Hughes, James Antrican, Margaret Wilkinson and Peter
Kinderman assisted by Tanya Woolf and David Spektor
2
with the “golden rule” of all formal world religions, namely “do unto others as you would
have them do unto you”
Principle Two: Generic mental health (and learning disability) services therefore need an overarching psychologically-informed framework, model or culture in which all staff can operate If we accept the core psychological needs described above under Principle One, it follows that
our public health and care services require operational policies and frameworks that are
informed and guided by these psychological principles. Without such an overarching
framework, there will be considerably less psychological coherence or safety in the systemic
culture of care in which all staff and service users are expected to live and breathe. These
standards must apply not just to service users but also to care staff, administrative and
reception staff, managers and care institutions as a whole if they are to become effective
“professional families”. Policy developments to date (eg. national service frameworks,
clinical governance, standards for better health, NICE guidelines, the Ten Essential
Capabilities, New Ways of Working) have so far lacked this broader psychological dimension
but could quite easily be expanded and amplified.
Principle Three: Attachment Theory is the most universal and most rigorously tested of all psychological theories relating to mental health and well-being. To date it provides the soundest scientific evidence-base around which to design and measure mental health (and learning disability) services. However, it has yet to be truly utilised by policy makers.
Research universally shows that those in our society with the most severe mental health
problems also have the most severely disturbed or disrupted attachments to care-givers over the developmental years. Severe mental health problems are consistently linked to histories of
abuse (physical, sexual, emotional), trauma, neglect, abandonment and discontinuity of
attachment. Research also consistently shows that in our attempts to help those with severe
mental health problems it is the quality of our attachments and relationships with them that is
the single most effective therapeutic ingredient, regardless of any particular therapy brand,
profession, model or approach. Attachment underpins and links all core psychological
therapies (CBT, psychodynamic and systemic) and the commonality between them in this
respect is far more critical than any differences in technique or brand. If we truly want
evidence-based mental health and learning disability care practices, then the global lessons of
attachment theory, tested over decades and universally accepted across the three fields of
biological, social and psychological research, need to be built into the fabric of operational
policy and training. This could vastly improve the safety and the effectiveness of the overall
culture of care. It could significantly improve the way in which all staff are trained, supported
and managed. It could significantly improve the ways in which services operate, for example
how they conceptualise and handle referrals, waiting lists, appointments, caseloads,
discharges, transfers of care, follow-ups and outcome measurement.
Principle Four: In mental health, relationships are both cause and cure. Relationships are the “baby, not the bathwater”. This means that our individual staff members as people are more crucial even than the particular “treatments” they provide. For each service user, the relationship that they form with the care staff and the care system IS the treatment! We cannot therefore properly care for service users except by also caring for our staff. In mental health it is primarily failures and problems of attachment and relationship that
damage the developing child and his or her capacity to become a happy and productive
citizen. Our unhappiest citizens have been abused, traumatised, neglected, abandoned and/or
passed between care-givers during their developing years. All too often they then re-
experience themselves as “unwanted children” in our public mental health and care
institutions, being passed from one service provider to another without continuity or stability
3
of attachment. In public services the pressure to “discharge” people from care can often be
experienced as another rejection rather than as genuine progress. This “revolving door”
treatment culture can be depersonalising and costly for our society both in human and
financial terms. It can escalate rather than reduce problems of low self-esteem, alienation,
self-harm and destructive behaviour. Staff too in our public services are also frequently
moved around and reorganised so that it is hard for staff to form meaningful attachments to
each other, to their units, to their clients and to a model of care. It will be far cheaper and
much more effective in the long run therefore to develop psychologically-informed policies
and practices that enshrine the personal value of care staff (in terms of the 8 core needs
above) individually and as a “professional family”. Such an attitude amongst staff will then be
passed on to the service users. In other words our society is still too often placing its most
damaged and vulnerable citizens into care environments where those that are expected to care
for them are not fully trained, nurtured, valued, contained and supported psychologically.
According to the “golden rule” (above) we cannot expect staff to show a more caring attitude
for service users (who will often by definition be very suspicious, hostile and disrespectful) if
they themselves do not feel sufficiently respected and cared for by those that they depend on
in turn. Our culture of care is therefore less safe, stable and healthy psychologically than it
could be. Staff operating under psychologically-informed national policy and guidance could
be happier, less stressed, more available to service users and more confident about how to
help them. They could take less time off through sickness and they could have more sense of
purpose in their own work. This would translate to service users with a reduction in human
and financial cost measured for example by rates of re-referrals, self-harm, destructive
behaviour and critical incidents.
Principle Five: The concept of a “treatment choice” between a medical and a psychological approach is a false one. It is impossible to operate in a psychological vacuum without a psychological impact. Mental distress, however extreme, always has a psychological meaning and context. In trying to respond to mental distress there is always a relationship formed between user and provider which will exert a powerful influence on outcome, regardless of the techniques or treatments that are ultimately selected. Even apparently “stand alone” medical treatments cannot be extricated from their psychological context and impact. Psychological factors are always critical in understanding mental distress and any treatment response will always have a psychological impact for good or ill. There is no realistic option not to have a psychological impact on those who turn to us for
help even when a formal psychological therapy is not being offered. Any attempt to respond
to mental distress by staff in our public services automatically conveys a psychological
attitude and stance (for good or ill) to the service user even if this is not intended. Vulnerable
service users will also always bring their own attitudes into the relationship and this can
create a positive or a negative interaction with carer attitudes. These psychological
interactions are always present and are always critical to outcome regardless of the particular
techniques, models or approaches that might be used.
National policy and guidance could be expanded to spell out explicitly the desirable
psychological attitudes and standards of communication and relationship that all mental
health services should meet. Psychologically-minded policy would foster psychologically-
minded practice. By not being fully psychologically-minded in our national policy, there will
be at best a failure to make the most of opportunities to improve the lives of vulnerable people
and at worst the increased risk of repeating, entrenching and exacerbating past rejections and
failures of relationship.
4
Seven Key Areas of Practical Application
1. Pilot Sites - The above principles could be inexpensively operationalised and tested
by being used to retrain staff (in terms of the basic principles) and redesign the
service model (including referrals, admissions, allocations, basic therapy model,
discharge, caseloads, structure of time, team communications and support model,
supervision, management, leadership and administration arrangements) in one or
more experimental pilot sites as compared with control sites in which “treatment as
usual” was provided. Potential pilot sites could include (1) a typical acute adult
psychiatric ward (2) a typical care, nursing or residential home (3) a typical adult
community mental health team (4) a typical primary care health centre or clinic.
Outcome measures could include re-referral and re-admission rates, critical incident
rates, risk measures, satisfaction measures (staff, service users and significant others),
symptom measures and medication usage. 2. Existing policy standards and good practice guidelines (eg. The Ten Essential
Capabilities, Clinical Governance or Standards for Better Health, Nice Guidelines)
can be embellished and amplified to take account of these universal psychological
principles.
3. The vitally important “Improving Access to Psychological Therapies” (IAPT)
national project can be built upon further to incorporate the above principles, thus
creating a broader, cultural or systemic dimension. This might be termed “Improving
Access to Psychologically-Minded Care”
4. Current Core Guidance for all health and care professions on “New Ways of
Working” could be amplified and embellished to take account of these vital
principles.
5. Staff Training - these principles could be used to design basic generic
(psychologically-informed) training courses and manuals for all staff, including
managers and administrative staff
6. Evaluation measures and standard setting - these principles could be used to redesign
key dimensions of measurement of the effectiveness of treatments and services in
relation to how far they meet or satisfy universal psychological needs. They can also
be used to define operationally the psychological standards that mental health
services should meet. For example, using these principles a service user should be
able to expect a secure and stable attachment with at least one professional and also
that his basic life story should be recognised and remembered by all others involved
with his or her care .
7. These principles could be used to improve the quality of existing service development
and workforce planning. For example, using attachment theory would lead to a more
radical and dynamic concept of what a caseload should look like. Under attachment
theory, no mental health care worker or professional should have more attachments to
service users than they can hold in mind at any one time. This limit might vary in
different contexts but would be set according to psychological parameters of risk. To
go beyond this limit would then be seen to constitute unsafe practice psychologically
and creating a meaningful and practical definition of this limit would help both staff
and service users to feel more contained.
Martin Seager, May 2007
Appendix 14.
BPS / DCP Briefing paper 1: Clinical and other applied psychologists within the NHS
British Psychological Society Division of Clinical Psychology Briefing Paper 1
Clinical & other applied psychologists in the NHS
1st May 2007
… highlighting key issues in employing and managing psychologists in the NHS …
Key issues at a glance
• Clinical psychologists use psychological theory in order to offer a range of professional services to individuals,
groups or organisations
• Their core skills include research and evidence based interventions applicable to service redesign.
• Psychologists have a distinctive psychological
perspective on many issues in across a breadth of
activity in healthcare.
• Psychologists are set to play key roles in the Mental Health Act and Mental Capacity Acts … and the
Improving Access to Psychological Therapies programme.
• Like many professionals in the NHS, clinical psychologists
are working with the Care Services Improvement Partnership (CSIP) on … New Ways of Working …and
developing leadership and professional management in NHS Trusts.
Chartered psychologists
There are approximately 17,000 applied psychologists working in public service in the UK (Department of Health,
Home Office and British Psychological Society, 2004). Applied psychologists perform a wide range of roles, and
consequently have different specific job titles: Clinical
Psychologists, Neuropsychologists, Forensic Psychologists, Occupational Psychologists, Counselling Psychologists,
Health Psychologists, Educational Psychologists and Sport & Exercise Psychologists.
Since 2001 the number of clinical psychologists in the NHS has risen by 1,608 (29%) to 7,122 and the number of
training places has increased by 157 (37%) to 582. The number of clinical psychologists in post has increased by
over 3,000 since 1997.
Contact details and websites
The British Psychological Society St Andrews House, 48 Princess Road East , Leicester LE1
7DR Tel: 0116 254 9568 [email protected] http://www.bps.org.uk
Core skills
The core skills of a clinical psychologist are: • Assessment;
• Formulation; • Intervention;
• Evaluation and research; • Communication.
The information gained from assessment of psychological
processes and behaviour is used by psychologists to develop
formulations. These summarize and integrate this assessment information with psychological theory and
research to provide a framework for describing a problem, how it developed and is being maintained.
Because of their particular training in the linkage of theory
to practice, psychologists draw on a number of different explanatory models and so a formulation may comprise a
number of provisional hypotheses. What makes this activity unique to psychologists is the knowledge base and
information on which they draw. The ability to access, review, critically evaluate, analyse and synthesise data and
knowledge from a psychological perspective is one that is distinct to psychologists. Intervention, if appropriate, is
based on the formulation. This approach clearly prioritizes an evidence-based approach to healthcare.
Evaluation is a critical and integral part of the psychologist's
work. Research includes the ongoing evaluation of assessment, formulation and intervention in relation to
specific services provided. It also includes explorations of psychological processes and outcomes and the development
and evaluation of specific psychological interventions.
These competencies, built on the body of psychological theory and research and applied to helping people solve
personal, family, group, work or organisational problems, makes psychology unique in health and social care.
Source: Quality Assurance Agency for Higher Education
(2004) Benchmark Statement: Health Care Programmes, Phase 2, Clinical psychology. Gloucester: Quality Assurance
Agency for Higher Education.
British Psychological Society Division of Clinical Psychology: http://www.bps.org.uk/dcp/dcp_home.cfm
Lynn Hartshorn, Advisor – Division of Clinical Psychology: Direct line: 0116 2529529
E-mail : [email protected]
Training and qualifications
All psychologists working in mental health teams have undergone in-depth and extensive training in the application
of psychological science to mental disorders.
Clinical psychology is the only healthcare profession where a doctorate is the minimum entry requirement to practice.
After a minimum of 6 years university education, during which time they are awarded both undergraduate university
degrees and their doctorates, psychologists qualify and specialise in specific areas of work – such as adult mental
health, working with children and young people, or forensic and prison settings. Psychologists are not normally
considered for consultant level posts for 6 years post qualification, during which time are obliged to undertake
continuing professional development, and many obtain further specialist postgraduate training. Only after some 12
years of education and training, therefore, are psychologists working in mental health likely to reach consultant level.
Since 2001 the number of clinical psychologists in the NHS
has risen by 1,608 (29%) to 7,122 and the number of training places has increased by 157 (37%) to 582. The
number of clinical psychologists in post has increased by over 3,000 since 1997.
Evidence based interventions Clinical psychologists are more than psychological
therapists. While many do practise psychotherapy at a high level, this is not a skill distinct to clinical psychologists, nor
should it be. The background and training of clinical psychologists is rooted in the science of psychology, and
clinical psychology is one of the applications of psychological science to help address human problems. The ability to
design and carry out innovative applied research is a key skill developed in clinical psychologists’ training and is
important for the development and delivery of evidence-based practice. Psychologists are also, therefore, competent
in the critical evaluation of research activity; for instance in the development and testing of new interventions and
activities, based on psychological theory. Thus practice feeds and draws on research and theory that in turn
influences practice. The role of psychologists in developing evidence-based
clinical guidance can be seen in the work of the National Collaborating Centre for Mental Health (NMCCMH) The
NMCCMH is a partnership between the British Psychological Society's Centre for Outcomes Research and Effectiveness
(CORE) and the Royal College of Psychiatrists' Research Unit (CRU), and is one of seven collaborating centres established
and funded by National Institute for Clinical Excellence (NICE) to develop clinical guidelines on their behalf.
Sources: Quality Assurance Agency for Higher Education
(2004) Benchmark Statement: Health Care Programmes, Phase 2, Clinical psychology. Gloucester: Quality Assurance
Agency for Higher Education. British Psychological Society Division of Clinical Psychology. (2001) The core purpose and
philosophy of the profession. Leicester: British Psychological Society.
Service redesign
Psychologists therefore have invaluable skills in problem solving and innovation; skills which can assist Trusts in
service redesign. These are coupled with clinical and therapeutic skills, which can help retain a focus on service
user needs and aspirations. Psychologists are research skilled and research literate – they can understand, critically
review and add to the evidence base not just for clinical practice but also for organisation development and change
management.
How to use a scarce resource Psychologists are a scarce resource and their skills need to
be targeted to where they will be used most efficiently. Clinical and other applied psychologists have high
expectations to meet. The Agenda for Change process has
made psychologists more visible, it has clarified our competencies and our role. But it is sometimes unclear what
we do – or what should be expected of us. Given current financial constraints in the NHS, there are understandable
pressures on managers to maximise their return on investment. This briefing paper aims to give guidance about
our unique skills in mental health, physical and health and other areas of health and social care.
We understand that NHS Trusts are independent organisations that are free to make their own decisions;
nevertheless, we have a valid perspective on what constitutes appropriate organisational arrangements for the
delivery of safe and effective psychological services to the public. We believe that service users and the wider public
are protected through proper clinical governance, accountability, professional leadership and supervision.
A psychological perspective…
A psychological perspective places psychological issues
centrally in understanding mental disorder. This perspective has important implications for mental health service policy:
i) Services should be planned on the basis of need and functional outcome rather than diagnostic categories, where
residential care is necessary, a concept of ‘hospital’ care should be avoided.
ii) The current emphasis on specialist teams should continue, but the focus of these teams should be based on
underlying psychological principles, iii) Services should fully embrace the recovery approach,
iv) Services should facilitate genuine service user involvement,
v) Access should be improved to psychological therapies based on individual case formulations and driven by
recovery models, vi) Nurses should develop increasing competencies in
psychosocial interventions, occupational therapists and social workers should see their roles develop,
and vii) Psychologists should be prepared to offer consultation and clinical leadership.
Kinderman, P. (2005) A psychological model of mental
disorder. Harvard Review of Psychiatry; 13 : 1–16; Kinderman, P. & Tai, S. (2006) Clinical implications of a
psychological model of mental disorder. Behavioural and Cognitive Psychotherapy, 35, 1–14.
Kinderman, P, Sellwood, W & Tai S (2007 in press) Policy implications of a psychological model of mental disorder.
Journal of Mental Health.
Improving Access to Psychological
Therapies Guidelines from NICE (the National Institute for Health and
Clinical Excellence), the NSF for Mental Health and academic papers have repeatedly stressed the effectiveness and
appropriateness of psychological therapies for a range of mental health problems. The Department of Health’s and
the Care Services Improvement Partnership’s (CSIP) Programme: “Improving Access to Psychological Therapies”
(IAPT) sets out a framework for action, including two national demonstration sites, to address these issues in
England.
Clearly, as experts in conducting and delivering psychological interventions, clinical and applied
psychologists have a key role here. Psychologists have experience of working together with other psychological
therapists, and in providing training in a range of therapies.
We envisage the IAPT programme engaging a broad range of psychological therapists, and anticipate Trusts employing
a range of professionals, including new graduates, to be trained in specific therapies such as CBT – cognitive
behavioural therapy. Psychologists are therefore also important as managers, supervisors and trainers of such
psychological therapists. It will also be important that new services are evaluated with respect to clinical outcomes and
users’ perspectives; psychologists have an important role in collecting such practice-based evidence. Finally,
psychologists’ training enables them to formulate complex care planes where the application of manualised and
deliverable packages of therapy can be integrated into more holistic care plans.
Turpin, T., Hope, R., Duffy, R., Fossey M & Seward J.
(2006). Improving access to psychological therapies: implications for the mental health workforce. Journal of
Mental Health Workforce Development. 1(2):7-15.
Leadership and professional
management in Trusts Several Department of Health reports (NHS Psychotherapy
Services in England: Review of Strategic Policy, 1996; Treatment Choice in Psychological Therapies and
Counselling, 2001; have collated evidence for the effectiveness of psychological therapies and offered practical
guidance about how to drive forward the evidence based practice agenda. These were supported in the NHS Plan
(2000), the Priorities and Planning Framework (PPF) for 2003-6 and Organising and Delivering Psychological
Therapies (Department of Health /NIMHE, 2004).
Good practice in the management, training, access, choice, and supervision of psychological therapists includes:
- Improved access to therapies to avoid long waiting time
- Attention to the psychotherapeutic needs of different groups: for example, older people, people from minority
groups - Involvement of users in choosing the most appropriate
therapy for their condition and situation
- Systematic training in psychological therapies for mental health professionals supported by specialist
supervision once they return to the workplace - Clear leadership, both professionally and managerially,
is best achieved through the development of an organisation wide body i.e. a Psychological Therapies
Management Committee.
The British Psychological Society further recommends:
- Psychologists, by virtue of their training, competencies and experience, can lead and manage teams, and take
'clinical responsibility' while supervising more junior staff
- There should be specific Board-level representation for the delivery of Psychological Services
- Services must be aligned with the vision of future service delivery and the key external drivers for
organising Psychological Services. This includes the need to consider how psychological therapies and
approaches are organised and delivered in multi-professional, multi-disciplinary context
• The overarching approach of applied psychologists is the application of psychology across whole of health and care
system
Source: British Psychological Society Division of Clinical
Psychology. (2007) Leading psychological services. Leicester: British Psychological Society.
Mental Heath Act & Mental Capacity Act
The introduction of the Mental Capacity Act 2005 and the proposed changes to the 1983 Mental Health Act are
significant for psychology.
In the case of the Mental Capacity Act 2005, substantial legal responsibilities will fall to psychologists – to clinical
psychologists and neuropsychologists. These will be additional clinical roles, but also substantial legal
responsibilities.
Similarly, the proposals to replace the Responsible Medical Officer under the Mental Health Act 1983 with a Responsible
Clinician – who may be a psychologist – is important for all employers. These changes are in keeping with best quality
mental health care, and allow for proper multidisciplinary
practice. Such an approach explicitly permits proper use of the skills and competencies of the workforce - including
psychologists. A second controversial aspect of the proposed reforms – ‘Supervised Community Treatment Orders,
permitting compulsory care outside of hospitals – may also involved substantial changes in the roles of psychologists
employed in health and social care
Kinderman P (2007) Reforms to the Mental Health Act and implications for psychologists. Issues in Forensic Psychology
No. 6 86-91
Breadth of activity
Clinical and other applied psychologists work across a wide range of areas of key importance to health service targets in
addition to their core activities in mental health. Within the NHS, psychologists work with individuals, couples, families,
groups and at the organisational and community level. They work in a variety of settings, including hospital wards, day
centres, Community Mental Health Teams, NHS Trusts, primary and social care contexts and forensic settings, and
with all age groups from very young children to older
people. They work with people with mild, moderate and severe mental health problems, developmental and learning
disabilities, physical and sensory disability, and brain injury; people who have substance misuse problems and people
with a range of physical health problems (e.g. HIV and AIDS, cancer, heart disease, pain, diabetes).
Psychologists work with people with long term neurological
and other conditions – conducting skilled neurological or other complex assessment, working to improve motivation
and rehabilitation and coordinating pain management. Psychologists and psychological approaches are also
important in helping combat anti-social behaviour; including the ‘respect’ agenda in the community and helping address
challenging behaviour in forensic and secure clinical settings. Health psychologists and specialist clinical
psychologists also work in the public health arena and in assisting in health behaviour change.
A key message for Department of Health policy leads and
for senior NHS managers is to think beyond merely mental health and psychological therapies when considering the
contribution of psychology.
New Ways of Working
The “New Ways of Working” Programme of the Department of Health, National Institute for Mental Health in England
(NIMHE) and the Care Services Improvement Partnership (CSIP) is designed to help professions working in mental
health to become more modern and flexible. As part of this programme, applied psychologists have an ambitious plan
examining: - Models of organising, leading & managing psychological
therapies services in trusts - Pathways and access to psychological therapies
- The training model for applied psychologists - The undergraduate curriculum
- Role of assistants/associates in the future workforce - Career pathways and roles
- Applied psychology and multidisciplinary team working - Mental health legislation
The “New Ways of Working for Applied Psychologists” group
will report in spring of 2007 with a range of recommendations and plans for ongoing work. Flexibility
and increasing access to psychological services will be key
elements.
The British Psychological Society The British Psychological Society (BPS) is the learned and
professional body for psychologists in the United Kingdom. The BPS has a total membership of over 42,000 and is a
registered charity. The profession (or professions) encompassed by the term ‘psychologist’ is, however, not at
present regulated by Statute. The BPS fully supports the principle of independent statutory regulation of
psychologists and we welcome the imminent publication of a Government White Paper. The BPS is, however, authorised
under its current Charter to maintain a Register of Chartered Psychologists, to hold a Code of Conduct and to
have investigatory and disciplinary systems in place to consider complaints of professional misconduct relating to
its members. This curious legal position is enshrined in the European Communities (Recognition of Professional
Qualifications) (First General System) Regulations 2005. The BPS is also an examining body granting certificates and
diplomas in specialist areas of professional applied
psychology and has quality assurance programmes for accrediting both undergraduate and postgraduate university
degree courses. In these activities, it works alongside Government Agencies such as the Quality Assurance Agency
for Higher Education.
Branches of psychology
The Society recognizes several different branches of applied psychology, including -
Clinical Psychology Neuropsychology
Educational and Child Psychology Forensic Psychology
Counselling Psychology Health Psychology
Occupational Psychology (details of all these groups can be found at:
http://www.bps.org.uk/the-society/organisation-and-governance/professional-practice-board)
The largest single group of applied psychologists are clinical
psychologists. There are some 7000 currently employed in the NHS. Clinical psychology (according to the
Government’s Quality Assurance Agency for Higher Education, 2004) aims to reduce psychological distress and
to enhance and promote psychological wellbeing by the systematic application of knowledge derived from
psychological theory and research. The core skills of a clinical psychologist are defined as: assessment,
formulation, intervention, evaluation and research, and communication.
About 400 forensic psychologists work in the NHS, the
Prison Service, in a range of Offender Management Services and in the special, high and medium secure hospitals. Their
competencies include assessment, evaluation and risk-assessment, but also psychological interventions and
therapies aimed at reducing the risk of re-offending. In addition, there are some 300 counselling psychologists
(whose competencies include the delivery of psychological therapies) as well as health psychologists (addressing the
physical healthcare of people with mental health problems) and neuropsychologists working in health and social care.
Sources: British Psychological Society, Department of Health
& Home Office (2005). English survey of applied
psychologists in health & social care and in the probation & prison service. British Psychological Society, Leicester;
Lavender, T. & Paxton, R. (2004). Estimating the applied psychology demand in adult mental health. British
Psychological Society, Leicester.
Advertising and competencies There is overlap between the competencies of psychologists
in these Divisions. In some cases, therefore, a particular job could be appropriately filled by a psychologist from more
than one Division. Senior psychology managers should ensure that the competencies of each individual role are
described and each post advertised appropriately. This may best be achieved through phrases such as “Clinical or
Counselling Psychologist” or “Forensic / Clinical Psychologist” or “Health or Clinical Psychologist”.
The National Assessors group of the British Psychological
Society are experienced in assessing the match between and individual psychologist and the specific competencies
for a particular post. The Department of Health recommends
(http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuida
nceArticle/fs/en?CONTENT_ID=4005761&chk=8sfUDX) that two National Assessors are involved in any appointments
made to Agenda for Change bandings 8c and above.
Appendix 15.
Potential contribution of applied psychologists to implementing NHS reform
IMPROVED CLIENT
EXPERIENCE
Value for money • Ability to assess and formulate
complex problems
• Effective therapies and therapists
• Therapy innovations
• Service redesign
• Working through other staff (GWs,
psychology assistants etc) to
broaden delivery of therapies
• Disseminating psychological
knowledge within teams
• Education and training
• Attending to the psychological
needs of staff and organisations
Standards • Knowledge of wide range of
interventions and competencies
• Knowledge of professional
accreditation
• Expertise around clinical
governance and risk
• Promoting ethical practice
• Expertise around supervision and
training supervisors
• Critical thinkers and problem
solvers
• Ability to think organisationally
and to support other staff
• Supporting Trust Boards in
delivering business plans
• Ensuring that standards and
knowledge are regularly updated
through R&D
User Choice • Knowledge of wide range of
therapies and therapists
• Working with users to promote
understanding of range of
psychological approaches in
order to achieve informed
choice
• Promoting well-being, psycho-
education and self-help
• Providing individually tailored
psychological formulations
• Championing a psychosocial
understanding of mental health
• Supporting user agendas and
promoting social inclusion
Commissioning • Advising commissioners on
needs assessments and
effective interventions
• Knowledge of a wide range of
psychological interventions,
not restricted to a single
therapeutic modality
• Knowledge of psychological
issues and disorders across the
age range
• Integrating mental and
physical health needs
• Providing a bio-psychosocial
approach
• Addressing user perspectives,
recovery and social inclusion
POTENTIAL CONTRIBUTION OF APPLIED PSYCHOLOGISTS TO IMPLEMENTING NHS REFORM
Appendix 16.
Report of the High Level Group on Clinical Effectiveness
Clinical Efectiveness 19/10/07 15:44 Page fci
Report of the High Level Group
on Clinical Effectiveness
Chaired by Professor Sir John Tooke
A report to Sir Liam Donaldson
Chief Medical Officer
Clinical Efectiveness 19/10/07 15:44 Page ifc2
DH INFORMATION READER BOX
Policy HR/Workforce Management Planning Clinical
Estates Performance IM & T Finance Social Care/Partnership Working
Document Purpose For information
ROCR Ref: Gateway Ref: 8945
Title Report of the High Level Group on Clinical Effectiveness
Author DH/CMO
Publication Date 23 October 2007
Target Audience PCT CEs, NHS Trust CEs, SHA CEs, Care Trust CEs, Foundation Trust CEs, Medical Directors, Directors of PH, Directors of Nursing, Local Authority CEs, Directors of Adult SSs, PCT PEC Chairs, NHS Trust Board Chairs, Special HA CEs, Allied Health Professionals, GPs, Emergency Care Leads, Directors of Children’s SSs
Circulation List
Description The Government established a High Level Group (HLG) to report to the Chief Medical Officer on the scope for enhancing and incentivising more effective and efficient clinical care and to make recommendations for future action. This is the HLG’s report.
Cross Ref N/A
Superseded Docs N/A
Action Required N/A
Timing N/A
Contact Details Deirdre Feehan Service Reviews Department of Health Wellington House 133-155 Waterloo Road London SE1 8UG 020 7972 4789
For Recipient’s Use
Clinical Efectiveness 19/10/07 15:44 Page 1
Contents
Foreword 3
Open letter from the Chair of the High Level Group on Clinical Effectiveness 5
Part 1: Issues and Recommendations 7
Introduction 8
Issues 10
Recommendations 13
High Level Group on Clinical Effectiveness – Membership 14
Part 2: Scoping Report 15
Summary 16
Section 1: Activities in the NHS related to supporting clinical effectiveness 17
Section 2: How to approach the issues of clinical effectiveness and
barriers to implementation of guidelines or effective practices 21
Section 3: Current knowledge on the effectiveness of strategies to
promote the uptake of clinically effective practice 26
Appendix 1: Activities in the NHS related to supporting clinical effectiveness 35
Appendix 2: Department of Health selection criteria for referral of topics
to NICE 45
Appendix 3: Intervention-based and clinical condition-based reviews
and protocols in the Effective Practice and Organisation of
Care Review Group of the Cochrane Library 47
Clinical Efectiveness 19/10/07 15:44 Page 3
Foreword
The NHS, like many other healthcare systems,
experiences inappropriate variation in treatments and
treatment rates. Yet all citizens have the right to
expect the same high standard of care and the same
level of access to treatment and services. That was
the case when the NHS was founded and remains
so today.
However, since 1948 when the NHS was set up, the
range and complexity of available treatments have
grown substantially, as has the public’s demand for
medical care. The cost of healthcare has also
continued to rise. So it is imperative that the NHS
makes the best use of its resources to provide high
quality, equitable care for patients.
That is why in 2005 I focused on the issue of
variation in clinical practice in my Chief Medical
Officer’s Annual Report On the state of the public
health. The lead chapter, Waste Not, Want Not,
highlighted the adverse impact of inappropriate
variation in clinical practice on the use of resources
across the NHS as well as on individual patients.
In 2006, therefore, the Government asked me to set
up an independent High Level Group (HLG) to report
to me on the scope for enhancing and incentivising
more effective and efficient clinical care, with
recommendations for a programme of action.
I am grateful to have received the report and
recommendations of the High Level Group on Clinical
Effectiveness from Professor Sir John Tooke, the
Group’s Chair. I would like to thank Sir John and his
HLG colleagues for the thoroughness of the report
and the hard work that went into delivering this to
me within a challenging timetable.
The scoping report for the HLG from Professor
Martin Eccles sets out a summary of existing activity
on clinical effectiveness. It also shows that there is a
great deal of work already being carried out in this
area by a number of organisations and many
examples of good practice. Nevertheless, it also
identifies two major issues - a lack of overarching
high level leadership and the need for more effective
partnership between the NHS and higher education.
I accept that there needs to be better alignment and
coordination of activity in this field at a national level.
I am encouraged that, through the HLG, NICE (the
National Institute for Health and Clinical Excellence)
and the NHS Institute for Innovation and
Improvement have already agreed to work together
to better align and integrate appropriate workstreams
on clinical effectiveness. Since the HLG developed its
recommendations, Lord Darzi has published his
interim report on Our NHS, Our Future and
announced the creation of a new Health Innovation
Council (HIC). The Council, whose membership will
include representatives from NICE and the NHS
Institute for Innovation and Improvement, will have an
oversight role for the whole innovation pathway and
provide leadership in encouraging innovation at the
local level as well as local clinical and management
ownership. I am pleased to announce that the
Department of Health will therefore take forward
appropriate recommendations from the HLG through
the Health Innovation Council.
The HLG also identified the need to harness more
effectively the capacities of academia. I am very
pleased that at the same time as this report is being
published, the Department of Health’s Research and
Development Directorate is announcing the
establishment of NIHR (National Institute of Health
Research) Academic Health Centres of the Future.
These will develop innovative models for conducting
applied health research and translating research
findings into improved outcomes for patients,
through partnerships between academia and the
NHS across the health community covered by the
Centre.
I am also grateful to Sir John for suggesting practical
ways forward on educational issues to key bodies
such as the Medical Schools Council, ACCEA (the
Advisory Committee on Clinical Excellence Awards)
and the GMC (the General Medical Council). I look
forward to their responses.
3
Clinical Efectiveness 19/10/07 15:44 Page 4
Foreword
In addition, following my 2005 Annual Report, NICE
has launched a new programme to assist the NHS in
reducing spending on ineffective treatments.
I also recommended varying tariff payments in the
NHS so that less effective treatments would result in
less money going to hospitals that persist in
providing them. This issue will be examined by the
recently established Clinical Advisory Panel. Part of
the panel’s remit is to examine the optimal use of the
NHS’ Payment by Results policy as support for the
delivery of high quality clinical care. The Department
of Health, together with the British Association of Day
Surgery, is also testing approaches to tariff setting so
as to identify those which best reduce inappropriate
variation in standards of patient care.
I also called for more active knowledge management
to improve access to quality assured clinical
information. National Knowledge Weeks and the
National Knowledge Board will also help to ensure
that information and guidance produced nationally
will be accessible locally.
As the High Level Group has identified, there is no
simple answer to improving clinical effectiveness.
Clinical engagement is key and we need to harness
the knowledge and expertise of clinicians to promote
clinically effective practice. I commend this report
and the initiatives arising from it to clinicians and
managers across the NHS.
Sir Liam Donaldson Chief Medical Officer, England
4
Clinical Efectiveness 19/10/07 15:44 Page 5
Open letter from the Chair of the HighLevel Group on Clinical Effectiveness
Sir Liam Donaldson
Chief Medical Officer, England
Dear Sir Liam
In October 2006, you asked me to chair the High
Level Group on Clinical Effectiveness. I was delighted
to accept your invitation to bring together an
impressive team of experts to consider how clinical
effectiveness in the NHS can be improved. I would
like to thank the members of the High Level Group
for sharing their expertise in this important area and
I am very grateful to them for their enthusiasm and
dedication to the Group’s work.
In the chapter Waste Not, Want Not in your 2005
report On the State of the Public Health, you focused
on the issue of variation in clinical practice. This
highlighted the need to reduce inappropriate variation
in clinical practice to deliver therapeutic treatment
equitably. It is vital to the delivery of effective
healthcare for patients and effective use of resources
that the NHS reduces the use of treatments of little
therapeutic value, ensures the use of treatments of
proven effectiveness and minimises the misuse of
treatments.
The High Level Group focused on the scope for
enhancing and incentivising more effective and
efficient clinical care. Patients have the right to
expect the same high standard of care and treatment
wherever they access NHS services. It is also
important for the NHS to make best use of resources
by adopting effective therapies and abandoning
ineffective interventions.
We commissioned a scoping report from Professor
Martin Eccles, Professor of Primary Care Research at
Newcastle University. His report established that
there is a plethora of clinical effectiveness
workstreams being undertaken by a range of
organisations, and some fine examples of good
practice in local organisations, but no overarching
high-level leadership or capitalisation on the potential
productive relationships between the NHS and
academia.
From our work, we have identified no “single bullet”
to address the issue of clinical effectiveness. Instead,
systematic, context-specific initiatives are needed,
requiring local clinical engagement. Evidence-based
medicine should be complemented by evidence-
based implementation, demanding attention to
education programmes from undergraduate studies
onwards.
Our report makes recommendations on:
● alignment of central activities and support
● promoting local ownership
● ensuring clinical engagement
● harnessing the capacities of academia
● the research agenda.
We have worked closely with colleagues at NICE (the
National Institute for Health and Clinical Excellence),
the NHS Institute for Innovation and Improvement
and the Healthcare Commission. They have agreed
to support a cross-sectoral group to take forward the
alignment agenda and propose mechanisms to
ensure better integration of workstreams. NICE and
the NHS Institute have also agreed to a joint
appointment to support the cross-sectoral group.
I have written to the Medical Schools Council to
encourage them to review their curricula to ensure
that the right foundations are being laid for clinically
effective practice and to the GMC (the General
Medical Council) to ensure such requirements are
reflected in the imminent revision of “Tomorrow’s
Doctors”. It will also be important to encourage
postgraduate training initiatives which help clinicians
develop skills in improvement science and resource
management. In this regard I would hope that the
creation of a management track during core specialty
training as outlined in my Modernising Medical
Careers (MMC) Inquiry Interim Report would facilitate
this agenda.
5
Clinical Efectiveness 19/10/07 15:44 Page 6
Open letter from the Chair of the High Level Group on Clinical Effectiveness
A major educational event involving the Medical
Schools Council, PMETB (Postgraduate Medical
Education and Training Board), the GMC, the
Academy of Medical Royal Colleges and the NHS
Institute for Innovation and Improvement will be
planned to coincide with the 150th anniversary of the
Medical Act 1858 to focus on the needs of the whole
educational continuum and the implications for
professional practice.
The Group has also identified the importance of
partnership working between the NHS and higher
education to deliver advances in medical practice.
We believe that the health service can do more to
harness more effectively the capacity of higher
education to assist with this agenda. We have
therefore made a key recommendation that new
models of community wide “academic health
centres” should be developed to encourage relevant
research and engagement and embed a critical
culture which is more receptive to change.
I am also pleased that Professor Martin Eccles has
agreed to chair an expert group to define the
research agenda and inform the considerations of
the National Institute of Health Research (NIHR)
Service Delivery and Organisation Programme.
All the stakeholders with whom we have engaged in
the course of the High Level Group’s work have
eagerly supported the need to improve clinical
effectiveness and promote clinical engagement.
The High Level Group’s work has been a vital
initiative to address these key issues. Improving
clinical effectiveness and clinical engagement will
continue to be a key priority to improve patient
care and make the best use of NHS resources.
I commend to you this report of the High Level
Group on Clinical Effectiveness and its
recommendations.
Professor Sir John Tooke Chairman
High Level Group on Clinical Effectiveness
6
Clinical Efectiveness 19/10/07 15:44 Page 7
Part 1 Issues and Recommendations
Clinical Efectiveness 19/10/07 15:44 Page 8
Introduction
1.1 In October 2006 the Chief Medical Officer
asked Professor Sir John Tooke to chair a High Level
Group (HLG) on Clinical Effectiveness in response to
the chapter “Waste not, want not” in his 2005 report
On the State of the Public Health. The scope of the
HLG’s work was defined by the findings of this
report:
● Variation in the provision of specific health
services may be appropriate but it can also
suggest waste or inequity within the NHS.
● Both under-use and over-use of medical
interventions can be costly and expose patients
to unnecessary risk.
● Variation that cannot be explained by the needs
of patients may occur on the basis of geography
(“postcode prescribing”), on account of the
preferences and habits of clinical decision
makers, or due to other factors, such as the
socioeconomic status of patients.
● Variation is demonstrable in many areas of
medical practice, including prescribing patterns,
hysterectomy, treatment for people with coronary
disease, and tonsillectomy among children.
● Inappropriate variation may be a function of poor
knowledge, the flawed application of the correct
knowledge, a lack of resources, or the
inappropriate allocation of extant resources.
● The efforts of the National Institute for Health and
Clinical Excellence (NICE) and NHS Connecting
for Health in the effective dissemination of
knowledge should be redoubled.
● Commissioners of health services should reaffirm
their commitment to the NHS principle of equity,
and techniques should be developed further to
facilitate benchmarking of provision.
● NICE should be asked to issue guidance to the
NHS on disinvestment, away from established
interventions that are no longer appropriate or
effective, or do not provide value for money.1
On the State of the Public Health, Annual report of the Chief Medical Officer 2005. Department of Health, 2006.
1.2 The Group’s terms of reference were:
● To identify illustrative and informative examples of
major clinical significance drawn from major
domains of clinical care in England where there
are significant variations in (evidence-based) best
practice and/or where efficiency and organisation
of care fall short of international benchmarks.
● To review the evidence base for measures aimed
at enhancing the effectiveness and efficiency of
clinical care that might be applied to these
domains.
● Drawing on these analyses, to recommend a
programme of action to enhance the
effectiveness and efficiency of clinical care,
including specific incentives that might be
employed.
1.3 High Level Group members are listed at
page 14.
1.4 The HLG subsequently commissioned
Professor Martin Eccles of the Institute of Health and
Society at Newcastle University to summarise
existing activity within government, the NHS, the
Royal Colleges and professional and other relevant
bodies, and set out current thinking on clinical
effectiveness and barriers to implementation of
guidelines and the boundaries of current knowledge.
His work forms Part 2 of this publication. It shows
that there is a wide range of activities aimed at
supporting clinical effectiveness ongoing within the
NHS, but the degree to which they are fully
integrated and aware of each other’s activities is not
clear. Additionally, it is not clear which organisation
has lead responsibility for the several dimensions of
clinical effectiveness. The report also identifies the
rapidly increasing volume of evidence available to
inform promotion of clinical effectiveness. Professor
Eccles proposed that a series of explicit frameworks
would be useful in order to address systematically
the promotion of clinical effectiveness and suggested
8
1
Clinical Efectiveness 19/10/07 15:44 Page 9
Introduction
that such frameworks are not currently commonly
used.
1.5 The Group considered this evidence and
identified specific underlying issues, and has made
recommendations to the Chief Medical Officer to
address them. These include possible ways forward
to improve clinical effectiveness in the NHS and
promote clinical engagement to deliver this.
9
Clinical Efectiveness 19/10/07 15:44 Page 10
Issues
2.1 The HLG’s view is that the NHS does not
systematically address evidence-based clinical
effectiveness (EBCE). There are a number of factors
behind this:
● A policy climate that emphasises aspects of
performance other than those that relate to
EBCE. Whilst many of these may be important,
they are prosecuted at the cost of the clinical
effectiveness agenda (e.g. clinical governance
versus clinical effectiveness). This produces
disincentives for managers to engage with this as
an issue.
● Whilst there is much activity that, in general,
relates to EBCE, the coordination and alignment
of these activities is unclear.
● EBCE is complex and requires a systematic,
organisation-wide approach.
● The absence of systematic data on the quality of
clinical care. Whilst there are some areas of data
(e.g. some areas of the Quality and Outcomes
Framework in primary care) there are many where
this is not the case. There was a general feeling
within the HLG that such data should be the
subject of legitimate and routine discussion at
Board level in healthcare organisations, and is
not.
● Healthcare organisations have little or no financial
resource to direct towards EBCE. This is a
“chicken and egg” problem; where other things
are important and urgent they will attract attention
and funding. Until EBCE is important and urgent,
it will not.
● Were resources to be available, most
organisations do not have trained staff with the
requisite skills to address EBCE. Novel skills
would be likely to include:
■ being able to utilise the “evidence” in Section
3 of Part 2 of this report;
■ understanding the science of behaviour
change at an individual, team and
organisational level;
■ understanding theoretical perspectives on
human behaviour change; conducting
diagnostic analyses;
■ identifying and using explicit change models
and frameworks.2,3
2 Sanson-Fisher RW, Grimshaw JM, Eccles MP. The science of changing provider’s behaviour: the missing link in evidence-based
practice. Medical Journal of Australia, 2004; 180: 205–6.
3 Grol R, Wensing M, Eccles M (Eds). Improving Patient Care: Implementing change in clinical practice. Oxford, Elsevier, 2004.
● Sadly, there is the issue of “paradigm wars”.
The nature and credibility of evidence will be
challenged from disciplinary, rather than scientific
perspectives. Rather than concentrating on
legitimate debates, such as how best to match
study design to question posed, arguments will
instead continue to be conducted about
questions such as whether randomised controlled
trials (RCTs) are ever relevant in quality of care or
organisational research.
What do we mean by evidence-based
clinical effectiveness?
2.2 What are the core activities that comprise
EBCE, not only for clinicians but for all staff working
in the NHS? There are current definitions of clinical
effectiveness (e.g. footnote 6 on page 17) but these
do not automatically translate into the structure,
staffing and skills that would be required. Defining
these (by some means) would be a large step along
the road to defining what a systematic approach to
EBCE would look like.
2.3 This would be an important prerequisite to
subsequent steps.
10
Clinical Efectiveness 19/10/07 15:44 Page 11
Issues
Engaging constituencies
2.4 Fundamental to the HLG’s approach is
engagement of the constituency – clinicians,
managers and patients – throughout the process.
This needs to include a Clinical Reference Board of
respected clinicians, currently not in management
roles, as well as links with the professions through
the Colleges and Academy of Royal Colleges.
2.5 Part of the process of engaging constituencies
will involve engaging with those involved in the
current activities listed in Appendix 1.
Strong central clinical voices
2.6 As a new generation of medical leaders
emerges through a variety of educational initiatives
this need will begin to be addressed; but the voice
for clinical quality needs to be heard more strongly at
Strategic Health Authority level and professional
bodies need to promote the need for evidence-
based transformational change.
What are the educational needs
raised by this agenda?
2.7 Education spanning undergraduate selection
through to Continuous Professional Development,
revalidation and remediation needs to embrace not
only the technical aspects of evidence-based
practice and change management but also the
inculcation of a new professionalism, which
acknowledges the resource management and
service responsibilities of the doctor and other clinical
leaders.
2.8 Pursuing an EBCE agenda would rapidly
identify a number of educational needs of which this
list provides a starting point:
● There is a need for clinicians to critically appraise,
understand and be able to use the results of
evidence-based implementation. In general,
evidence-based medicine skills (question
recognition and formulation, searching, critical
appraisal, interpretation and application of
research evidence) are still absent or poorly
developed in much of clinicians’ education, both
undergraduate and postgraduate. These skills are
an essential underpinning for a culture of clinical
effectiveness, and national standards and training
are needed.
● Diagnosis and treatment of clinical effectiveness
problems, including understanding of how to use
the science of behaviour change at an individual,
team and organisational level; understanding
theoretical perspectives on human behaviour
change; conducting diagnostic analyses;
identifying and using explicit change models and
frameworks. Knowledge and skills in this area will
draw heavily on the social sciences.4
● An understanding of the relationships between
health policy, management and evidence. This will
deal with issues such as the differing use of
evidence by different groups.5
2.9 Examples of two programmes from Canada
that address these issues to some extent are the
Alberta SEARCH Training Programme
(www.searchca.net/users/folder.asp) and the
Canadian Health Services Research Foundation
EXTRA Programme
(www.chsrf.ca/extra/index_e.php).
What are the research needs raised
by this agenda?
2.10 The research agenda was not the main focus
of the scoping document. However, a number of
areas emerged from the content; there are doubtless
many more.
Secondary research
2.11 There is a need for continuing efforts to
identify and synthesise the relevant literature and to
continue to develop the methods of synthesis in this
area.
Primary research
2.12 There is a need for research at all points of the
process of promoting effective practice:
● the nature and applicability of evidence;
● the choice and performance of various change
models;
● the role of behavioural theory within this area;
● the development of methods of formative
evaluation;
● the production of standard tools and instruments;
4 Wensing M, Wollersheim H, Grol R. Organizational interventions to implement improvements in patient care: a structured review of
reviews. Implementation Science, 2006; 1: 2.
5 Eccles M. What is the role of research and evidence in policy making? In: Rawlins M, Littlejohns P (Eds). Delivering Quality in the NHS.
Oxford, Radcliffe Medical Press, 2004.
11
Clinical Efectiveness 19/10/07 15:44 Page 12
Issues
● the systematic development and trialling of
interventions across a range of conditions and
NHS settings.
What is the clinician focus of the
High Level Group’s work?
2.13 Nowadays many areas of clinical activity are
multidisciplinary. All of the writings on improving
quality of care identify the importance of appropriate
involvement of all members of clinical teams.
2.14 It will be important to ensure appropriate
engagement of both primary care (where over 90%
of patient contacts occur) and public health.
What are the available incentives?
2.15 Job planning needs to recognise the
requirement for protected time to manage change
and re-engineer services.
2.16 Reward systems need to reflect the value of
adopting clinically effective practice. The
“development” domain of the Clinical Excellence
Award (CEA) system could be better defined to
recognise such achievements.
2.17 Status may motivate, as well as financial
reward, and consideration should be given to the
creation of a virtual faculty (analogous to the National
Institute for Health Research NHS research faculty) of
drivers of implementation. Faculty membership could
contribute to CEA recognition.
12
Clinical Efectiveness 19/10/07 15:44 Page 13
Recommendations
Alignment of central activities
and support
3.1 The need for central support to encourage
clinically effective practice is widely recognised and
there is currently a wealth of activity, delivered by a
number of agencies.
Recommendation 1
We recommend that there should be better alignment and coordination of such activities at a national level, in the first instance with the creation of a cross-sectoral group to take this agenda forward.
Promoting local ownership
3.2 The analysis of initiatives seeking to improve
clinical effectiveness reveals that there is no “magic
bullet” and solutions are context specific, requiring
local diagnosis of the cause and often systematic
multi-layer interventions. This can only be achieved if
the local providers of healthcare are appropriately
empowered to respond to these challenges, a need
that will be even greater with the decentralisation of
NHS “control” and a multiplicity of providers
emerging as part of the plurality agenda.
Recommendation 2
We recommend a range of measures to promote local ownership of the clinical effectiveness agenda, including:
● the need for demonstration of Board-level commitment;
● the creation and alignment of individual, team and institutional incentives to engage in such activity;
● the recognition and celebration of strong local practice including nationally coordinated web-based exposure and “virtual” faculty membership.
Ensuring clinical engagement
3.3 Integral to local ownership is the critical issue
of clinical engagement. Clinicians are key
determinants of resource utilisation. Furthermore
meeting population health needs, just like meeting
those of the individual patient, requires an
appreciation of the context, the complexity of the
factors at play and the evidence base for particular
interventions; qualities that doctors in particular
should be able to exhibit. Harnessing such potential
requires a contemporary interpretation of
professionalism on the part of the clinician, adequate
education and training, and alignment of incentives.
Recommendation 3
We recommend a range of measures to equip and encourage clinicians to aspire to take the lead in promoting clinically effective practice, including:
● a fundamental review of the curricula from undergraduate studies through to revalidation to ensure that relevant technical skills and knowledge of improvement science are taught, and that the developing professional identity embraces the need to combine patient advocacy with broader responsibilities to the population served;
● putting clinicians, working in partnership with health service managers, at the heart of the local initiatives referred to in recommendation 2 above.
Harnessing the capacities
of academia
3.4 Many key advances in medical practice have
derived from the NHS and higher education working
in close partnership. University hospitals outperform
non-university hospitals on quality criteria in the most
recent Annual Health Check conducted by the
Healthcare Commission. Yet changes in NHS
13
Clinical Efectiveness 19/10/07 15:44 Page 14
Recommendations
organisation and the commissioning of education
and training threaten the advantages such
partnership can bring. Educational outreach,
academic detailing and peer leaders are helpful
approaches in the pursuit of clinical effectiveness.
Moves to provide more care in the community and
the growing importance of public health and chronic
disease management offer opportunities for new
models of “academic health centres” to drive
quality improvement.
Recommendation 4
We recommend that the health service harnesses better the capacity of higher education to assist with this agenda through promoting the development of new models of community-wide “academic health centres” to encourage relevant research, engagement and population focus and embed a critical culture that is more receptive to change.
Pursuing the research agenda
3.5 If the solutions were straightforward, they
would have been discerned by now. The HLG
has uncovered many areas where the evidence base
is lacking. In the long run the adoption of a
non-evidence-based approach undermines the very
culture that is being promoted.
Recommendation 5
We recommend that an expert group be formed to reveal the major evidence deficits in relation to the implementation of clinical effectiveness and highlight the issues of organisational receptiveness and culture and functional teams for particular attention. The outcome of such work should feed in to commissioning considerations of the NHS R&D Service Delivery and Organisation Programme.
High Level Group on Clinical
Effectiveness – Membership
Professor Chairman, and
Sir John Tooke Dean, Peninsula Medical School
Sir Iain Chalmers Editor, James Lind Library
Professor Chief Executive Officer, NHS
Bernard Crump Institute for Innovation and
Improvement
Ian Dodge Reform Implementation,
Department of Health
Professor Professor of Public Health,
Shah Ebrahim London School of Hygiene and
Tropical Medicine
Professor Professor of Primary Care
Martin Eccles Research, Newcastle University
Professor Director, Centre for Evidence-
Paul Glasziou based Medicine, University of
Oxford
Sir Muir Gray Director of Clinical Knowledge,
Process and Safety, NHS
Connecting for Health
Dr Gillian Leng Implementation Systems Director,
National Institute for Health and
Clinical Excellence
Professor
Stuart Logan
Director, Health and Social Care,
Peninsula Medical School
Professor Chairman, National Institute for
Sir Michael Rawlins Health and Clinical Excellence
Hugh Rogers NHS Institute for Innovation and
Improvement
Dr Sheila Shribman National Clinical Director for
Children, Young People and
Maternity Services, Department
of Health
Dr Jenny Simpson Chief Executive, British
Association of Medical Managers
John Bromley Secretariat, Department of Health
Deirdre Feehan Secretariat, Department of Health
Anne Moger Secretariat, Department of Health
14
Clinical Efectiveness 19/10/07 15:44 Page 15
Part 2 Scoping Report for the High Level Group on Clinical Effectiveness
by
Professor Martin Eccles
Paula Whitty (Section 1)
Institute of Health and Society
Newcastle University
Clinical Efectiveness 19/10/07 15:44 Page 16
Summary
4.1 This scoping report has three sections.
4.2 Section 1 presents a descriptive background
of who is currently doing what. It covers initiatives
within the Department of Health (DH), the National
Institute for Health and Clinical Excellence (NICE), the
NHS Institute for Innovation and Improvement, and
the Healthcare Commission; ongoing workstreams
within the Royal Colleges and other professional
bodies, and local initiatives in the NHS.
● There is a wide range of national-level activities
aimed at supporting clinical effectiveness ongoing
within the NHS.
● The degree to which activities are fully integrated,
and participants are aware of each other’s
activities, is not clear.
● It is not clear whether any single organisation has
lead responsibility for the several dimensions of
clinical effectiveness.
● It is much less certain what is happening at a
local level; activities appear to be much less well
documented.
● We are not aware of local organisations with the
capability to carry out detailed diagnostic analysis,
intervention development, or comprehensive
monitoring of key clinical outcomes or proxy
outcomes.
4.3 Section 2 presents current thinking on how to
approach the issues of clinical effectiveness and
barriers to implementation of guidelines or effective
practices.
4.4 When it comes to promoting clinically effective
practice, everyone is sure that they know what needs
to be done. Their solutions usually reflect discipline,
areas of expertise or interest; they seldom agree, and
are more likely to be belief- than evidence-based.
● Different players in healthcare use different
approaches to changing clinical practice; most of
these approaches are more based on beliefs than
on scientific evidence.
● Implementing such changes seldom entails a
single action; it usually demands good planning
and a combination of different interventions.
● Before a strategy to implement change is
selected, the obstacles to change should be
identified.
● Evidence-based medicine should be
complemented by evidence-based
implementation.
4.5 This section presents a series of frameworks
that offer a structure for thinking about improving
clinical effectiveness in the context of the NHS in
England. The frameworks reflect:
● levels of organisation within healthcare;
● priorities for choosing topics for attention;
● a model for diagnosing and treating problems of
clinical effectiveness;
● available empirical treatments for clinical
effectiveness problems.
4.6 Section 3 presents an overview of current
knowledge on the effectiveness of strategies to
promote the uptake of clinically effective practice.
● Evidence of “what to do” (effectiveness of
interventions) to promote clinical effectiveness
should come from (systematic reviews of)
randomised controlled trials (RCTs).
● Evidence of “how to do it” should come from
formative evaluations, ideally conducted within or
alongside RCTs.
● There is a large and increasing amount of
evidence to inform the uptake of clinically effective
practice.
● While there may be methodological issues within
this literature, it represents a valuable resource to
underpin evidence-based clinical effectiveness.
16
Clinical Efectiveness 19/10/07 15:44 Page 17
Section 1
Activities in the NHS related to supporting clinical effectiveness
Summary
● There is a wide range of national-level activities
aimed at supporting clinical effectiveness ongoing
within the NHS.
● The degree to which activities are fully integrated,
and participants are aware of each other’s
activities, is not clear.
● It is not clear whether any single organisation has
lead responsibility for the several dimensions of
clinical effectiveness.
● It is much less certain what is happening at a
local level; activities appear to be much less well
documented.
● We are not aware of local organisations with the
capability to carry out detailed diagnostic analysis,
intervention development, or comprehensive
monitoring of key clinical outcomes or proxy
outcomes.
Introduction
5.1 This section provides an overview of current
activity on clinical effectiveness in the English NHS;
detail is provided in the tables in Appendix 1.
It covers initiatives within DH, NICE, the NHS Institute
for Innovation and Improvement, and the Healthcare
Commission; ongoing workstreams within the Royal
Colleges and other professional bodies, and an
overview of local initiatives in the NHS.
5.2 Note that we have attempted to give a
reasonably comprehensive overview of relevant
activities, regardless of whether or not there is an evidence-base for the effectiveness of the initiatives described. We have also focused on the
activities and not on the outcomes of those activities.
5.3 The inclusion of activities as relevant is
informed by the NHSE 1996 definition of clinical
effectiveness6 and the domain outcome in DH
Standards for Better Health.7 However, while some
of the activities described do have a bearing on
cost-effectiveness/efficiency, the focus here is mainly
on clinical effectiveness. We have also omitted
activities related to the basic underpinning of clinically
effective care such as new evidence generation
through research, and undergraduate or other basic
clinical training.
5.4 To ensure reasonable coverage of relevant
activities, they were initially mapped and are
categorised in Appendix 1 using the following
framework:8
● setting evidence-based standards;
● supporting delivery of evidence-based
standards/effective care;
● monitoring the delivery of effective care.
5.5 Activities deemed to be supporting delivery
of effective care are further sub-divided as:
● inputs (knowledge, skills, other resources);
● processes that support delivery;
● activities that focus on outcomes.
5.6 A draft of this section and Appendix 1 has
been rapidly reviewed for omissions by colleagues
leading on clinical effectiveness in two acute Trusts
and two Primary Care Trusts (PCTs).
5.7 The detailed list of relevant activities is
provided in Appendix 1. The remainder of this
section of the report provides an overview, and also
highlights obvious gaps in current provision.
6 “The extent to which specific clinical interventions, when deployed in the field for a particular patient or population, do what they are
intended to do – i.e. maintain and improve health and secure the greatest possible health gain from the available resources.” Promoting
Clinical Effectiveness – A framework for action in and through the NHS. NHSE, 1996.
7 “Patients achieve health benefits that meet their individual needs through health care decisions and services based on what assessed
research evidence has shown provides effective clinical outcomes.” In: Standards for Better Health. Department of Health, July 2004.
8 Adapted from A First Class Service. Department of Health, 1998.
17
Clinical Efectiveness 19/10/07 15:44 Page 18
Section 1: Activities in the NHS related to supporting clinical effectiveness
National-level activities
5.8 National activities fall, broadly, into
government- and non government-funded initiatives.
Of the government-funded initiatives, there are “core”
clinical effectiveness organisations or programmes
(e.g. NICE) and “supportive” programmes (such as
the National Programme for IT (NPFIT)/NHS
Connecting for Health (CfH)). Non government-
funded initiatives are chiefly those funded and
provided by professional bodies, although there are
some charitable foundations operating in the broader
quality field (e.g. the Health Foundation).
5.9 There is clear responsibility for setting evidence-
based clinical standards through NICE. Currently NICE
produces guidance in four areas of health:
● Technology appraisals – guidance on the use of
new and existing medicines and treatments within
the NHS in England and Wales.
● Clinical guidelines – guidance on the appropriate
treatment and care of people with specific
diseases and conditions within the NHS in
England and Wales.
● Interventional procedures – guidance on whether
interventional procedures used for diagnosis or
treatment are safe enough and work well enough
for routine use in England, Wales, Scotland and
Northern Ireland.
● Public health intervention and programme
guidance.
5.10 National Service Frameworks (NSFs) also set
standards at an organisational level. There will always
be an issue of coverage, particularly in keeping up
with technology appraisal of new treatments. NICE
has also recently gained responsibility for a
workstream to identify “inappropriate interventions”.
5.11 The Healthcare Commission has clear
responsibility for assessing performance against
Standards for Better Health, and new and existing
national targets, in individual healthcare organisations.
While the Commission’s Annual Health Check currently
covers Trust structures, policies and procedures
relevant to clinical effectiveness reasonably well,
evidence on the actual delivery of NICE guidance is
more limited. NICE and the Healthcare Commission
are working together to improve the availability of
indicators related to the delivery of NICE guidance,
and this also forms a key plank of NICE’s
Implementation Programme. The coverage of NICE
guidance in the Healthcare Commission’s assessment
activities is shown in Table 1.
5.12 Other evidence on clinical outcomes or the
delivery of effective care is limited to national targets
assessment or service reviews. The Healthcare
Commission is currently reviewing its overall
approach to clinical effectiveness assessment,
including the potential for a wide-ranging basket of
clinical indicators to operate within its wider
surveillance activities.
5.13 There is also a range of other bodies whose
findings contribute to the monitoring of effective care,
notably the national clinical audits (which are usually, but
not exclusively, funded by the Healthcare Commission
and operated by the Royal Colleges or Health and Social
Care Information Centre (HSIC)). However, even taking all
these activities together with those of the Healthcare
Commission, NICE’s Implementation Programme, and
other initiatives such as the Better Metrics project, there
is no comprehensive national programme that covers all
key areas of clinical care.
5.14 There is a wide range of activities which
potentially offer support to the delivery of clinically
effective care, but also some gaps.
5.15 Knowledge provision (on what is effective
practice) is (potentially) well covered by initiatives;
whereas training on evidence-based practice has
declined substantially since its heyday in the late
1990s (probably mirroring the decline of the
Table 1. Coverage of NICE guidance in the Healthcare Commission’s assessment activities
Healthcare Commission assessment
NICE guidance
Technology appraisals Clinical guidelines Interventional
procedures
Public health
guidance
National clinical audits – Yes – –
Service reviews Yes Yes – –
Assessment of core standards Yes Yes Yes –
Assessment of developmental standards – Yes – Yes
New national targets Yes Yes – –
National reviews – Yes – –
Independent sector inspections Yes Yes Yes –
18
Clinical Efectiveness 19/10/07 15:44 Page 19
Section 1: Activities in the NHS related to supporting clinical effectiveness
“evidence-based medicine” (EBM)” movement as a
popular method for promoting clinical effectiveness).
5.16 Incentives (targets, financial incentives) are
strong in those areas also covered by the early NSFs
(particularly heart disease; cancer and mental health
are well-supported by targets but not in the Quality
and Outcomes Framework (QOF), though there is
more mental health coverage in the latest revision).
5.17 NICE’s Implementation Programme includes a
numbers of tools to support the delivery of its
guidance. There is generic advice on implementation
through their “How to” guide, which identifies steps
separately for technology appraisals, clinical
guidelines and interventional procedures guidance.
Implementation advice tailored to specific topics,
accompanied by slide sets, is available for more
recent guidance and includes example action plans.
NICE is planning to produce a “How to influence
practice” guide, which may cover some of the more
detailed aspects of implementation not yet covered
by their tools (e.g. “diagnostic analysis” to identify
barriers to and facilitators of the delivery of high
quality care, and intervention development
techniques to systematically develop the most
suitable tailored interventions to improve care).
5.18 The NHS Institute for Innovation and
Improvement has a broader role to support the NHS
in service transformation/improvement. In particular,
its “Delivering Quality and Value” programme aims to
improve efficiency as well as effectiveness of care.
Outputs from this programme include the “Better
Value, Better Care Indicators” and nine “Focus On”
documents to date for high volume clinical topics.
These documents provide illustrative care pathways
and overarching organisational characteristics that
appear to lead to best practice in these areas, as
well as case studies and “field tests”. Within specific
care groups or disease areas, there may also be
practical support available through other national
Institutes (e.g. the National Institute for Mental Health
in England (NIMHE)) or national support teams (e.g.
for heart disease or diabetes). The functions of the
latter teams are currently being reviewed by the
Office of the Strategic Health Authorities.
Local initiatives
5.19 There are a number of expectations related to
clinical effectiveness laid on Trusts, including in
national guidance9 and the Standards for Better
Health.7 There is also a legal requirement for
organisations to fund NICE-recommended
technology appraisals, as well as more recent
clarification on how Trusts should proceed in
situations where new treatments have not yet been,
or are not planned to be, appraised by NICE.10
5.20 The clinical and cost-effectiveness standard
within Standards for Better Health states:
Core standards
C5. Healthcare organisations ensure that:
a) they conform to NICE technology appraisals
and, where it is available, take into account
nationally agreed guidance when planning and
delivering treatment and care;
b) clinical care and treatment are carried out
under supervision and leadership;
c) clinicians continuously update skills and
techniques relevant to their clinical work; and
d) clinicians participate in regular clinical audit
and reviews of clinical services.
Developmental standard
D2. Patients receive effective treatment and care
that:
a) conform to nationally agreed best practice,
particularly as defined in National Service
Frameworks, NICE guidance, national plans
and agreed national guidance on service
delivery;
b) take into account their individual requirements
and meet their physical, cultural, spiritual and
psychological needs and preferences;
c) are well coordinated to provide a seamless
service across all organisations that need to
be involved, especially social care
organisations; and
d) is delivered by healthcare professionals who
make clinical decisions based on evidence-
based practice.
5.21 Healthcare organisations had to declare their
performance against the core standards, including
C5 above, for the first time at the end of 2005/06.
After selective inspection of 20% of Trusts, which in
some cases will have resulted in amendments to
their self-assessment, their performance was
published in the Healthcare Commission’s 2005/06
Annual Health Check (AHC) in October 2006. For this
HSC 1999/065: Clinical Governance in the New NHS www.dh.gov.uk/_PublicationsAndStatistics/LettersAndCirculars/DH_4004883
10 HSC 1999/176; Good Practice Guidance. Department of Health, 2006.
19
9
Clinical Efectiveness 19/10/07 15:44 Page 20
Section 1: Activities in the NHS related to supporting clinical effectiveness
AHC, the percentages of Trusts declaring “fully met”
for C5 were: (a) 85%; (b) 94% (c) 96% (d) 95%. The
first Trust declarations on the developmental clinical
and cost effectiveness standard will not be available
until 2007, and only for acute and mental health
Trusts.
5.22 Other surveys of the implementation of clinical
governance have tended to suggest that less
progress has been made on quality improvement
than on quality assurance. For example, a national
survey of healthcare managers’ perceptions
suggested that they perceived higher achievement
against items concerning structural change,
corporate accountability and risk management than
against those concerned with quality improvements
and outcomes. Benchmarking and the use of clinical
indicators were two of the items which respondents
considered were particular areas of
underachievement.11
5.23 The local activities listed in Appendix 1 are
drawn from example clinical effectiveness strategies
and from the author’s and reviewees’ experience.
Clinical effectiveness initiatives are not separate from
the core business of organisations – e.g. the various
system reform/redesign initiatives are all relevant.
In terms of current reforms, one of the key initiatives
is commissioning, and ensuring this is based on
quality standards is essential – hence the NICE
initiative to produce commissioning guides.
5.24 While some relevant activities may have been
missed, we are not aware of local organisations with
the capability to carry out detailed diagnostic
analysis, intervention development, or comprehensive
monitoring of key clinical outcomes or proxy
outcomes.
11 Freeman T, Walshe K. Achieving progress through clinical governance? A national study of health care managers’ perceptions in the
NHS in England. Quality and Safety in Health Care, 2004; 13: 335–43.
20
Clinical Efectiveness 19/10/07 15:44 Page 21
Section 2
How to approach the issues of clinical effectiveness and barriers to implementation of guidelines or effective practices
Summary
6.1 When it comes to promoting clinically effective
practice, everyone is sure that they know what needs
to be done. Their solutions usually reflect discipline,
areas of expertise or interest; they seldom agree, and
are more likely to be belief- than evidence-based.
● Different players in healthcare use different
approaches to changing clinical practice; most of
these approaches are more based on belief than
on scientific evidence.
● Implementing such changes seldom entails a
single action; it usually demands good planning
and a combination of different interventions.
● Before a strategy to implement change is
selected, the obstacles to change should be
identified.
● Evidence-based medicine should be
complemented by evidence-based
implementation.
6.2 This section presents a series of frameworks
that offer a structure for thinking about improving
clinical effectiveness in the context of the NHS in
England. The frameworks reflect:
● levels of organisation within healthcare;
● priorities for choosing topics for attention;
● a model for diagnosing and treating problems of
clinical effectiveness;
● available empirical treatments for clinical
effectiveness problems.
Introduction
6.3 When it comes to promoting clinically effective
practice, everyone is sure that they know what needs
to be done. Their solutions usually reflect discipline,
areas of expertise or interest; they seldom agree, and
are more likely to be belief- than evidence-based.
The reason for suggesting the need for an explicit,
systematic approach to clinical effectiveness is
illustrated by Grol (1997).12
“That improvements are possible in many areas of
clinical care has become increasingly clear. The
different players within health care, however –
clinicians, epidemiologists, health services
researchers, educationalists, social scientists,
economists, health authorities – often have different
ideas on the best strategies to improve practice
and the best way of making changes.”
An example
Let us assume that aggregated data, collected by
health authorities, disclose that the rate of
caesarean section in a specific district is
exceptionally high. A committee is formed with
experts and representatives of various interests to
develop plans for improving obstetric care. Hearing
the problem, all are worried.
The clinician either denies there is a problem or
proposes setting up a well designed course to
increase clinicians’ knowledge and skills.
“OK,” says the clinical epidemiologist, “but we first
need to know what the evidence is on the
indications for a caesarean section. We should
perform a meta-analysis and come up with
evidence-based guidelines to disseminate among
the obstetricians.”
“No,” says the educational expert: “that is a top
down approach and such strategies will usually fail.
Form small groups of doctors and let them discuss
the problem, using cases and experiences from
their own practices as the basis for local
arrangements on new routines.”
12 Grol R. Personal paper: Beliefs and evidence in changing clinical practice. BMJ, 1997; 315: 418–21.
21
Clinical Efectiveness 19/10/07 15:44 Page 22
Section 2: How to approach the issues of clinical effectiveness and barriers to implementation of guidelines or effective practices
“We should take a look at the facts first,” says the
health services researcher. “Let us set up a
multicentre audit first and collect data on actual
variation between hospitals and include data on
casemix. Feeding this information back to the
hospitals will probably stimulate improvement.”
“You are all focusing too much on the individual
doctor,” says the management expert. “The
problem is not the doctor, but the system. We
should analyse the process of decision making and
performing the caesarean sections and see what
structures determine the process. Next we need a
quality improvement team.”
“This is all too much talking,” says the
representative of the health authorities. “Doctors are
sensitive only to what happens to their budgets. We
need to put a pressure on them to limit the number
of caesarean sections per hospital, give hospitals a
reasonable budget, and provide the obstetricians
with an incentive when they reduce the rate.”
6.4 Having expanded the arguments within the
paper, Grol’s summary points are:
● Different players in healthcare use different
approaches to changing clinical practice; most of
these approaches are more based on belief than
on scientific evidence.
● Implementing such changes seldom entails a
single action; it usually demands good planning
and a combination of different interventions.
● Before a strategy to implement change is
selected, the obstacles to change should be
identified.
● Evidence-based medicine should be
complemented by evidence-based
implementation.
Frameworks
6.5 This section presents a series of frameworks
that offer a structure for thinking about improving
clinical effectiveness in the context of the NHS in
England. The frameworks reflect:
● levels of organisation within healthcare;
● priorities for choosing topics for attention;
● a model for diagnosing and treating problems of
clinical effectiveness;
● available empirical treatments for clinical
effectiveness problems.
6.6 Each of these frameworks, in its own way,
acknowledges both the complexity of healthcare
delivery and the fact that local circumstances will
vary. Whilst there are interventions that have been
shown in research studies to be effective across a
range of contexts, the introduction of such
interventions into a local healthcare setting will
always be dependent on an understanding of local
context. This understanding of context can be
central to successful clinical effectiveness. The
frameworks all identify the importance of, but do not
seek to control, this local variation but clearly identify
it as something that should be understood at a
local level.
Levels of engagement – seeing the whole
picture
6.7 Efforts to improve the quality of care,
particularly for chronic diseases which are complex
to manage, need to occur at and be coordinated
across multiple levels – such as the patient, clinician,
team, organisation, policy. In their article in Milbank
Quarterly,13 Ferlie and Shortell said:
6.8 “Fuelled by public incidents and growing
evidence of deficiencies in care, concern over the
quality and outcomes of care has increased in both
the United Kingdom and the United States. Both
countries have launched a number of initiatives to
deal with these issues. These initiatives are unlikely to
achieve their objectives without explicit consideration
of the multilevel approach to change that includes the individual, group/team, organization, and larger environment/system level. Attention must be
given to issues of leadership, culture, team
development, and information technology at all
levels. A number of contingent factors influence
these efforts in both countries, which must each
balance a number of tradeoffs between centralization and decentralization in efforts to
sustain the impetus for quality improvement over
time. The multilevel change framework and
associated properties provide a framework for
assessing progress along the journey.” (The
emphasis is mine.)
6.9 This framework highlights the importance of
considering the multiple levels at which healthcare
is delivered and the interplay between them.
13 Ferlie EB, Shortell SM. Improving the quality of health care in the United Kingdom and the United States: a framework for change.
The Milbank Quarterly, 2001; 79(2): 281–315.
22
Clinical Efectiveness 19/10/07 15:44 Page 23
Section 2: How to approach the issues of clinical effectiveness and barriers to implementation of guidelines or effective practices
Choosing topics
6.10 Many of the taxonomies for choosing topics
relate to guideline development. They vary slightly in
emphasis but address many of the same general
issues. Three examples are offered.
6.11 The first, from NICE, is summarised here and
is in full in Appendix 2. NICE’s criteria clearly refer to
the specific context in which this taxonomy operates.
The selection criteria take into account:
● burden of disease (population affected, morbidity,
mortality);
● resource impact (i.e. the cost impact on the NHS
or the public sector);
● policy importance (i.e. whether the topic falls
within a government priority area);
● whether there is inappropriate variation in practice
across the country;
● factors affecting the timeliness or urgency for
guidance to be produced.
6.12 The criteria used by Shekelle and colleagues14
focus on attributes of the clinical condition:
6.13 “Guidelines can be developed for a wide range
of subjects. Clinical areas can be concerned with
conditions (abnormal uterine bleeding, coronary
artery disease) or procedures (hysterectomy,
coronary artery bypass surgery). Given the large
number of potential areas, some priority setting is
needed to select an area for guideline development.
Potential areas can emerge from an assessment of:
● the major causes of (modifiable) morbidity and
(premature) mortality for a given population;
● uncertainty about the appropriateness of
healthcare processes (i.e. inappropriate variation);
● evidence that they (clinical interventions) are
effective in improving patient outcomes;
● the need to conserve resources in providing care.”
6.14 The criteria for topic selection given by
Burgers and colleagues15 are less explicit about these
but go on to include dimensions of the perceived
feasibility of addressing the process:
● “the topic concerns a relevant problem that
occurs frequently, and guideline development
allows improvement in health or cost reduction;
● it is possible to define the topic and focus on the
most crucial aspects;
● there is uncertainty or difference of opinion about
the best care;
● there is a need to bring together scientific
knowledge and expertise, or there are new
insights;
● sufficient scientific evidence is available;
● there is a real opportunity to achieve consensus
on the final recommendations;
● it is possible to formulate feasible
recommendations.”
6.15 One consideration for the use of any set of
criteria is the degree to which current clinical
effectiveness activities cover the major relevant
clinical conditions.
A model for diagnosing and treating
problems of clinical effectiveness
6.16 It is important to have an integrated structure
with which to represent various steps and sequences
of a process to change behaviour and improve
clinical effectiveness. There are several such
available, one of which, from Grol16 (2005), is
reproduced overleaf.
6.17 The topic selection criteria above feature
within the top boxes of this model. The Ferlie and
Shortell “levels” feature throughout the model. Thus
local context could be part of what generated the
initial problems, would influence the structure of the
planning process and would be an important
consideration in the “diagnostic analysis” of
performance group and setting. It would also shape
the implementation plan.
6.18 A model such as this may look simple.
However, when clinical governance leads from a
(small) number of NHS organisations were
interviewed about what evidence-based strategies
they could routinely and systematically use to
promote clinical effectiveness, they did not identify
any systematic approach.17 They reported that, in
14 Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: Developing guidelines. BMJ, 1999; 318: 593–6.
15 Burgers J, Grol R, Eccles M. Clinical guidelines as a tool for implementing change in patient care. In: Grol R, Wensing M, Eccles M
(Eds). Improving Patient Care: Implementing change in clinical practice. Oxford, Elsevier, 2004.
16 Grol R, Wensing M. Effective implementation: A model. In Grol R, Wensing M, Eccles M (Eds). Implementation of Change in Clinical
Practice, pp41–57. Oxford, Elsevier, 2005.
17 Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay C, Vale L, Whitty P, Eccles M, Matowe L, Shirren L, Wensing M,
Dijkstra R, Donaldson C. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technology
Assessment, 2004; 8(6) iii-iv, 1–72.
23
Clinical Efectiveness 19/10/07 15:44 Page 24
Section 2: How to approach the issues of clinical effectiveness and barriers to implementation of guidelines or effective practices
Figure 1. Implementation of change: a model
Research findings
or guidelines
Problems identified, good experiences or
best practices
Adapting or improving proposal
Supplementary analyses
New strategies
Adapting plan
Goals not achieved
Development of concrete proposal/ targets for improvement or change
Analysis of performance, target group and setting
Development/selection of strategies and measures to change practice
Development, testing and execution of implementation plan
(Continuous) evaluation and (where necessary) adapting plan
Planning ● clear aims ● coordination/team ● involving target group ● budget ● time schedule
terms of available skills and resources, all they
planned were postal distribution of educational
materials, audit and feedback and educational
meetings. Similarly, in the USA at an American
College of Chest Physicians meeting in 2004,18
67 out of 87 participants (a 77% response rate)
completed a survey about feasibility, acceptability,
and cost for each of six implementation strategies.
Respondents indicated that distribution of
educational material and educational meetings were
feasible, acceptable and of low cost; differences
between the rating of these two strategies were not
statistically significant. Respondents reported
educational outreach visits, computer reminders and
patient-mediated interventions as feasible and
acceptable, but rated educational outreach visits as
more costly. Audit and feedback scored lower than
all other implementation strategies in terms of
feasibility and acceptability; respondents also rated
audit and feedback as unfavourably as educational
outreach visits in terms of cost.
6.19 The skills, structures and resources to
systematically integrate the use of a model such as
Grol’s at a local level are not known.
Available empirical treatments for clinical
effectiveness problems
6.20 Another time when it is helpful to have a
framework is when thinking about the range of
available effective “treatments” for a clinical
effectiveness problem. This step represents Grol’s
“Evidence-based implementation” (the effectiveness
of interventions is dealt with in Section 3) and fits into
the “Development/selection of strategies” box of
Grol’s model.
6.21 On page 25, we present the (empirically-based)
taxonomy of interventions used by the Cochrane
Collaboration Effective Practice and Organisation of
Care (EPOC) Group. The purpose of presenting the
taxonomy is to demonstrate both the range and
complexity of the available candidate “treatments”.
There are two important points regarding the
taxonomy. Firstly, it is empirically derived; this means
that it will not be absolutely exhaustive. Secondly,
there is a considerable volume of published evidence
behind many of the techniques listed (see Section 3).
6.22 EPOC reviews, and hence the taxonomy,
include professional, financial, organisational or
regulatory interventions. A summarised list is
presented here; full details can be obtained from the
Data Collection Checklist at http://epoc.cochrane.org
18 Schunemann HJ, Cook D, Grimshaw J, Liberati A, Heffner J, Tapson V, Guyatt G. Antithrombotic and Thrombolytic Therapy: From
Evidence to Application. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 2004; 126: 688S–696S.
24
Clinical Efectiveness 19/10/07 15:44 Page 25
Section 2: How to approach the issues of clinical effectiveness and barriers to implementation of guidelines or effective practices
Professional interventions
a) Distribution of educational materials
b) Educational meetings
c) Local consensus processes
d) Educational outreach visits
e) Local opinion leaders
f) Patient-mediated interventions
g) Audit and feedback
h) Reminders
i) Marketing
j) Mass media.
Financial interventions
Provider interventions
a) Fee-for-service
b) Prepaid
c) Capitation
d) Provider salaried service
e) Prospective payment
f) Provider incentives
g) Institution incentives
h) Provider grant/allowance
i) Institution grant/allowance
j) Provider penalty
k) Institution penalty
l) Formulary.
Patient interventions
a) Premium
b) Co-payment
c) User fee
d) Patient incentives
e) Patient grant/allowance
f) Patient penalty.
Organisational interventions
Provider-orientated interventions
a) Revision of professional roles
b) Clinical multidisciplinary teams
c) Formal integration of services
d) Skill mix changes
e) Continuity of care
f) Arrangements for follow-up
g) Case management
h) Satisfaction of providers with the conditions of
work and the material and psychic rewards
i) Communication and case discussion between
distant health professionals.
Patient-orientated interventions
a) Mail order pharmacies
b) Presence and functioning of adequate
mechanisms for dealing with patients’
suggestions and complaints
c) Consumer participation in governance of
healthcare organisation.
Structural interventions
a) Changes to the setting/site of service delivery
b) Changes in physical structure, facilities and
equipment
c) Changes in medical records systems
d) Changes in scope and nature of benefits and
services
e) Presence and organisation of quality monitoring
mechanisms
f) Ownership, accreditation, and affiliation status of
hospitals and other facilities
g) Staff organisation.
Regulatory interventions
A regulatory intervention is any intervention that aims
to change health services delivery or costs by
regulation or law. These interventions may overlap
with organisational and financial interventions.
a) Changes in medical liability
b) Management of patient complaints
c) Peer review
d) Licensure.
25
Clinical Efectiveness 19/10/07 15:44 Page 26
Section 3
Current knowledge on the effectiveness of strategies to promote the uptake of clinically effective practice
Summary
● Evidence of “what to do” (effectiveness of
interventions) to promote clinical effectiveness
should come from (systematic reviews of)
randomised controlled trials (RCTs).
● Evidence of “how to do it” should come from
formative evaluations, ideally conducted within or
alongside RCTs.
● There is a large and increasing amount of
evidence to inform the uptake of clinically effective
practice.
● Whilst there may be methodological issues within
this literature, it represents a valuable resource to
underpin evidence-based clinical effectiveness.
Introduction
7.1 When reading an evaluation of an intervention
that they might wish to use, a reader should consider
aspects of both the internal and external validity.
Internal validity will relate to elements of study design
and how unbiased, or “true”, the results are. External
validity will relate to attributes of the population
studied and how they relate to the population to
which the reader wishes to apply the results.
7.2 In using evidence about the effectiveness of
strategies to promote the uptake of clinically effective
practice both these considerations apply.
Evaluative designs
7.3 Evidence about the effectiveness of strategies
to promote the uptake of clinically effective practice
comes from a number of sources. Healthcare is
complex, with a myriad of factors able to have an
impact on the process and outcome of care. This
very complexity means that, to understand the
unbiased effect of an intervention, the gold standard
design is the RCT, with its ability to control for known
and unknown confounders. There are now many
hundreds of these and they are routinely drawn
together in systematic reviews.
7.4 There are situations where it is not feasible to
use an RCT design and other, non-experimental,
designs are used. Where it is not possible to identify
a control site (e.g. mass media interventions),
interrupted time series designs are the most robust
design. For infrequent occurrences (e.g. hospital
takeovers) case study designs are appropriate.
However, any non-experimental design lays the onus
of avoiding bias at all stages (design, conduct and
interpretation) onto the investigator.19 This problem is
topically illustrated by the differing interpretations of
the impact of the Institute for Healthcare
Improvement (IHI) 100,000 Lives Campaign. The IHI
report is of 122,300 lives saved; an independent
assessment suggests that this estimate may be
systematically biased and that the true figure is
unknowable but considerably smaller.20,21
The context for RCTs of strategies to
promote clinically effective practice
7.5 RCTs, however, do not sit alone – they
represent a point in a scientific continuum22 of
evaluation that draws on prior work exploring issues
such as the underlying theory, the range and role of
moderating and mediating factors on the behaviours
of interest and the development and pilot testing of
19 Shadish, WR, Cook, TD, Campbell, DT. Experimental and Quasi-Experimental Designs for Generalized Causal Inference. Boston,
Houghton-Mifflin, 2002.
20 Wachter RM, Pronovost PJ. The 100,000 Lives Campaign: A scientific and policy review. Joint Commission Journal on Quality and
Patient Safety, 2006; 32: 621–7. Authors reply pp 631–3.
21 Berwick DM, Hackbarth AD, McCannon CJ. IHI replies to “The 100,000 Lives Campaign: A Scientific and Policy review”. Joint
Commission Journal on Quality and Patient Safety, 2006; 32: 628–30.
22 Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, Tyrer P. Framework for design and evaluation of
complex interventions to improve health. BMJ, 2000; 321(7262): 694–6.
26
Clinical Efectiveness 19/10/07 15:44 Page 27
Section 3: Current knowledge on the effectiveness of strategies to promote the uptake of clinically effective practice
Table 2. MRC Framework for the evaluation of complex interventions
Evaluation of drugs Pre-clinical Phase I Phase II Phase III Phase IV
Evaluation of
implementation strategies
Theory Modelling Exploratory trial Definitive RCT Long-term
implementation
and sustainability
candidate interventions. This is commonly referred to
as the Medical Research Council (MRC) Framework
for the evaluation of complex interventions and is
represented in Table 2 above.
7.6 Whilst RCTs represent the gold standard for
evaluating what happened, they say little about how
observed effects may have been achieved or why.
To understand this it is necessary to conduct
process evaluations (also known as formative
evaluations23,24) embedded within trials – these are
conducted much less commonly, though examples
do exist.25,26 Development work, such as that
conducted within Phases 1 and 2 of the MRC
Framework, also offers the means of identifying the
factors to be measured within a process evaluation.
Synthesising clinical effectiveness
literature
7.7 The synthesis of literature in this area is
challenging. As with all reviews, how the question
(which the review is addressing) is framed will
influence the literature that is synthesised. Identifying
the literature is not straightforward as it is spread
across a wide number of journals and there are no
core journals that would be likely to contain a large
proportion of the core literature (hence EPOC
maintaining a specialist register of relevant studies).
Having identified the studies, data extraction is
complex with studies often reporting multiple study
outcomes with no clearly identified primary endpoint.
This can be compounded by design problems,
principally failing to allow for the clustered nature of
data which results in an overestimate of statistical
significance. Data synthesis is then problematic.
Because of the heterogeneity of endpoints, reviews
often use narrative summary. When studies cannot
be re-analysed, the use of the median effect size is
the most informative way of quantifying the effect.
However, as the quality of the literature improves it
is possible to envisage this improving.
The effect of computerising guidelines25,26
The study evaluated the use of a computerised decision support system (CDSS) to implement evidence-based
clinical guidelines for the management of adult patients with asthma or angina seen in 60 general practices in
northern England. The RCT evaluation showed that there were no significant effects of CDSS on consultation
rates, process of care measures (including prescribing) or any quality-of-life domain for either condition.
A usage log across all practices showed that levels of use of the CDSS were low. Interviews conducted with
physicians in five participating practices provided insights into why this was so. Interviewees were largely
enthusiastic about the benefits of computing for general practice, and were optimistic about the potential for
computers to present guidelines in a manageable format. However, the CDSS was felt by most practitioners
to be difficult to use and unhelpful clinically. They believed that they were already familiar with the content of
the guidelines, although they did not always follow recommendations for reasons that included limitations of
the guidelines, patient preferences, lack of incentives and perceived structural barriers. The investigators
concluded that even if it is possible to solve the technical hardware and software problems of producing a
system that fully supports chronic disease management, there remains the challenge of integrating CDSS into
clinical encounters in which busy practitioners manage patients with complex, multiple conditions.
23 Hulscher M, Laurant M, Grol R. Process evaluation of change interventions. In: Grol R, Wensing M, Eccles M (Eds). Implementation of
Change in Clinical Practice. Oxford, Elsevier, 2005.
24 Stetler CB, Legro MW, Wallace CM, Bowman C, Guihan M, Hagedorn H, Kimmel B, Sharp ND, Smith JL. The role of formative
evaluation in implementation research and the QUERI experience. Journal of General Internal Medicine, 2006; 21: S1–8.
25 Eccles M, McColl E, Steen N, Rousseau N, Grimshaw J, Parkin D, Purves I. Effect of computerised evidence-based guidelines on
management of asthma and angina in adults in primary care: cluster randomised controlled trial. BMJ, 2002; 325: 941–7.
26 Rousseau N, McColl E, Newton J, Grimshaw J, Eccles M. Practice based, longitudinal, qualitative interview study of computerised
evidence-based guidelines in primary care. BMJ, 2003; 326: 314–322.
27
Clinical Efectiveness 19/10/07 16:09 Page 28
Section 3: Current knowledge on the effectiveness of strategies to promote the uptake of clinically effective practice
Figure 2. New primary studies related to clinical effectiveness
500
400
300
200
100
0
1967 1971 1975 1979 1983
New Papers
1987 1991 1995 1999 2003
Volume of literature
7.8 As with many other areas of clinical practice,
the volume of literature relevant to promoting clinical
effectiveness is rapidly increasing. The Cochrane
Collaboration EPOC Review Group maintain a register
of relevant studies. The number of new primary
studies by year of publication is shown in Figure 2.
7.9 This also applies to systematic reviews. When
EPOC conducted an overview of systematic reviews
of professional interventions for the time period
1966-199827 they identified 41 reviews. An ongoing
update has identified 78 new systematic reviews of
professional interventions; organisational, financial
and regulatory interventions are being included for
the first time and there are 295, 20 and 9 of these
respectively.
7.10 Systematic reviews in this general area may
include study designs other that RCTs. The degree to
which this occurs will vary from topic to topic and
review to review. If a reviewer feels their question can
be answered solely by RCTs (as is becoming
increasingly common in the light of the increasing
literature) then they will usually include only RCTs.
However, if there are not any (or only a few) RCTs the
reviews will often include study designs other than
RCTs. For this reason EPOC includes interrupted
time series designs and controlled before and after
designs meeting pre-specified criteria.
The focus of systematic reviews
7.11 Systematic reviews of the evidence of the
effects of strategies to promote the uptake of
clinically effective practices fall into two broad
groups. Firstly there are intervention-based reviews
of strategies to influence the behaviour of individuals or organisations. These tend to be
reviews of the effectiveness of an empirically defined
intervention (such as reminders or audit and
feedback) across a range of healthcare professionals,
settings and clinical conditions. Secondly there are
reviews of strategies to improve care for a defined
clinical condition (e.g. diabetes mellitus) or problem
(e.g. poor prescribing) (condition- or problem-based reviews). These are usually reviews of the
effectiveness of various empirically defined strategies
across a range of healthcare professionals and
settings, but only for a single clinical condition.
7.12 The two approaches produce complementary
information. Which you would choose to read
depends upon what question you wish to address.
If, at a health system level, a quality improvement
budget is being invested across a range of
conditions, then the intervention-based reviews are
likely to be most informative. If the question is how
best to improve care for patients with a specific
condition, such as diabetes mellitus, then condition-
based reviews addressing studies of diabetes care
are likely to be most informative. However, it will
often be the case that cross referencing across the
two bodies of reviews will be informative.
Current knowledge: an overview
7.13 For the purposes of this scoping report, any
attempt to draw together the messages from this
literature will inevitably be an overview. The examples
have been chosen either because they have been
conducted to high methodological standards, or
because they are “the best that is available”, or both.
27 Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, Grilli R, Harvey E, Oxman A, O’Brien MA. Changing provider
behavior: an overview of systematic reviews of interventions. Medical Care, 2001; 39(8 Suppl 2): II2–45.
28
Clinical Efectiveness 19/10/07 15:44 Page 29
Section 3: Current knowledge on the effectiveness of strategies to promote the uptake of clinically effective practice
7.14 The report focuses on the scale of the review
and the summary messages. There are
methodological issues with most reviews in this area;
the interested reader is directed to the original
publications.
7.15 The reviews are presented in the two groups:
intervention-based and condition/problem-based.
The contents of the EPOC Review Group module of
reviews is summarised at the end as it contains
examples of both.
Intervention-based reviews of strategies to
influence the behaviour of individuals or
organisations
Effectiveness and efficiency of guideline
dissemination and implementation strategies
(Grimshaw et al. 200417)
7.16 Two hundred and thirty-five studies reporting
309 comparisons met the inclusion criteria. The
overall quality of the studies was poor. Seventy-
three per cent of comparisons evaluated multi
faceted interventions, although the maximum number
of replications of a specific multi-faceted intervention
was 11 comparisons. Overall, the majority of
comparisons reporting dichotomous process data
(86.6%) observed improvements in care; however,
there was considerable variation in the size of the
observed effects both within and across
interventions. Commonly evaluated single
interventions were reminders (38 comparisons),
dissemination of educational materials (18
comparisons), and audit and feedback (12
comparisons). There were 23 comparisons of multi
faceted interventions involving educational outreach.
The median absolute improvement in performance
across interventions ranged from 13.1% in 13 cluster
randomised comparisons of reminders, 8.1% in four
cluster randomised comparisons of dissemination of
educational materials, 7.0% in five cluster
randomised comparisons of audit and feedback, and
6.0% in 13 cluster randomised comparisons of
multifaceted interventions involving educational
outreach. The authors found no relationship between
the number of component interventions and the
effects of multi-faceted interventions.
Organisational interventions: a structured review of
reviews (Wensing et al, 2006).28
7.17 A total of 36 reviews, including 684 studies (of
rigorous evaluations of organisational changes, and
published between 1995 and 2003) were included;
not all were high-quality reviews. Twenty-one of the
36 reviews were of high quality as defined by the
review authors. The reviews were too heterogeneous
for quantitative synthesis.
7.18 Overall:
● Revision of professional roles (nine reviews) can
improve professional performance, although
effects on patient outcomes remain uncertain.
Revision of roles seemed especially effective in
preventive care, but the effects of specialised
nurses in primary care remain uncertain.
● Multidisciplinary teams (five reviews) can improve
patient outcomes. They have primarily been
tested in highly prevalent chronic diseases.
● Integrated care systems (eight reviews) can
improve patient outcomes and save costs. They
have been extensively tested in highly prevalent
chronic conditions.
● Knowledge management (six reviews) can
improve professional performance and patient
outcomes (mainly by the implementation of
computers in clinical practice settings).
● The effects of quality management (two reviews)
on professional performance and patient
outcomes remain uncertain.
● Professional performance was generally improved
by revision of professional roles and computer
systems for knowledge management. Patient
outcomes were generally improved by
multidisciplinary teams, integrated care services,
and computer systems. Cost savings were
reported from integrated care services.
7.19 The authors concluded that, whilst there is a
growing evidence base of rigorous evaluations of
organisational strategies, the evidence underlying
some strategies is limited, and for no strategy can
the effects be predicted with high certainty.
Condition- or problem-based reviews
Evidence-based Practice Centres evidence reports
7.20 In early 2003, the Institute of Medicine (IOM) in
the United States released its report Priority Areas for
National Action: Transforming Health Care Quality.
The report listed 20 clinical topics for which “best
practices” were strongly supported by clinical
evidence. The rates at which these practices had
been implemented in the United States had been
disappointingly low, at a cost of many thousands of
28 Wensing M, Wollersheim H, Grol R. Organisational interventions to implement improvements in patient care: a structured review of
reviews. Implementation Science, 2006, 1: 2.
29
Clinical Efectiveness 19/10/07 15:44 Page 30
Section 3: Current knowledge on the effectiveness of strategies to promote the uptake of clinically effective practice
lives each year. In response, the Agency for
Healthcare Research and Quality (AHRQ) engaged
the Stanford-UCSF Evidence-based Practice Center
(EPC) to perform a critical analysis of the existing
literature on quality improvement (QI) strategies for a
selection of the 20 disease and practice priorities
noted in the IOM Report. The methods and three
published reports summarised here represent the
current products.
7.21 As well as representing high quality reviews,
these are also noteworthy for being commissioned
as a strategic response to an identified “quality
problem”.
7.22 Further details of these reports can be found
by selecting the “Healthcare Services” then “Quality
Improvement and Patient Safety” links at
www.ahrq.gov/clinic/epcindex.htm#quality
Closing the Quality Gap: A Critical Analysis of Quality
Improvement Strategies: Volume 1 – Series Overview
and Methodology. August 2004
7.23 “In Volume 1 of Closing the Quality Gap, we
provide an overview of our methods and the
theoretical underpinnings of the field, which we will
rely on to review and analyze the literature on the
quality gap in a number of the IOM-identified priority
areas that will appear in subsequent volumes. We
then set forth our methodology: our reviews generally
are restricted to studies that are likely to have strong
validity (randomized controlled trials, well controlled
before-after studies, and interrupted time series
studies). To ensure consistency across our reviews,
we introduce a taxonomy for nine QI strategies:
1. Provider reminder systems.
2. Facilitated relay of clinical data to providers.
3. Audit and feedback.
4. Provider education.
5. Patient education.
6. Promotion of self-management.
7. Patient reminders.
8. Organizational change.
9. Financial, regulatory, or legislative incentives.”
Closing the Quality Gap: A Critical Analysis of Quality
Improvement Strategies: Volume 2 – Diabetes Care
7.24 “Main results: Fifty-eight articles reporting a
total of 66 trials met the established inclusion criteria.
The most common interventions employed were
organizational change in 40 trials, patient education
in 28 trials, and provider education in 24 trials. Fifty-
two trials involved interventions employing more than
one QI strategy, with a median of two strategies per
trial and a maximum of five.
7.25 The included trials reported a median absolute
reduction in HbA1c of 0.48% (interquartile range:
0.20% to 1.38%), and a median improvement in
clinician adherence of 4.9% (interquartile range: 3.8%
to 15.0%). Trials in the lower two quartiles of sample
size reported substantially larger effect sizes, as did
non-randomized trials, strongly suggesting the
presence of publication bias, with publication of
smaller non-randomized trials occurring more often
when reported improvements are large. Multi-faceted
trials reported a median reduction in HbA1c of
0.60% (interquartile range: 0.30% to 1.40%),
compared to a median reduction of 0.0%
(interquartile range: -0.08% to 0.16%) for trials of a
single intervention (p = 0.01). The benefit of
employing more than one QI strategy appeared to
persist among larger, randomized trials, but the small
number of studies limits the reliability of this
impression.
7.26 The investigators did not find any specific type
of QI strategy to confer unambiguous benefit.
Provider education and disease management were
the only strategies to approach statistical
significance, compared with interventions absent
these strategies.
7.27 Conclusion: The authors’ analysis showed no
particular type of QI to have an advantage over
others, but suggested that employing at least two
strategies provides a greater chance of success than
single-faceted interventions, in terms of improving
glycemic control or provider adherence. These
conclusions are limited by probable publication bias
favoring smaller trials and non-randomized trials, and
the confounding presence of multiple QI strategies in
a given intervention, as well as important patient and
provider factors, and organizational characteristics.”
Closing the Quality Gap: A Critical Analysis of Quality
Improvement Strategies: Volume 3 – Hypertension
Care
7.28 “Main results: Sixty-three articles reporting a
total of 82 comparisons met the inclusion criteria.
Studies of hypertension identification were found to
be too heterogeneous for quantitative analysis. The
majority of screening studies were clinic-based (with
a few offered at work sites), and the most common
strategies involved patient and/or provider reminders.
These generally showed positive results; several
studies found that patients were more likely to know
their blood pressure or attend clinic visits after
receiving reminders.
30
Clinical Efectiveness 19/10/07 15:44 Page 31
Section 3: Current knowledge on the effectiveness of strategies to promote the uptake of clinically effective practice
7.29 Across all studies with a variety of strategies,
the median reductions in systolic blood pressure
(SBP) and diastolic blood pressure (DBP) were 4.5
mmHg (interquartile range: 1.5 to 11.0) and 2.1
mmHg (interquartile range: -0.2 to 5.0) respectively.
The median increase in the proportion of patients in
the target SBP range and target DBP range was
16.2% (interquartile range: 10.3% to 32.2%) and
6.0% (interquartile range: 1.5% to 17.5%)
respectively. Studies that focused on improving
provider adherence showed a range of median
reduction of 1.3% to a median improvement of 3.3%
across all QI strategies. Overall, patient adherence
showed a median improvement of 2.8% (interquartile
range: 1.9% to 3.0%).
7.30 Conclusion: The findings of this review
suggest that QI strategies appear, in general, to be
associated with the improved identification and
control of hypertension. It is not possible to discern
with complete confidence which specific QI
strategies have the greatest effects, since most of
the studies included more than one QI strategy. All of
the assessed strategies may be beneficial under
some circumstances, and in varying combinations.
There may be other useful strategies that have not
been studied in trials meeting the inclusion criteria for
evidence-based review; it is not possible to draw
conclusions about these strategies.”
Closing the Quality Gap: A Critical Analysis of Quality
Improvement Strategies: Volume 4 – Antibiotic
Prescribing Behaviour
7.31 “Main results: Fifty-four studies reporting a
total of 74 trials met the inclusion criteria; 34 studies
(reporting 41 trials) addressed the treatment decision,
and 26 studies (reporting 33 trials) addressed the
selection decision. Six studies evaluated both
decisions. Study methodologic quality was generally
fair. Nearly all studies took place in outpatient primary
care clinics.
7.32 Studies addressing the antibiotic treatment
decision: Most studies addressed prescribing for
acute respiratory infections (ARIs). Interventions were
effective at reducing prescribing, with a median
absolute effect of -8.9% (interquartile range: 12.4%
to 6.7%). No individual QI strategy (or combination of
strategies) was more effective at reducing
prescribing. Within clinician education, active
educational strategies appeared more effective than
passive strategies. When extrapolated to a
population level, strategies targeting general
antibiotic prescribing appeared to reduce antibiotic
prescribing more than strategies targeting prescribing
for a single condition. Few studies addressed
secondary endpoints; patient satisfaction was not
worsened by QI interventions, but effects on
antimicrobial resistance or costs could not be
assessed.
7.33 Studies addressing the antibiotic selection
decision: Interventions targeted prescribing for ARIs
or urinary tract infections (UTIs). Interventions were
effective, with a median absolute improvement in
prescribing of recommended antibiotics of 10.6%
(interquartile range: 3.4% to 18.2%). Clinician
education alone appeared more effective than
education in combination with audit and feedback,
but this finding likely represents confounding. Very
few studies addressed secondary outcomes.
7.34 Conclusion: Quality improvement efforts
appear generally effective at reducing both
inappropriate treatment with antibiotics and
inappropriate selection of antibiotics. While no single
QI strategy was more effective than others, active
clinician education may be more effective than
passive education, particularly for addressing the
antibiotic treatment decision. Greater reductions in
overall prescribing may be achieved through efforts
targeting prescribing for all ARIs, rather than
targeting single conditions. The available evidence is
of only fair quality, and further research on the cost-
effectiveness and potential harms of these
interventions is needed.”
Other AHRQ reviews
7.35 There are other AHRQ-commissioned reviews
that are not part of the “Closing the Quality Gap”
series. They cover end-of-life care and outcomes,
costs and benefits of health information technology,
and quality-based purchasing strategies. I have
included a summary of the latter because of its
potential specific relevance to the work of the HLG.
Strategies To Support Quality-based Purchasing:
A Review of the Evidence
7.36 “Although evidence of quality problems has
been available for years, purchaser interest in quality-
based purchasing (QBP) is a recent phenomenon.
Furthermore, employers who support QBP have
expressed uncertainty about how to measure quality,
especially outcomes, and what incentives to offer to
stimulate performance improvement.
7.37 We evaluated 5,045 publications. Nine were
randomized controlled trials, and many of these did
not report key characteristics of the incentive or the
context in which incentives were applied. Incentives
used included additional fee-for-service, quality
31
Clinical Efectiveness 19/10/07 15:44 Page 32
Section 3: Current knowledge on the effectiveness of strategies to promote the uptake of clinically effective practice
bonuses, and public release of performance data.
The results were mixed: among the 11 performance
indicators evaluated, 7 showed a statistically
significant response to QBP strategies while 4 did
not. We also found 18 ongoing research projects,
none randomized. These will yield data about the
approaches to QBP currently in use, provider
awareness of and concerns about QBP, and some
preliminary estimates of the potential impact of QBP.
7.38 Regarding assessments of outcomes reports,
we found that, under reasonable assumptions and
applications, outcomes reports generate meaningful
information about provider performance. Providers
with good (expected) performance are unlikely to be
labelled as poor quality in any given period, and very
unlikely to be mislabelled more than once in a 3-year
period, even if one allowed approximately 10% of
hospitals to be labelled poor performers annually.
In addition, hospitals with superior performance were
quite likely to be identified as such at least once in
3 years.
7.39 Conclusions: Little is known about the impact
of QBP on clinical performance. However, it does
appear that basing incentives on measurements of
outcomes is feasible without undue risk to the
reputation or financial status of good hospitals.
Ongoing research will only address some of the gaps
in our knowledge about QBP, suggesting that much
more additional research is needed. This should
include comparisons of alternative QBP approaches
and qualitative assessment of the barriers to and
facilitators of quality improvement in response to
QBP incentives.”
Cochrane Collaboration EPOC Review
Group reviews
7.40 When systematic reviews are compared, in
general Cochrane reviews are found to be of higher
quality than non-Cochrane reviews. They therefore
represent a source of high quality evidence. The
EPOC Review Group in the Cochrane Collaboration
Database of Systematic Reviews hosts nine reviews
of interventions aimed at professionals, 23 reviews of
organisational interventions and six condition- or
problem-based reviews. The titles are listed in
Appendix 3 and the full reviews can be found by
going to the Cochrane EPOC Group link at
www.mrw.interscience.wiley.com/cochrane/cochrane
_clsysrev_crglist_fs.html or through the National
Library for Health at www.library.nhs.uk
The EPOC overview of reviews
7.41 In order to illustrate the broad messages
about the effects of interventions, the following draft
text illustrates the overview of systematic reviews of
interventions aimed at changing the behaviour of
individual healthcare professionals. As with previous
examples, this is meant to be illustrative; the final
referencing of this text is incomplete.
7.42 The Cochrane EPOC Review Group supports
reviews of interventions to improve healthcare
systems and healthcare delivery. It has identified over
4,500 randomised and quasi-experimental studies of
professional, organisational, financial and regulatory
interventions within its scope. EPOC has prepared
two overviews of systematic reviews (Bero 1998,
Grimshaw 2002) and is currently updating this. It has
identified over 150 systematic reviews of professional
behaviour change strategies. In this section, we
summarise the results of key reviews selected
because they were high quality and most up to date.
We provide a definition of each intervention, the likely
mechanism of action of the intervention, the results
of the key review(s) and additional comments relating
to the practical delivery of the intervention (including
resources required). Interventions were considered:
generally effective if two-thirds or more identified
studies demonstrated improvements; having mixed
effects if between one-third and two-thirds of
identified studies demonstrated improvements; and
generally ineffective if less than one-third of identified
interventions demonstrated improvements. Wherever
possible, we describe the range of effect sizes
observed within reviews.
Printed educational materials
7.43 EPOC defined printed educational materials as
the “distribution of published or printed
recommendations for clinical care, including clinical
practice guidelines, audio-visual materials and
electronic publications. The materials may have been
delivered personally or through mass mailings”.
In general, printed educational materials target
knowledge and potentially skill gaps for individual
healthcare professionals.
7.44 Farmer and colleagues identified 21 studies of
the effects of printed educational materials, including
six cluster randomised trials. Based upon the cluster
randomised trials, printed educational materials
appear generally effective, resulting in a median
absolute improvement of care of 4.9% across
studies. Printed educational materials are commonly
used, are relatively low cost and generally feasible in
most settings.
32
Clinical Efectiveness 19/10/07 15:44 Page 33
Section 3: Current knowledge on the effectiveness of strategies to promote the uptake of clinically effective practice
Educational meetings
7.45 EPOC defines educational meetings as the
“participation of healthcare providers in conferences,
lectures, workshops or traineeships”. An important
distinction is between didactic meetings (that largely
target knowledge barriers at the level of individual
healthcare professional/peer group) and interactive
workshops (that can target knowledge, attitudes and
skills at the level of the individual healthcare
professional/peer group level).
7.46 O’Brien and colleagues identified 32
randomised trials of educational meetings. Interactive
or mixed/interactive educational meetings were
generally effective, resulting in moderate effects
(between 11–20% absolute improvements in care).
In contrast, didactic meetings were largely ineffective.
Educational meetings are commonly used; the main
cost relates to the release time for healthcare
professionals and they are generally feasible in
most settings.
Educational outreach
7.47 EPOC defines educational outreach or
academic detailing as “use of a trained person who
met with providers in their practice settings to give
information with the intent of changing the provider’s
practice. The information given may have included
feedback on the performance of the provider(s)”.
Avorn and Soumerai suggest that educational
outreach derives from social marketing approaches
to target an individual’s knowledge and attitudes.
Typically the detailer aims to get a maximum of three
messages across during a 10–15 minute meeting
with a healthcare professional. The detailer will tailor
their approach to the characteristics of the individual
healthcare provider and will typically use additional
provider behaviour change strategies to reinforce
their message. Most studies of educational outreach
have focused on changing relatively simple
behaviours in the control of an individual physician;
for example, the choice of drug to prescribe.
7.48 Grimshaw (2004) identified 13 cluster
randomised trials of multi-faceted interventions to
implement clinical practice guidelines. Educational
outreach was generally effective, resulting in a
median absolute improvement of care of 4.9%
across studies. The effects of educational outreach
for changing more complex behaviours is less
certain. Educational outreach programs have been
used across a wide range of healthcare settings,
especially to target prescribing behaviours.
Educational outreach requires considerable
resources, including the costs of detailers and
preparation of materials. Nevertheless, Mason
observed that educational outreach may still be an
efficient way to change prescribing patterns.
Local opinion leaders
7.49 EPOC defines local opinion leaders as “use of
providers nominated by their colleagues as
‘educationally influential’. The investigators must have
explicitly stated that their colleagues identified the
opinion leaders”. Opinion leadership is the degree to
which an individual is able to influence other
individuals’ attitudes or overt behaviour informally in a
desired way with relative frequency. This informal
leadership is not a function of the individual’s formal
position or status in the system; it is earned and
maintained by the individual’s technical competence,
social accessibility, and conformity to the system’s
norms. When compared with their peers, opinion
leaders tend to be more exposed to all forms of
external communication, have somewhat higher
social status and be more innovative. However, the
most striking feature of opinion leaders is their unique
and influential position in their system’s
communication structure; they are at the centre of
interpersonal communication networks
(interconnected individuals who are linked by
patterned flows of information). Opinion leaders target
the knowledge and attitudes of their peer group.
7.50 Doumit (2007) identified 12 randomised trials
of opinion leaders. Opinion leaders were generally
effective for improving appropriate care, resulting in a
median absolute improvement of care of 10.0%
across studies. The majority of studies in healthcare
have used an instrument derived by Hiss to identify
opinion leaders; this seeks to identify individuals who
are up to date, good communicators and humanistic.
The potential success of opinion leaders is
dependent upon the existence of intact social
networks within professional communities. Grimshaw
and colleagues (2006) observed that the existence of
such networks varied across communities and
settings within the UK. They also observed that
opinion leaders were condition specific; in other
words, colleagues identified different opinion leaders
for different clinical problems. Doumit (2006) also
observed that opinion leaders were not stable over
time. The resources required for opinion leaders
include costs of the identification method, training of
opinion leaders and additional service costs.
Audit and feedback
7.51 EPOC defines audit and feedback as “any
summary of clinical performance of health care over
a specified period of time. The summary may also
33
Clinical Efectiveness 19/10/07 15:44 Page 34
Section 3: Current knowledge on the effectiveness of strategies to promote the uptake of clinically effective practice
have included recommendations for clinical action.
The information may have been obtained from
medical records, computerised databases, or
observations from patients”. Adams and colleagues
observed that healthcare professionals often
overestimated their performance by around 20–30%.
Audit and feedback target healthcare provider/peer
groups’ perceptions of current performance levels,
and are useful for creating cognitive dissonance
within healthcare professionals as a stimulus for
behaviour change.
7.52 Jamveldt (2005) identified 118 randomised
trials of audit and feedback. Audit and feedback
alone, audit and feedback with educational meetings,
audit and feedback as part of multi-faceted
intervention were generally effective, resulting in a
median absolute improvement of care of 10.0%. In
general, larger effects were seen if baseline
compliance was low. The resources required to
deliver audit and feedback include data abstraction
and analysis costs and dissemination costs. The
feasibility of audit and feedback may depend on the
availability of meaningful routine administrative data
for feedback.
Reminders
7.53 EPOC defines reminders as “patient- or
encounter-specific information, provided verbally, on
paper or on a computer screen, which is designed or
intended to prompt a health professional to recall
information. This would usually be encountered
through their general education, in the medical
records or through interactions with peers, and so
remind them to perform or avoid some action to aid
individual patient care. Computer-aided decision
support and drugs dosage are included”. Reminders
prompt the professional to remember to do
important items during professional–patient
interactions.
7.54 Grimshaw (2004) identified 14 cluster
randomised trials of reminders to implement clinical
practice guidelines. This review found that reminders
were generally effective, resulting in a median
absolute improvement of care of 14.1%. The majority
of studies have been undertaken in highly
computerised US academic health science centres
(Shekelle 2006) and their generalisability to other
settings is less certain. Most studies have examined
the effects of relatively simple reminders; the results
of more complex decision support systems for
chronic disease have been less successful. The
resources required vary across the delivery
mechanism and there is insufficient knowledge about
how to prioritise and optimise reminders.
Multi-faceted interventions
7.55 EPOC defines multi-faceted interventions as
“any intervention including two or more
components”. Multi-faceted interventions potentially
target different barriers in the system. Grimshaw et al
(2004) explored whether there was a dose response
curve for multi-faceted interventions and observed
that effect sizes did not necessarily increase with
increasing numbers of components. They observed
that “Few studies provided any explicit rationale or
theoretical base for the choice of intervention. As a
result, it was unclear whether researchers had an
a priori rationale for the choice of components in
multi-faceted interventions based upon possible
causal mechanisms, or whether the choice was
based on a ‘kitchen sink’ approach. It is plausible
that multi-faceted interventions built upon a careful
assessment of barriers and coherent theoretical base
may be more effective than single interventions.”
Multi-faceted interventions are likely to be more
costly than single interventions. If planning multi
faceted interventions, it is important to consider
carefully how components are likely to interact to
maximise benefits.
34
Clinical Efectiveness 19/10/07 15:44 Page 35
Appendix 1
Activities in the NHS related to supporting clinical effectiveness
With acknowledgement to Anne Moger, whose initial
draft for the High Level Group on Clinical
Effectiveness formed the basis of this appendix.
The structure of the table is:
National level
Organisations/activities relating to setting
evidence-based standards
Organisations/activities supporting the delivery of
evidence-based standards
Inputs (knowledge, skills, other resources)
Processes that support delivery and/or focus
on outcomes
Organisations/activities relating to monitoring the
delivery of effective care
Regional/SHA-level initiatives
Inputs (knowledge, skills, other resources)
Processes that support delivery and/or focus on
outcomes
Local initiatives
Inputs (knowledge, skills, other resources)
Processes that support delivery and/or focus on
outcomes
Monitoring the delivery of effective care.
Organisation Activity
National level
SETTING EVIDENCE-BASED STANDARDS
Department of Health (DH) NHS Cancer Plan (2000)
Paediatric Intensive Care – Reports of CNO’s Taskforce and the National Coordinating Group (1999)
National Service Frameworks for: Coronary Heart Disease
Mental Health
Older People
Diabetes
Long-term Conditions
Renal Services
Children, Young People and Maternity Services
Chronic Obstructive Pulmonary Disease (in development)
Standards for Better Health (DH 2004) Domain 2 Clinical and cost-effectiveness
Other heathcare strategy documents For example:
National Stroke Strategy (in development)
“Winning ways: working together to reduce healthcare associated infection in England.”
Our NHS, our future, forthcoming NHS Next Stage Review by Lord Ara Darzi.
35
Clinical Efectiveness 19/10/07 15:44 Page 36
Appendix 1: Activities in the NHS related to supporting clinical effectiveness
Organisation Activity
NICE guidance Technology appraisals
Clinical guidelines
Interventional procedures guidance
Public health guidance
Inappropriate Interventions Programme – new workstream within Technology Appraisals and Clinical Guidelines programmes
Contribute to Standards for Better Health.
National Institute for Health and Clinical Excellence (NICE)
Most professional bodies develop clinical guidelines and all are responsible for setting quality standards for their profession. Several operate clinical effectiveness committees. They may also have R&D/evaluation programmes and/or run clinical audits. (Those that are involved with national clinical audits are identified separately below under “monitoring”.)
Professional bodies (those identified from a web search as developing guidelines) (not exhaustive): British Association for Emergency Medicine
British Association for Sexual Health
British Dietetic Association
British Society of Paediatric Dentistry
British Thoracic Society
Chartered Society of Physiotherapy
Royal College of Nursing
Royal College of Obstetricians and Gynaecologists
Royal College of Physicians
Royal College of Speech and Language Therapists
Royal College of Surgeons
Recommendation in Good Doctors, Safer Patients (subject to consultation), that the clinical professions, led by the Academy of Medical Royal Colleges and with input from representatives of patients, establish standards in areas of specialised medical practice.
Academy of Royal Medical Colleges
SUPPORTING DELIVERY OF EVIDENCE-BASED STANDARDS
INPUTS (KNOWLEDGE, SKILLS, OTHER RESOURCES)
Cochrane Collaboration, Database of Abstracts of Reviews of Effects (DARE), Clinical Knowledge Summaries (e.g. British Medical Journal (BMJ) Clinical Evidence), NHS Health Technology Assessment (HTA) programme, Bandolier.
(BMJ Clinical Evidence series is not available to NHS staff in England (though it is in Scotland and Wales). Available through personal or institutional subscription.)
Research synthesis to underpin standards
National Library for Health (NLH) The NLH aims to “deliver a world class information service, benefiting the NHS by improving the quality of care by enabling evidence-based decision making, and supporting education and research. It will save users’ time, extend services to previously unserved groups, and improve the cost effectiveness of library provision.”
Includes electronic access to:
● evidence-based reviews (Cochrane Collaboration, DARE, Clinical Knowledge Summaries, NHS HTA programme, NLH specialist libraries, Bandolier)
36
Clinical Efectiveness 19/10/07 15:44 Page 37
Appendix 1: Activities in the NHS related to supporting clinical effectiveness
Organisation Activity
● guidance (NICE, other clinical guidelines, care pathways and protocols)
● drugs guidance (British National Formulary etc)
● primary databases (Medline etc).
Also working in partnership with NLH:
Map of Medicine, which aims to provide “quick access to best practice guidelines” (presented in algorithm form and amenable to local modification). Based on NICE guidance where available.
Relevant activities include:
NHS Care Records Service (potential to link to decision support systems)
Electronic transmission of prescriptions (e-systems to reduce errors etc).
Large number of projects linked with NLH (e.g. Better Prescribing), Map of Medicine, to potentially provide online access to care pathways, guidelines etc.
NHS Connecting for Health (which is responsible for delivering the National Programme for IT (NPFIT))
Knowledge-based commissioning plan: 1. The Annual Population Value Review
2. The Annual Review of Evidence, Process, Outcome and Configuration (EPOC)
3. The National Innovation Management Project
4. The National Clinical Networks Development Programme.
Director of Clinical Knowledge, Process and Safety
Training in evidence-based practice: CEBM: research into and training in EBM, including annual week-long residential course in teaching EBM and MSc in evidence-based health care
CASP: bespoke courses aimed at public health and management.
University of Oxford Centre for Evidence Based Medicine (CEBM), Critical Appraisal Skills Programme (CASP) (the Public Health Resource Unit, University of Oxford) and a range of universities.
PROCESSES THAT SUPPORT DELIVERY AND/OR FOCUS ON OUTCOMES
Department of Health Targets (Public Service Agreement (PSA) 03/06 and 05/08, and Local Delivery Plan (LDP) 03/06; performance monitoring requirements for LDP 05/08) e.g. thrombolysis “call to needle” times
Guidance to the NHS on requirements to implement NICE guidance HSC 1999/065: Clinical governance in the new NHS
Quality and Outcomes Framework (QOF) Clinical domain of QOF uses evidence-based indicators; financial incentives in GP contract directly linked to these
Guidance on clinical governance HSC 1999/176; DH Good Practice Guidance 2006
Health Reform in England and related strategies Financial Sustainability Review – ongoing work around clinical variation/cost effectiveness
Programme budgeting Links to the Knowledge-based Commissioning Plan; the current lead is Andrew Jackson from DH Finance, Leeds
Commissioning frameworks/toolkits e.g. Stroke (Action on Stroke Services: an Evaluation Toolkit (ASSET)), diabetes.
37
Clinical Efectiveness 19/10/07 15:44 Page 38
Appendix 1: Activities in the NHS related to supporting clinical effectiveness
Organisation Activity
National Institute for Health and Clinical Excellence (NICE)
NICE implementation programme NICE has set up a programme to help support implementation of NICE guidance. The aim of the programme is to embed the implementation of NICE guidance into core systems for clinical effectiveness within the local NHS. To achieve this, the programme has three key strands: a “leverage” approach – working through national initiatives such as those for inspection and commissioning; providing practical support tools; and evaluating change. The implementation team does not get involved in developing the guideline recommendations but works alongside the guideline developers, the communications team and field-based teams to:
● ensure intelligent dissemination to the appropriate target audiences
● actively engage with the NHS, local government and the wider community
● work nationally to encourage a supportive environment
● provide tools to support putting NICE guidance into practice
● demonstrate significant cost impacts – either costs or savings at local and national levels
● evaluate uptake of NICE guidance
● share learning
● develop educational material to raise awareness of NICE guidance and encourage people to input into its development.
NICE produces several implementation tools, including a “How to” guide, implementation advice (specific to recently produced guidance) and slide sets. A “How to influence practice” guide is in development.
The “How to” guide identifies implementation steps separately for technology appraisals, clinical guidelines and interventional procedures guidance. The steps are: assessing relevance; identifying a clinical lead; baseline assessment (“what needs to change as a result of this guidance?”); developing an action plan and assessing costs; providing funds/disseminating guidance and implementing plan; reviewing and monitoring.
Implementation advice (the “How to” guide steps tailored to specific topics) accompanied by slide sets, is available for more recent guidance and includes example action plans.
To collate information on uptake of NICE recommendations, a database is provided on the NICE website, Evaluation of Reviews of NICE Implementation Effectiveness (ERNIE).
NHS Institute for Innovation and Improvement
The NHS Institute for Innovation and Improvement aims to support the NHS in service transformation/improvement. Of particular relevance to clinical and cost-effectiveness:
Delivering Quality and Value Priority Programme The aim is a “paradigm shift in clinical efficiency and effectiveness, resulting in local health systems being able to provide efficient, clinically and cost-effective healthcare for the benefit of patients”.
● Focus On: High Volume Care (This includes the programme’s documents and outputs from the work on high volume care patient pathways (nine high volume clinical topics to date)
● Focus On: Productivity and Efficiency
● Better Value, Better Care Indicators (This provides information about the metrics for better value and better care published in October 2006).
38
Clinical Efectiveness 19/10/07 15:44 Page 39
Appendix 1: Activities in the NHS related to supporting clinical effectiveness
Organisation Activity
Other national institutes For example, National Institute for Mental Health in England (NIMHE), (part of the Care Services Improvement Partnership (CSIP)) Examples of relevant activities include:
High impact changes for mental health services
Acute Inpatient Care programme.
Charitable foundations e.g. The Health Foundation
From their website: “The Health Foundation wants to make the quality of healthcare in the UK the best it can be. Working with others, we are helping to shape a future healthcare system that offers safe, effective and responsive care for all.
We are a charitable foundation and operate independently from government, political parties or other interest groups...
Our work is currently focused around five main aims:
● building and making public the knowledge base for quality and performance improvement
● developing leaders to improve health and healthcare services
● supporting organisational efforts to improve quality and performance in health and healthcare services
● engaging clinicians in quality improvement
● engaging patients for better health and healthcare outcomes.”
National clinical support teams All national programmes are currently under review by the Office of Strategic Health Authorities
Cancer Services Collaborative Improvement Partnership (CSCIP) The CSCIP is a national NHS programme that supports local cancer service teams (Networks) to improve their cancer and diagnostic services and help reduce their waiting times. Working closely with the National Cancer Programme, the CSCIP works with Networks to achieve the objectives of the NHS Cancer Plan 2000 for all cancer services (excluding paediatrics) and associated services.
NHS Heart Improvement Programme Role is to:
Support cardiac network development
Ensure spread of service improvement within cardiac networks
Facilitate the introduction of new service improvement tools and recognised clinical innovations.
National Diabetes Support Team (NDST) “The NDST was set up to support healthcare professionals as they strive to implement the Diabetes National Service Framework (NSF) standards.”
NHS Clinical Governance Support Team (CGST) The CGST has set its stall out as a learning organisation that uses the knowledge of its staff and its relationships with other NHS organisations to support those who shape the healthcare experience for patients, carers, and the public.
Clinical decision support systems See NHS Connecting for Health. In the meantime, most GP systems have some decision support functionality. Also, bespoke systems such as some diabetes registers.
R&D – Implementation Research (also referred to as Knowledge Translation Research)
The study of methods to promote the uptake of research evidence into practice is currently largely absent from the UK.
The closest NHS–funded national programme is the Service Delivery and Organisation (SDO) R&D Programme. The Medical Research Council (MRC) Health Services and Public Health Research Board lists implementation as one of its research areas. There are also a number of universities that specialise in implementation research, including Newcastle and Manchester.
39
Clinical Efectiveness 19/10/07 15:44 Page 40
Appendix 1: Activities in the NHS related to supporting clinical effectiveness
Organisation Activity
SDO programme Aims to produce research evidence directed at improving the organisation and delivery of health services, and to promote the uptake and application of that evidence in policy and practice.
Institute of Health and Society, University of Newcastle Led by Professor Martin Eccles, the programme involves studies of how to implement evidence in clinical practice.
National Primary Care Research and Development Centre, Manchester Led by Professor Martin Roland, the centre’s research is organised around four main areas: organisations, quality, self-management and workforce.
MONITORING THE DELIVERY OF EFFECTIVE CARE
Healthcare Commission (HC) The Healthcare Commission has responsibility for assessing performance against Standards for Better Health, and new and existing national targets, in individual healthcare organisations. The clinical and cost-effectiveness standard domain outcome states that “Patients achieve health benefits that meet their individual needs through healthcare decisions and services based on what assessed research evidence has shown provides effective clinical outcomes”. The detailed clinical and cost-effectiveness standard is:
Core standards C5 Health care organisations ensure that:
a) they conform to NICE technology appraisals and, where it is available, take into account nationally agreed guidance when planning and delivering treatment and care;
b) clinical care and treatment are carried out under supervision and leadership;
c) clinicians continuously update skills and techniques relevant to their clinical work; and
d) clinicians participate in regular clinical audit and reviews of clinical services.
C6 Health care organisations cooperate with each other and social care organisations to ensure that patients’ individual needs are properly managed and met.
Developmental standard D2 Patients receive effective treatment and care that:
a) conform to nationally agreed best practice, particularly as defined in National Service Frameworks, NICE guidance, national plans and agreed national guidance on service delivery;
b) take into account their individual requirements and meet their physical, cultural, spiritual and psychological needs and preferences;
c) are well coordinated to provide a seamless service across all organisations that need to be involved, especially social care organisations; and
d) is delivered by healthcare professionals who make clinical decisions based on evidence-based practice.
Healthcare organisations declared their performance against the core standards, including C5 above, for the first time at the end of 2005/06. After selective inspection of 20% of Trusts, which in some cases will have resulted in amendments to their self-assessment, their performance was published in the Healthcare Commission’s 05/06 Annual Health Check (AHC) in October 2006. The first Trust
40
Clinical Efectiveness 19/10/07 15:44 Page 41
Appendix 1: Activities in the NHS related to supporting clinical effectiveness
Organisation Activity
declarations on the developmental clinical and cost-effectiveness standard will not be available until 2007, and then only for acute and mental health Trusts. This will be accompanied by publication of an “information toolkit” including clinical effectiveness indicators on cancer, heart disease, stroke and mental health for all acute and mental health Trusts.
New and existing national targets assessment includes assessment on smoking, cancer, heart disease, sexual health, mental health and hospital-acquired infection.
Other relevant performance assessment activities within the Healthcare Commission include: service reviews, the “acute hospital portfolio” programme; national clinical audits (see later); some special investigations; and outcomes reported by patients.
Department of Health National monitoring of PSA, LDP targets, including national patient experience surveys.
Royal Colleges and clinical societies, including: Royal College of Physicians
Royal College of Surgeons
British Cardiac Society
University of York
National Clinical Audit Support Programme (Health and Social Care Information Centre (HSIC))
National clinical audits: Most are funded by the Healthcare Commission (HC) but there are some other funders, e.g. British Heart Foundation (cardiac rehabilitation audit at University of York). Full list of HC-funded audits (including those in development) is:
Cancer Bowel cancer
Head and neck cancer
Lung cancer
Oesophago-gastric (stomach) cancer
Mastectomy and breast reconstruction
Child and maternity Neonatal intensive care
Heart Adult cardiac surgery
Paediatric cardiac surgery and interventions
Cardiac interventions (e.g. opening up heart artery)
Myocardial infarction (MINAP) (heart attack)
Rhythm management (pacing/implantable cardiac defibrillators)
Heart failure
Cardiac ambulance services
Cardiac patients’ pathway and outcomes
Long-term conditions Diabetes
Renal services (kidney disease)
Mental health Violence in mental health settings
Dementia services and prescribing
Psychological therapies
Older people Continence: RCP audit
Stroke: hospital services
Carotid endarterectomy
Services for people who have fallen
Stroke: patients’ pathway, focusing on primary care.
41
Clinical Efectiveness 19/10/07 15:44 Page 42
Appendix 1: Activities in the NHS related to supporting clinical effectiveness
Organisation Activity
Various national clinical indicator initiatives
Secondary Uses Service (SUS) “SUS is a system designed to provide timely, pseudonymised, patient-based data and information for management and clinical purposes other than direct patient care. The data is made available through the NHS Care Records Service. These “secondary uses” will include functions such as healthcare planning, commissioning, public health, clinical audit, benchmarking, performance improvement, research and clinical governance.”
National Centre for Health Outcomes Development (NCHOD): “NCHOD is a unique national resource concerned with all aspects of health outcomes assessment. It was created in April 1998 following the outsourcing of the Department of Health’s Central Health Outcomes Unit and is based jointly at the London School of Hygiene and Tropical Medicine, University of London and the Department of Public Health, University of Oxford. Its current work programme is funded by The Information Centre for Health and Social Care. NCHOD is involved in three main groups of activities:
● design and development of measures of health outcome;
● production of comparative health outcome indicators using available routine data; in the form of the Compendium of Clinical and Health Indicators; and
● electronic publication of extensive statistical and bibliographic information about health outcomes in the Clinical and Health Outcomes Knowledge Base.”
NCHOD is currently supporting the DH “Information for Choice Taskforce” among other initiatives.
Better Metrics (www.healthcarecommission.org.uk/serviceproviderinformation/betterm etrics.cfm) “The better metrics project, which began in 2004, aims to improve the way the performance of health services is measured and monitored by:
● developing metrics that are more relevant to the work of doctors, nurses, and others who provide care to patients;
● identifying metrics that are already being used successfully by organisations to monitor and improve performance;
● sharing metrics with the Connecting for Health programme, as part of the process for developing electronic patient records, to improve routine monitoring of key clinical areas.
Better metrics have already been suggested for 13 key health areas including cancer, heart disease and stroke, diabetes and mental health. ... These metrics have been developed in collaboration with national clinical directors from the Department of Health and their colleagues in strategic health authorities, primary care trusts and other organisations in the NHS.”
Dr Foster Intelligence, including their “Intelligent Board” project (www.drfoster.co.uk/). Other examples include a “New Clinician Outcomes and Benchmarking Tool for consultant clinicians, surgeons and their managers”.
QQUIP – the Quest for Quality and Improved Performance – www.health.org.uk/qquip/
A five-year, £2.5 million research initiative of The Health Foundation. It has been set up to help answer three fundamental questions about healthcare in England:
● What is the current state of quality and performance?
● What works to improve quality and performance?
● Are we getting value for money from what is spent on the NHS?
The website brings together data to reveal hidden national and international trends on diseases, quality of care and the
42
Clinical Efectiveness 19/10/07 15:44 Page 43
Appendix 1: Activities in the NHS related to supporting clinical effectiveness
Organisation Activity
cost-effectiveness of treatments and government reforms. It is aimed at healthcare policy makers, researchers, clinicians, managers and patient groups so that they can make informed decisions based on the best possible data available.
QQUIP collects and analyses data from a wide range of already published and publicly available sources including databases such as the Organisation for Economic Co-operation and Development (OECD) Health Data, the Department of Health, the Healthcare Commission, professional databases and peer-reviewed published studies. It houses easy to use, at a glance data on priority areas such as cancer, heart disease, diabetes and mental health. It also looks at how well the NHS is performing in terms of its effectiveness, safety, responsiveness, efficiency and equity of access to care.
Regional/SHA-level initiatives
INPUTS (KNOWLEDGE, SKILLS, OTHER RESOURCES)
SHAs SHA workforce initiatives, e.g. funding of specific evidence-based training initiatives.
PROCESSES THAT SUPPORT DELIVERY AND/OR FOCUS ON OUTCOMES
SHAs Service redesign and/or system reform initiatives, e.g. funded implementation and evaluation of “lean thinking” or “six sigma” in a number of organisations across the patch.
Local implementation of NPFIT; SHAs have recently taken on operational responsibility. Potentially provides the opportunity to tune the programme to local clinical priorities.
Performance management of clinical priorities of commissioners and non-Foundation Trusts.
Regional organisations Clinical networks, e.g. cancer, heart disease.
Collaborative projects, e.g. mental health.
Public Health Observatories (PHOs) and cancer registries Monitoring of regional health data, which includes data on healthcare outcomes.
Academic-service collaborations, e.g. Public Health Institutes focusing on getting evidence into practice.
Local initiatives
Clinical effectiveness strategies Example strategies tend to cover: assessment of health needs, establishing evidence-based standards, implementation of NICE guidance and NSFs, other guidelines and protocols, evaluation of those standards including clinical audit and patient partnership initiatives, implementation of recommendations and re-evaluation, processes in place to support the professional development of staff.
INPUTS (KNOWLEDGE, SKILLS, OTHER RESOURCES)
Library initiatives e.g. Evidence-based summaries, “e”-alerts to new NICE guidance.
CPD, skills development e.g. Evidence-based practice and R&D training (including via funding for Masters programmes).
PROCESSES THAT SUPPORT DELIVERY AND/OR FOCUS ON OUTCOMES
Local application of the NICE “How to” guide, e.g. participation in the NIMHE funded project to pilot implementation of “stepped care” for depression, as part of implementing NICE depression guidelines.
NICE guidance implementation activities; other guideline implementation activities
Care pathways should be the quality-assessed and evidence-based way of consistently delivering high quality care for a particular circumstance (Bandolier 2003). The evidence base is usually provided by an evidence-based guideline.
Integrated care pathways
43
Clinical Efectiveness 19/10/07 15:44 Page 44
Appendix 1: Activities in the NHS related to supporting clinical effectiveness
Organisation Activity
They tend to:
● examine the external evidence for individual technologies
● combine this with local knowledge and experience and conditions
● involve a number of different disciplines of people, in a team decision and creating ownership of the product
● measure the results of the actions
● have information systems feeding back to the team on a timely basis
● amend the pathway in the light of results.
e.g. GP computer systems, diabetes registers. Clinical decision support systems
Clinical pharmacy services e.g. Medicines Management Services; PCT Pharmaceutical Advisers.
MONITORING THE DELIVERY OF EFFECTIVE CARE
Clinical audits At a minimum, these would be expected to cover: participation of clinicians in relevant national clinical audits; audits on the implementation of NICE technology appraisal guidance.
Other NICE guidance monitoring e.g. Reviewing prescribing information.
e.g. Gateshead PCT: in addition to their routine reporting and ad-hoc reports on NICE guidance implementation, they have developed a set of local high level indicators. These cover issues relating to improving quality and minimising cost growth. These indicators (reported quarterly to the Board) monitor progress, take account of local prescribing patterns, the direction and magnitude of change required. The current set of local indicators include implementation of NICE guidance, for example: use of selective SSRIs in depression, and use of proton pump inhibitors in management of dyspepsia.
Performance management reports At a minimum, to Trust Board.
e.g. Identification of differential GP practice performance on clinical QOF indicators.
Quality and Outcomes Framework (QOF)
Benchmarking programmes e.g. Subscribing to CHKS, Dr Foster Intelligence.
Commissioner–provider dialogue e.g. Service specifications, primary/secondary care protocols.
e.g. Gateshead: for the last two years Gateshead PCT and Gateshead NHS Foundation Trust (FT) have included clinical effectiveness indicators in their legally binding contract. This means that the FT routinely report to the PCT on a basket of quality indicators, and on a set of locally agreed quality and safety targets. This has included specific expectations of performance on preventive medication following myocardial infarction (2005/06 target) as well as diagnosing and establishing patients with heart failure on cost-effective medication (2006/07 target).
e.g. Active engagement in programmes of applied research in partnership with local universities.
R&D–evaluations of specific initiatives
44
Clinical Efectiveness 19/10/07 15:44 Page 45
Appendix 2
Department of Health selection criteria for referral of topics to NICE
(From www.nice.org.uk)
1) Is it appropriate for NICE to provide guidance on
the topic? In particular,
a) is the proposed topic within NICE’s remit?
b) has NICE already provided guidance or is
NICE developing guidance on the proposed
topic?
c) is the proposed topic emerging as a future
public health issue?
d) is the proposed topic an ultra-orphan disease?
2) Would guidance promote the best possible
improvement in public health and well-being
and/or patient care, and the reduction of
inequalities in health, given available resources?
In particular, are one or more of the following
satisfied?
a) does the proposed guidance relate to one of
the public health or NHS clinical priority areas,
or to other health-related government
priorities?
b) does the proposed guidance address an area
of action where better evidence of cost-
effectiveness would be expected to lead to
substantive cost-efficiencies in the delivery of
quality programmes or interventions?
c) does the proposed guidance relate to one or
more interventions or practices which might
impact significantly on NHS or other societal
resources (financial and other)?
d) does the proposed guidance relate to one or
more interventions from which the NHS could
disinvest without detriment to cost-effective
patient care, thus freeing up resources for use
elsewhere in the NHS?
And, for public health topics, one of the
following:
e) does the proposed guidance relate to an area
of public health action that has high policy
priority in the Department of Health and/or
across government?
f) does the proposed guidance address an area
of public health action that promotes
population health or well-being, and/or relates
to a significant burden of avoidable disease,
disability, injury or early death in the population
as a whole or in specific population
subgroups?
And, for clinical topics, one of the following:
g) does the proposed guidance address a
condition which is associated with significant
morbidity or mortality in the population as a
whole or in particular subgroups?
h) does the proposed guidance relate to one or
more interventions or practices which could:
i) significantly improve patients’ or carers’
quality of life; and/or
ii) reduce avoidable morbidity; and/or
iii) reduce avoidable premature mortality;
and/or
iv) reduce inequalities in health;
relative to current standard practice if used
more extensively or more appropriately?
3) Will NICE be able to add value by issuing
guidance? In particular, taking into account
whether:
a) there is available in the topic area a
substantive or developing body of research or
related evidence, where plausible linkages
between public health or clinical actions and
outcomes can be demonstrated; and/or
b) there is emerging evidence of widespread
variation in the efficacy of public health actions
in the topic area, such that publication of
formal guidance would make a significant
difference to improving the effectiveness of
public health programmes or interventions;
and/or
45
Clinical Efectiveness 19/10/07 15:44 Page 46
Appendix 2: Department of Health selection criteria for referral of topics to NICE
c) there is evidence and/or reason to believe
that, in the absence of guidance, there is or
will be:
i) inappropriate clinical practice, and/or
ii) inappropriate variation in clinical practice,
and/or
iii) inappropriate variation in access to clinical
interventions and/or treatment (between
geographical areas or social groups).
4) Would it be timely for NICE to provide guidance
on the proposed topic? In particular,
a) would the guidance still be relevant and timely
at the expected date of publication, and/or
b) for new clinical interventions, does the balance
of advantage for patient care lie with appraisal
at time of launch or at some specified future
date, taking account of:
i) the possible impact on uptake or equity of
access in the absence of guidance at time
of launch;
ii) for surgical and related interventions,
whether safety and efficacy have already
been assessed (or will be assessed in the
near future) by the Interventional
Procedures Advisory Committee; and/or
c) is there a degree of urgency for guidance
caused by factors other than those listed
above, e.g. is there significant public concern,
is this a new disease, or is this emerging as an
important new area for public health action?
July 2006
46
Clinical Efectiveness 19/10/07 15:44 Page 47
Appendix 3
Intervention-based and clinical condition-based reviews and protocols in the Effective Practice and Organisation of Care Review Group of the Cochrane Library
Further details of these reviews and protocols can be
found by going to the Cochrane EPOC Group link at
www.mrw.interscience.wiley.com/cochrane/cochrane
_clsysrev_crglist_fs.html
Reviews
Intervention-based reviews
Professional interventions
1) Audit and feedback: effects on professional
practice and healthcare outcomes
2) Computerised advice on drug dosage to
improve prescribing practice
3) Continuing education meetings and workshops:
effects on professional practice and healthcare
outcomes
4) Educational outreach visits: effects on
professional practice and healthcare outcomes
5) Guidelines in professions allied to medicine
6) Interprofessional education: effects on
professional practice and healthcare outcomes
7) Local opinion leaders: effects on professional
practice and healthcare outcomes
8) Tailored interventions to overcome identified
barriers to change: effects on professional
practice and healthcare outcomes
9) Teaching critical appraisal skills in healthcare
settings.
Organisational interventions
1) Capitation, salary, fee-for-service and mixed
systems of payment: effects on the behaviour of
primary care physicians
2) Care home versus hospital and own home
environments for rehabilitation of older people
3) Discharge planning from hospital to home
4) Effectiveness of intermediate care in nursing-led
inpatient units
5) Expanding the roles of outpatient pharmacists:
effects on health services utilisation, costs, and
patient outcomes
6) Hospital at home versus inpatient hospital care
7) Institutional versus at-home long-term care for
functionally dependent older people
8) Interventions to improve outpatient referrals from
primary care to secondary care
9) Interventions to promote collaboration between
nurses and doctors
10) Lay health workers in primary and community
healthcare
11) Mass media interventions: effects on health
services utilisation
12) Medical day hospital care for the elderly versus
alternative forms of care
13) Nursing record systems: effects on nursing
practice and healthcare outcomes
14) On-site mental health workers in primary care:
effects on professional practice
15) Organisational infrastructures to promote
evidence-based nursing practice
16) Patient reminder and patient recall systems for
improving immunisation rates
17) Pharmaceutical policies: effects of reference
pricing, other pricing, and purchasing policies
18) Specialist outreach clinics in primary care and
rural hospital settings
19) Strategies for integrating primary health services
in middle- and low-income countries at the point
of delivery
20) Substitution of doctors by nurses in primary care
21) Target payments in primary care: effects on
professional practice and healthcare outcomes
22) Telemedicine versus face to face patient care:
effects on professional practice and healthcare
outcomes
23) Telephone consultation and triage: effects on
healthcare use and patient satisfaction.
47
Clinical Efectiveness 19/10/07 15:44 Page 48
Appendix 3: Intervention-based and clinical condition-based reviews and protocols in the EPOC Review Group
Clinical condition- or problem-based
reviews
1) Dietary advice given by a dietician versus other
health professional or self-help resources to
reduce blood cholesterol
2) Effects of interventions aimed at changing the
length of primary care physicians’ consultation
3) Improving health professionals’ management
and the organisation of care for overweight and
obese people
4) Interventions to improve antibiotic prescribing
practices for hospital inpatients
5) Interventions to improve antibiotic prescribing
practices in ambulatory care
6) Interventions to improve the management of
diabetes mellitus in primary care, outpatient and
community settings.
Protocols
Intervention-based review protocols
1) Alternatives to inpatient mental health care for
children and young people
2) Case management: effects on professional
practice and healthcare outcomes
3) Changes in out-of-pocket payments on
utilisation of healthcare services
4) Computer-generated paper reminders: effects
on professional practice and healthcare
outcomes
5) Continuous quality improvement: effects on
professional practice and patient outcomes
6) Educational Games for Health Professionals
7) Effectiveness of shared care across the primary-
specialty care interface in chronic disease
management
8) Electronic access to health information and/or
knowledge by health professionals to improve
practice and patient care
9) Improving surgical practice – a systematic
review of effective education strategies to
improve surgical technical skills in operative
procedures
10) Local consensus processes: effects on
professional practice and healthcare outcomes
11) Manual paper reminders: effects on professional
practice and healthcare outcomes
12) On-screen computer reminders: effects on
professional practice and healthcare outcomes
13) Printed educational materials: effects on
professional practice and healthcare outcomes
14) Public release of performance data
15) Supervision outreach visits to improve the quality
of primary healthcare in low- and middle-income
countries
16) The impact of health financing strategies on
access to health services in low and middle
income countries.
Clinical condition- or problem-based
review protocols
1) Comprehensive geriatric assessment for older
adults admitted to hospital: a systematic review
2) Interventions for improving the appropriate use
of imaging in people with musculoskeletal
conditions
3) Interventions for increasing the proportion of
health professionals practising in under-served
communities
4) Interventions for promoting information and
communication technologies adoption in
healthcare professionals
5) Interventions for reducing medication errors in
children in hospital
6) Interventions for reducing preventable
drug-related hospital admissions or preventable
drug-related morbidity in primary care
7) Interventions to improve hand hygiene
compliance in patient care
8) Interventions to improve the management of
asthma in primary care settings
9) Interventions to increase clinical incident
reporting in healthcare
10) Interventions to increase the use of screening
and brief intervention programmes for hazardous
alcohol consumption by patients in primary care
settings
11) Interventions to reduce waiting lists for elective
procedures
12) Non-clinical interventions for reducing
unnecessary caesarean section
13) Outreach and Early Warning Systems (EWS) for
the prevention of intensive care admission and
death of critically ill adult patients on general
hospital wards
14) Pharmaceutical policies: effects on rational drug
use, an overview of 13 reviews
15) Pre-hospital emergency pathways for people
with suspected stroke
48
Clinical Efectiveness 19/10/07 15:44 Page 49
Appendix 3: Intervention-based and clinical condition-based reviews and protocols in the EPOC Review Group
16) Preventive staff-support interventions for health
workers
17) Primary and community healthcare professionals
in hospital emergency departments: effects on
process and outcome of care and resources
18) Psychologically mediated effects of the physical
healthcare environment on work-related
outcomes of healthcare personnel
19) Sensory environment on health-related
outcomes of hospital patients
20) Smart home technologies for health and social
care support.
49
Clinical Efectiveness 19/10/07 15:44 Page bcii
© Crown copyright 2007
283028 1p 500 Oct 07 (CWP) Produced by COI for the Department of Health
If you require further copies of this title quote 283028/Report of the High Level Group on Clinical Effectiveness and contact:
DH Publications Orderline PO Box 777 London SE1 6XH Email: [email protected]
Tel: 08701 555 455 Fax: 01623 724 524 Textphone: 08700 102 870 (8am to 6pm Monday to Friday)
283028/Report of the High Level Group on Clinical Effectiveness may also be made available on request in Braille, on audio, on disk and in large print.
www.dh.gov.uk/publications
Appendix 17.
Recording activity pilot spread sheet Psychology work survey
Recording activity pilot
Recording Activity Pilot As part of New Ways of Working, etc. we are having to work out methods of costing our Services. I do not want everything we do loaded on to our ‘cost per client contact’. I have agreed with the powers that be to try this method – essentially to estimate the % of time we spend over a typical month, doing the different things in our job descriptions. Method:
1. Estimate for each of the four weeks in June 2006 the % of time spent in each activity.
2. Look back over your diary to help with reliability and validity.
3. Each week should add up to 100%.
4. Use the best guess you can to reflect how time is spent
5. Assume a week is 37.5hrs. Work out the hours/mins per activity, then
calculate % as hrs/37.5 x 100. Easy. It took me approximately 1 hour to do the 4 weeks.
I know this is a pain, but if we don’t come up with something that reflects our Agenda for Change Job Descriptions, someone will come up with a crude and unhelpful alternative. Can you return to Kath/Katrina by 18 August. I will collate it all and feedback to see what we think! Thanks Paul
ACTIVITY DEFINITIONS Direct Clinical Direct Contacts = EPEX recorded time Supervision = Both giving and receiving Consultation = Talking about clients (not entered on ePEX) to
anybody Related Admin = All travel, admin, etc that is client related Teaching Delivered Preparation = Your preparation to teach Delivery = Teaching contact time Related admin/travel = To teaching NOTE: teaching can be formal/informal – basically you telling someone/group things about Psychology – not related to a specific client
Teaching Received Contact time = Length of session you attended Related admin travel = To being taught Research Planning = Thinking about projects Doing = Directly engaged in Related Admin/Travel = To research NOTE: Research is audit, evaluation, projects, etc. It’s a ‘catch all’. It usually relates
to service/group issues rather than individual clients.
Planning/Policy Solihull meetings = All non client meetings concerning only Solihull
PCT service Solihull Admin/travel = As above Non Solihull meetings = All non client meetings concerning services
outside Solihull PCT Non Solihull Admin/Travel = As above Other
If you are unable to code or can’t make an informed guess about how time was spent – try and allocate time somewhere, if you can
Annual Leave/Sick
As it says on the tin.
NAME:Week 1 - % Week 2 - % Week 3 - % Week 4 - % Overall average % Example of Overall %
June 5-9 June 12-16 June 19-23 June 26-30% % % % % %
Direct Clinical WorkDirect Contacts 40Supervision 5Consultation 2Related Admin/Travel/Management 15
Teaching DeliveredPreparation 1Delivery 2Related Admin/Travel 2
Teaching ReceivedContact Time 3Related Admin/Travel 2
Planning 5Doing 7Related Admin/Travel 0
Planning/PolicySolihull Meetings 3Solihull Admin/Travel 3Non-Solihull Meetings 2Non-Solihull Admin/Travel 2
OtherAnything not covered above 6
Annual Leave/Sick 0
0 0 0 0 0 100
TOTAL
ACTIVITY
Research
RECORDING ACTIVITY PILOT
Appendix 18.
Step by step guide to job planning
Step by step guide to job planning 7
Introduction
This section of the workbook outlines the suggested steps that could be taken in order to achievean agreed job plan. The job planning process is described in Schedule 3 of the consultant contract.A more detailed description and guidance on job planning can be found in the documentConsultant Job Planning – Standards of Best Practice provided in Appendix 1 of this workbook.These documents should be read alongside this one.
If a consultant works for more than one employer, one should be identified as the lead employerwho will assume responsibility for agreeing all of the job plan.
The job plan should cover:
• The consultant’s main duties and responsibilities
• The scheduling of commitments
• Accountability arrangements – professionally and managerially
• Agreed personal objectives and their relationship with wider service objectives
• The support needed to fulfil the job plan.
In developing the job plan the following should be borne in mind:
• It is a prospective agreement setting out duties, responsibilities and objectives for the coming year
• It should cover all aspects of a consultant’s professional practice
• It may be modelled on the previous year’s plan
• The plan may be wholly or partly team based
• It should include local and national service objectives
• It should include personal objectives
• Resources and support required are agreed and stated
• The process is separate from, but linked to, appraisal.
Who is involved?
Many people can be involved in the job planning process. The three most important are:
Consultant or team of consultants for part of the process (as each consultant willhave their own personal objectives and personal schedule)
Medical Manager Lead Clinician, Clinical Director or Medical Director
Chief Executive Although the job plan is an agreement between the employer andthe consultant, in practice the detailed discussion will take placebetween the consultant and their medical manager, whoseresponsibility it is to draw up the draft job plan. The Chief Executive’sresponsibility is to ensure that all consultants have agreed job plansas well as to sign them off.
7.1
Step by step guide to job planning7
7 Stepbystep job plannng.art 10/21/03 12:23 PM Page 7.1
Step by step guide to job planning7
Job plan review
There should be a job plan review every year. Much of the information required for the job planreview is the same or similar to that required for the appraisal process. In addition, one outcome ofthe appraisal process is a personal development plan. It would seem sensible, therefore, that thetwo processes should occur as close together in time as possible, with appraisal preceding jobplanning. If there is a significant change in any aspect of the job plan during the year it may benecessary to have an interim job plan review.
The purpose of the review is to:
• Consider what has affected the job plan
• Consider progress against the agreed objectives
• Agree any changes to duties and responsibilities
• Agree a plan for achieving personal objectives
• Agree support needed from the organisation
• Review relationship with private practice.
Information needs
The information needed to inform job planning will differ between specialties and even betweenconsultants in the same specialty. It is not possible, therefore, to give a definitive list of what mightbe required. The different parties to the job planning process also require different sets ofinformation. The following checklist provides suggestions about the sort of information required.The list is by no means exhaustive, nor is every item mentioned necessary.
Information checklists
Consultant:
• Last year’s job plan. If this is the first job plan or if either party feels that there might be need forsignificant change in the current job plan, a sensible diary kept over an appropriate number ofweeks. Included in this section starting on page 23 is the diary developed by the BMA and theDepartment of Health. You do not have to use this diary, but you may find it helpful
• List of main clinical responsibilities for employer
• Workload figures broken down in a meaningful way
• Timetable of private practice commitments
• List and scheduling of any fee paying services
• Teaching commitments
• CPD/CME requirements
• Personal development plan
• List and time commitment of other duties and responsibilities for main employer
• List and time commitment of duties and activities for other organisations such as work for tradesunions, GMC, CHAI, Royal Colleges.
• Clinical audit and clinical governance issues to be addressed
• Support provided by the organisation and support required
• Ideas for improvements to service quality, range or performance
• Thoughts on blockages to efficient service delivery.
7.2
7 Stepbystep job plannng.art 10/21/03 12:23 PM Page 7.2
Step by step guide to job planning 7
Medical Manager:
• Quantity and quality targets for the directorate and performance against them by the team andindividually in the previous year
• Knowledge of the relevant priorities within the local delivery plan
• Changes in services being required of, or offered by, the directorate
• Clinical audit and clinical governance issues affecting the directorate
• Knowledge of the resource base of the directorate including numbers of staff, changes in skill mixand those services, space and equipment available
• Understanding of current and new initiatives within the directorate or Trust.
In addition, the consultant and/or the medical manager may require information from othersources in order to complete the job plan accurately. Such information might include:
• Activities for other employers in the case of joint appointments
• Changes in practices and/or services of other directorates or other providers
• National clinical audit or clinical governance issues
• Changes in the health provision requirements of the local health community
• Information from tertiary centres regarding referrals
• The Royal Colleges, particularly regarding workload and changes in clinical practice
• The requirements of medical schools
• The needs of doctors in training
• Feedback from trainees.
Before the discussion
If the job planning process is to have meaning and to be helpful to both the consultant and theorganisation, some preparatory work is necessary by both parties.
It is very likely that a diary will need to be kept for a period of time to assess accurately the amount oftime consultants spend on different activities. Consultants and medical managers will need to agreehow long a diary needs to be kept. This will vary according to the predictability of the workload ofindividual consultants, but should be kept for the duration of at least one full on-call rota.
Other information will also need to be collected. In order to give some structure to the process it issuggested that the pro forma on the pages following the diary be used by the consultant whilstpreparing for the job planning discussion. If the job planning discussion takes place immediatelyafter the annual appraisal then much of the information can be shared. As the personaldevelopment plan will have been agreed at the appraisal session, it can immediately inform the jobplanning discussion.
Medical managers and consultants need to agree at the outset who should prepare the first draftjob plan. Whilst this is the responsibility of the medical manager, by agreement the consultant mayundertake this task."
7.3
7 Stepbystep job plannng.art 10/21/03 12:23 PM Page 7.3
Step by step guide to job planning7
Diary
The following diary has been adapted from that prepared by the British Medical Association’sCentral Consultants’ and Specialists Committee for the survey on hours of work and pattern ofworking that took place during 2001. It has been tailored to reflect the definitions of work and outof hours as set out in the ‘Heads of Agreement’ and consultant contract framework agreement.
The purpose of the diary is to help inform the job planning process. Consultants may find it helpfulto note down when they are undertaking private practice or other additionally remunerated work,particularly work of this nature that is irregular. If, however, should they prefer not to do this, thereis no requirement to do so.
Predictable emergency work (e.g. post take ward rounds) should be programmed where possibleinto the working week and count towards programmed activities. Less predictable emergency workshould be handled, as now, through on-call arrangements. For this reason, consultants may wish todistinguish between predictable and unpredictable on-call duties in their diary.
Completing the diary
On each page of the diary there are two tables. On the left hand side of the page is the diary andon the right hand side is a list of activity codes. For each day consultants should:
a Put the date underneath the day.
b At the end of every day, consultants should assign the relevant code to each half-hour block inthe first column and write it in the relevant box. Half-hour blocks may be bracketed togetherfor ease of completion. Please remember this is a survey of a consultant’s WORK activities, nottheir private life. All activities not related to NHS or other additionally remunerated work arecovered by the single code N2.
c The second column should be used to record on-call status. Half-hour blocks may be bracketedtogether for ease of completion.
7.4
7 Stepbystep job plannng.art 10/21/03 12:23 PM Page 7.4
Step by step guide to job planning 7
7.5
Monday Tuesday
Work code On-call? Work code On-call?
7AM to 7:30
7:30 to 8:00
8:00 to 8:30
8:30 to 9:00
9:00 to 9:30
9:30 to 10:00
10:00 to 10:30
10:30 to 11:00
11:00 to 11:30
11:30 to Noon
Noon to 12:30PM
12:30 to 1:00
1:00 to 1:30
1:30 to 2:00
2:00 to 2:30
2:30 to 3:00
3:00 to 3:30
3:30 to 4:00
4:00 to 4:30
4:30 to 5:00
5:00 to 5:30
5:30 to 6:00
6:00 to 6:30
6:30 to 7:00
7:00 to 7:30
7:30 to 8:00
8:00 to 8:30
8:30 to 9:00
9:00 to 9:30
9:30 to 10:00
10:00 to 10:30
10:30 to 11:00
11:00 to 11:30
11:30 to Midnight
Midnight to 12:30
12:30AM to 1:00
1:00 to 1:30
1:30 to 2:00
2:00 to 2:30
2:30 to 3:00
3:00 to 3:30
3:30 to 4:00
4:00 to 4:30
4:30 to 5:00
5:00 to 5:30
5:30 to 6:00
6:00 to 6:30
6:30 to 7AM
CODES
Direct clinical care
Emergency attendance C1
Out-patient or other clinic C2
Operating session (including anaesthetists) C3
Ward round C4
Other patient treatment or relative consultation C5
Telephone advice to hospital C6
Multi-disciplinary meetings about direct patient care C7
Investigative, diagnostic or laboratory work C8
Public health duties C9
Travelling time between sites, not to usual place of work C10
Patient administration C11
Supporting professional activities
Training S1
Continuous Professional Development S2
Teaching S3
Audit / Clinical Governance S4
Job Planning / Appraisal S5
Research S6
Clinical management S7
Additional responsibilities
Caldicott guardian A1
Audit lead or Clinical governance lead A2
Clinical tutor A3
Medical / clinical directors’ and lead clinicians’ PAs by substitution or additional remuneration A4
Other additional responsibilities A5
Other duties
Trade union duties D1
AAC external member D2
NCAA, GMC, CHAI D3
Work for Royal Colleges D4
Other D5
Additionally remunerated work (see notes on p23) P(e.g. private practice P1, Category 2 work P2and other additionally remunerated work P3)
Non-work activity
Absent from work (annual or sickness leave) N1
Other (i.e. time spent not working) N2
On-call status (column 2 – see notes on p23)
Predictable on-call 1
Unpredictable on-call 2
7 Stepbystep job plannng.art 10/21/03 12:23 PM Page 7.5
Step by step guide to job planning7
7.6
Wednesday Thursday
Work code On-call? Work code On-call?
7AM to 7:30
7:30 to 8:00
8:00 to 8:30
8:30 to 9:00
9:00 to 9:30
9:30 to 10:00
10:00 to 10:30
10:30 to 11:00
11:00 to 11:30
11:30 to Noon
Noon to 12:30PM
12:30 to 1:00
1:00 to 1:30
1:30 to 2:00
2:00 to 2:30
2:30 to 3:00
3:00 to 3:30
3:30 to 4:00
4:00 to 4:30
4:30 to 5:00
5:00 to 5:30
5:30 to 6:00
6:00 to 6:30
6:30 to 7:00
7:00 to 7:30
7:30 to 8:00
8:00 to 8:30
8:30 to 9:00
9:00 to 9:30
9:30 to 10:00
10:00 to 10:30
10:30 to 11:00
11:00 to 11:30
11:30 to Midnight
Midnight to 12:30
12:30AM to 1:00
1:00 to 1:30
1:30 to 2:00
2:00 to 2:30
2:30 to 3:00
3:00 to 3:30
3:30 to 4:00
4:00 to 4:30
4:30 to 5:00
5:00 to 5:30
5:30 to 6:00
6:00 to 6:30
6:30 to 7AM
CODES
Direct clinical care
Emergency attendance C1
Out-patient or other clinic C2
Operating session (including anaesthetists) C3
Ward round C4
Other patient treatment or relative consultation C5
Telephone advice to hospital C6
Multi-disciplinary meetings about direct patient care C7
Investigative, diagnostic or laboratory work C8
Public health duties C9
Travelling time between sites, not to usual place of work C10
Patient administration C11
Supporting professional activities
Training S1
Continuous Professional Development S2
Teaching S3
Audit / Clinical Governance S4
Job Planning / Appraisal S5
Research S6
Clinical management S7
Additional responsibilities
Caldicott guardian A1
Audit lead or Clinical governance lead A2
Clinical tutor A3
Medical / clinical directors’ and lead clinicians’ PAs by substitution or additional remuneration A4
Other additional responsibilities A5
Other duties
Trade union duties D1
AAC external member D2
NCAA, GMC, CHAI D3
Work for Royal Colleges D4
Other D5
Additionally remunerated work (see notes on p23) P(e.g. private practice P1, Category 2 work P2and other additionally remunerated work P3)
Non-work activity
Absent from work (annual or sickness leave) N1
Other (i.e. time spent not working) N2
On-call status (column 2 – see notes on p23)
Predictable on-call 1
Unpredictable on-call 2
7 Stepbystep job plannng.art 10/21/03 12:24 PM Page 7.6
Step by step guide to job planning 7
7.7
Friday Saturday
Work code On-call? Work code On-call?
7AM to 7:30
7:30 to 8:00
8:00 to 8:30
8:30 to 9:00
9:00 to 9:30
9:30 to 10:00
10:00 to 10:30
10:30 to 11:00
11:00 to 11:30
11:30 to Noon
Noon to 12:30PM
12:30 to 1:00
1:00 to 1:30
1:30 to 2:00
2:00 to 2:30
2:30 to 3:00
3:00 to 3:30
3:30 to 4:00
4:00 to 4:30
4:30 to 5:00
5:00 to 5:30
5:30 to 6:00
6:00 to 6:30
6:30 to 7:00
7:00 to 7:30
7:30 to 8:00
8:00 to 8:30
8:30 to 9:00
9:00 to 9:30
9:30 to 10:00
10:00 to 10:30
10:30 to 11:00
11:00 to 11:30
11:30 to Midnight
Midnight to 12:30
12:30AM to 1:00
1:00 to 1:30
1:30 to 2:00
2:00 to 2:30
2:30 to 3:00
3:00 to 3:30
3:30 to 4:00
4:00 to 4:30
4:30 to 5:00
5:00 to 5:30
5:30 to 6:00
6:00 to 6:30
6:30 to 7AM
CODES
Direct clinical care
Emergency attendance C1
Out-patient or other clinic C2
Operating session (including anaesthetists) C3
Ward round C4
Other patient treatment or relative consultation C5
Telephone advice to hospital C6
Multi-disciplinary meetings about direct patient care C7
Investigative, diagnostic or laboratory work C8
Public health duties C9
Travelling time between sites, not to usual place of work C10
Patient administration C11
Supporting professional activities
Training S1
Continuous Professional Development S2
Teaching S3
Audit / Clinical Governance S4
Job Planning / Appraisal S5
Research S6
Clinical management S7
Additional responsibilities
Caldicott guardian A1
Audit lead or Clinical governance lead A2
Clinical tutor A3
Medical / clinical directors’ and lead clinicians’ PAs by substitution or additional remuneration A4
Other additional responsibilities A5
Other duties
Trade union duties D1
AAC external member D2
NCAA, GMC, CHAI D3
Work for Royal Colleges D4
Other D5
Additionally remunerated work (see notes on p23) P(e.g. private practice P1, Category 2 work P2and other additionally remunerated work P3)
Non-work activity
Absent from work (annual or sickness leave) N1
Other (i.e. time spent not working) N2
On-call status (column 2 – see notes on p23)
Predictable on-call 1
Unpredictable on-call 2
7 Stepbystep job plannng.art 10/21/03 12:24 PM Page 7.7
Step by step guide to job planning7
7.8
Sunday
Work code On-call?
7AM to 7:30
7:30 to 8:00
8:00 to 8:30
8:30 to 9:00
9:00 to 9:30
9:30 to 10:00
10:00 to 10:30
10:30 to 11:00
11:00 to 11:30
11:30 to Noon
Noon to 12:30PM
12:30 to 1:00
1:00 to 1:30
1:30 to 2:00
2:00 to 2:30
2:30 to 3:00
3:00 to 3:30
3:30 to 4:00
4:00 to 4:30
4:30 to 5:00
5:00 to 5:30
5:30 to 6:00
6:00 to 6:30
6:30 to 7:00
7:00 to 7:30
7:30 to 8:00
8:00 to 8:30
8:30 to 9:00
9:00 to 9:30
9:30 to 10:00
10:00 to 10:30
10:30 to 11:00
11:00 to 11:30
11:30 to Midnight
Midnight to 12:30
12:30AM to 1:00
1:00 to 1:30
1:30 to 2:00
2:00 to 2:30
2:30 to 3:00
3:00 to 3:30
3:30 to 4:00
4:00 to 4:30
4:30 to 5:00
5:00 to 5:30
5:30 to 6:00
6:00 to 6:30
6:30 to 7AM
CODES
Direct clinical care
Emergency attendance C1
Out-patient or other clinic C2
Operating session (including anaesthetists) C3
Ward round C4
Other patient treatment or relative consultation C5
Telephone advice to hospital C6
Multi-disciplinary meetings about direct patient care C7
Investigative, diagnostic or laboratory work C8
Public health duties C9
Travelling time between sites, not to usual place of work C10
Patient administration C11
Supporting professional activities
Training S1
Continuous Professional Development S2
Teaching S3
Audit / Clinical Governance S4
Job Planning / Appraisal S5
Research S6
Clinical management S7
Additional responsibilities
Caldicott guardian A1
Audit lead or Clinical governance lead A2
Clinical tutor A3
Medical / clinical directors’ and lead clinicians’ PAs by substitution or additional remuneration A4
Other additional responsibilities A5
Other duties
Trade union duties D1
AAC external member D2
NCAA, GMC, CHAI D3
Work for Royal Colleges D4
Other D5
Additionally remunerated work (see notes on p23) P(e.g. private practice P1, Category 2 work P2and other additionally remunerated work P3)
Non-work activity
Absent from work (annual or sickness leave) N1
Other (i.e. time spent not working) N2
On-call status (column 2 – see notes on p23)
Predictable on-call 1
Unpredictable on-call 2
7 Stepbystep job plannng.art 10/21/03 12:24 PM Page 7.8
Step by step guide to job planning 7
7.9
Name
GMC/GDC registration no
Main employer
Other employer(s)
Date of completion of relevant appraisal
Start date of new job plan
Background details
List information on current main job that have you collected(delete those listed not collected)
1 Current job plan
2 List of main clinical responsibilities
3 Workload figures
4 Diary showing work other than on call
5
6
7
8
9
10
11
12
Timetable & workload information
1 Actual rota frequency (state frequency) 1 in
2 Timetable of predictable PAs
3 Diary showing unpredictable on-call work
Information required about your on-call
Other information to be collected by the Consultant
7 Stepbystep job plannng.art 10/21/03 12:24 PM Page 7.9
Step by step guide to job planning7
7.10
1
2
3
4
5
6
7
8
9
10
Information on activities that are supporting professional activities
Duty Time commitment
1
2
3
4
5
6
7
8
9
List of additional duties and responsibilities for main employer and time commitment
Duty Time commitment
1
2
3
4
5
6
7
8
9
List of external duties for other organisations, both NHS and non NHS, and time commitment
7 Stepbystep job plannng.art 10/21/03 12:24 PM Page 7.10
Step by step guide to job planning 7
7.11
Type of clinical work Scheduled time
1
2
3
4
5
6
7
8
9
List of private practice commitments
Type of clinical work Scheduled time
1
2
3
4
5
6
7
8
9
List of regular fee-paying services
Type of clinical work Frequency
1
2
3
4
5
6
7
8
9
List of non-regular fee-paying services
7 Stepbystep job plannng.art 10/21/03 12:24 PM Page 7.11
Step by step guide to job planning7
7.12
Objectives
List of the clinical and service objectives for you and your team as youunderstand them
List of your personal objectives, as agreed in the appraisal process
List of CPD/CME requirements
7 Stepbystep job plannng.art 10/21/03 12:24 PM Page 7.12
Step by step guide to job planning 7
7.13
Clinical audit and clinical governance issues
Ideas for service improvements
What do you feel prevents you from working efficiently? Detail below
7 Stepbystep job plannng.art 10/21/03 12:24 PM Page 7.13
Step by step guide to job planning7
7.14
Currently provided:
Not currently provided, but required:
What resources do you need to complete your duties and objectives effectively?Detail below
7 Stepbystep job plannng.art 10/21/03 12:24 PM Page 7.14
Step by step guide to job planning 7
Preparing the job plan
There should now be sufficient information for a draft job plan to be prepared. This needs toinclude the following elements:
• sessions, timing content and where they will happen
• on-call commitments and the work that is generated as a consequence of being on-call
• commitments to the organisation that do not occur on a regular, weekly basis
• additional duties for the organisation
• commitments to other organisations
• personal objectives
• the support required to undertake the job that is already provided by the organisation
• additional support needed.
The job planning meeting
It is essential that both parties allow sufficient, uninterrupted time (usually one hour, althoughmore time may be required for first job plans or where significant changes are being proposed). Itis also essential that sufficient time has been allowed to prepare for the meeting, that all relevantinformation has been collated and that a provisional job plan has been drawn up for discussion.
Both parties should make every possible effort to agree job plans. In the rare circumstances where aconsultant and employer fail to reach agreement on the content of a job plan, either initially or ata job plan review, they should follow the mediation and appeal procedures set out in Schedule 4 ofthe Terms and Conditions. Once the job plan has been agreed, a copy should be sent to the ChiefExecutive for formal ratification and a copy retained by both parties.
7.15
7 Stepbystep job plannng.art 10/21/03 12:24 PM Page 7.15
Appendix 19.
Psychological therapy staff possible time allocations by banding
Band 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%9 DCC = 20%8d DCC = 30%8c DCC = 50%8b DCC = 70%8a765
KEY
Peer supervision (Clinical)
Travel (between sites, not to usual place of work)Patient administrationReceiving clinical supervisionDelivering clinical supervision
MDT Meeting about direct patient care (Not CPA Meeting) Management and leadership (delivering)CPA Meeting (Standard and enhanced) Management and leadership (receiving)
Clinical telephone contact Audit/Clinical Governance/Service Improvement & Development activities
Other
Clinical consultancy/liaison Research
Face-to-face contact Receiving training/CPD Trade union dutiesGroup work Teaching (preparation and delivery) Work for professional organisation / representing the
profession / contributing to professional practice
Psychological Therapy Staff - Possible Time Allocations by Banding
Percentage of Time
Direct Clinical Care Supporting Professional Activity Other
Appendix 20.
Rough guide to influencing commissioners
The Rough Guide to “Influencing Commissioners”
Claire Maguire
Consultant Clinical Psychologist
PEC Member Bury PCT
BACKROUND
Tim Cate asked me to write a short briefing paper on how to influence
Commissioners following a presentation I made at the North West DCP’s AGM. I am
a Consultant Clinical Psychologist working within a Specialist Mental Health Trust as
a Clinical Lead for Primary Care Mental Health. About four and a half years ago the
Chief Executive of our local PCT invited staff from Mental Health Services to apply
for a position on the Professional Executive Committee. I was appointed as the “Other
Healthcare Professional” Member of the Committee in Autumn 2002. I was
successfully reappointed last year to sit on the Committee for a further four years (if
there still is a PEC then!).
The Role of the PEC
PEC’s were established as part of a PCT’s governance arrangements in April 2002.
It’s role was to lead the PCT Board through detailed thinking on priorities, service
policies and investment plans with decisions about how to take these forward largely
delegated to the Executive. It was described as the “engine room” of the PCT Model.
The new commissioning framework, published by the Department of Health in July
2006, announced a review of the role and composition of the PEC to ensure that this
part of the PCT structure can be fit for purpose in the new NHS market. Every PCT
will be currently reviewing the role of their PEC in this new climate. The Department
of Health affirm the need to retain PEC’s in the future, however their form and
function may alter.
How can you influence the PEC and influence commissioning?
Understanding the role of the PEC is critical to understanding how to influence
Commissioners. Psychologists can be involved on a number of levels.
1) It is really important to first of all find out who are the key “players” in your
area. Each PEC is made up of a group of senior clinicians and senior
management. The core membership will be GP’s and other Professionals such
as Dentists, Nurses, and Pharmacists. Then there will be members from the
Allied Health professionals, such as Speech and Language Therapists, OT’s,
Physiotherapists and even Psychologists depending upon your local area. It is
worth finding out how to become a PEC member in your local area. The
appointments to PEC’s are competency based and are often filled on a rolling
basis so members come up for election at different times.
2) Find out who is the Mental Health Lead for your PCT. It is vital to know who
“champions” Mental Health issues at PEC meetings. If no one does offer to do
it!
3) There are clear Mental Health Targets that PCT’s have to meet. These are
described in the Mental Health National Service Framework. Each PCT is
asked to assess their performance against these targets each autumn jointly
with local Mental Health providers and Social Services. Find out who is
responsible for the presentation of these targets to the PCT. They may already
contact you each Autumn when they are preparing their data for the SHA.
Offer to help them and see how well the targets are met in your locality. You
can access the information about the targets on the CSIP websites.
4) Usually these targets are discussed at Mental Heath Local Implementation
Teams (LIT’s) so if you do not already attend your local LIT start going. You
will find that you will be listened to if you can provide good quality services
that meet these targets and each year there is also a themed review of services.
Be proactive.
5) Psychologists have particular skills to offer around the Governance
arrangements for Mental health Services. It is useful to find out who your
Clinical Governance Lead is at the PCT and indeed make links with the
Governance Leads within Mental Health Trusts. In this area we are setting up
a Psychotherapeutics Committee along the lines of a Drugs and Therapeutics
Committee (which is something both GP’s and PCT’s are familiar with) This
committee will be looking at the governance arrangements around
Psychological Therapies. The PCT’s locally are very happy to be part of this
structure as it helps them identify and commission “safe” services.
6) Step out of your “comfort zone”. PCT’s need to commission services for the
whole population that they serve not just those people who are in contact with
specialist Mental Health Services. We need to look at what Psychologists can
offer to the “Wellbeing” agenda. This requires being up to date with National
Policy and Guidance and being creative about how we can contribute to areas
such as the care of people with Long Term Conditions, Psycho-oncology and
other physical health conditions (especially those mentioned in NICE
guidelines) Many PCT staff working to deliver Active Case Management
would value Clinical supervision if it was made available. We also need to be
more willing to engage with the Voluntary sector who may already provide
services in you locality.
7) Work closely with your Director for Public Health. It will increasingly be their
role to identify priorities. They are actively working to reduce health
inequalities, promote good health and encourage public involvement.
8) Embrace new ways of working and ensure that new roles are couched in high
quality governance frameworks. For example, many Graduate workers will go
on to Clinical Training and it is important to influence these new members of
our profession positively. Support Time and Recovery workers and Associate
Psychology roles also are opportunities, not threats if handled positively. It is
important to influence Training Courses to provide a Workforce fit to deliver
new ways of working.
9) Get involved with your patients (and their carers) experience and shape
services to meet needs and provide an evidence base to support change.
10) Use Research skills in a broader way to support service decisions and collate
good quality data to support bids for further finances.
11) Finally, last but no means least, find out all you can about Practice Based
Commissioning and how that is being implemented in your area. Good
communication with PbC commissioners and consortia will be essential. This
will be a challenge but it will also be an opportunity to encourage
development of provision and patient choice.
I hope this is helpful. It is by no means an exhaustive list and it may well be very
different in your area. A lot does depend upon the personalities of the key people and
the strength of Partnership arrangements. However a great deal can be achieved by
being an enthusiastic champion for the individuals, families, and groups that we work
with and for.
The time frame for PCT’s to initiate change can be very swift so it is important not to
sit on the sidelines and observe but to get involved (where possible) and shape the
change.
Claire Maguire.
Appendix 21.
Fairer commissioning power point presentation
“Fairer Commissioning”
OHOCOS: Third Sector Summit 12 March 2007
Bob RickettsHead of Demand-Side Reform
Department of Health
“Fairer Commissioning”
Commissioning environment:• Health Reform• ‘Commissioning’ defined• ‘Failure of commissioning’• ‘Unfair playing field’Commissioning challenge:• ‘Re-building commissioning: vision & progress since
‘OHOCOS’• Commissioning Framework for Health & Well-being• Next steps …
Commissioning - part of a comprehensivehealth reform programme
More diverse providers, withmore freedom to innovate and
improve services
(supply-side reforms)
Choice & Commissioning(demand-side reforms)
Money following the patients,rewarding the best and most
efficient providers, giving othersthe incentive to improve
(transactional reforms)
A framework of systemmanagement, regulation and
decision making whichguarantees safety and quality,fairness, equity and value for
money (system management reforms)
Better careBetter patientexperience
Better value for money
Reform is about creating an NHS which …
Knows the quality ofservices, and rewards
excellence
Improves quality,
responsiveness,
efficiency,
equality
Light touch monitoringwith robust safeguards
Develops & empowersorganisations and staff
Listens to users, anddesigns services to suit
their needs choices
‘Commissioning’
Definition:
“The means by which we secure the best value for patients &taxpayers. By ‘best value’ we mean:
• the best possible health outcomes, including reduced inequalities• the best possible healthcare• within the resources made available by the taxpayer”
“At the heart of commissioning are the millions of individual decisions ofpatients and clinicians that lead to the provision of care and thecommitment of resources. Behind these clinical decisions lies a rangeof separate but related processes that collectively make upcommissioning … a commissioning cycle.”
‘Health Reform in England: update and commissioning framework”July 2006
The ‘Commissioning Cycle’
Assessingneeds Designing services
Managing demand
Seeking public and patient views
Managing performance
(quality, performance,
outcomes)
Shaping the structure of supply
Referrals, individual needs
assessment; advice on choices; treatment / activity
Deciding prioritiesReviewing service provision
Patient / Public
National targets
Petitions
Publishedprospectus
‘Commissioning’
Roles:
“Commissioners play at least three roles:• Advocate for the individual• Advocate for communities• Guardian of taxpayers’ money
Taken together they create dilemmas and trade offs – theessence of the role of commissioning”
‘Commissioning for quality improvement’ –The Health Foundation, October 2006
‘Failure of Commissioning’
NHS has ‘commissioned’ for over a decade, but …• ‘Command & control’ delivery model has consistently reinforced the
‘provider line’• Commissioners have lacked robust levers• Simplistic ‘cost & volume’ approach• Waiting as the main control on demand• Not all available levers have been used• Inadequate regulatory regime – ‘bail out’• Low investment in developing commissioners• Seen as ‘low status’ – stories & role models?• Highly variable & fragmented practice• Lack of legitimacy (linked to ‘voice’ & patient /public engagement)• Very limited range of providers
‘Failure of Commissioning’
Social care has ‘commissioned’ for well over adecade:• Very successful in driving down costs• Greater understanding of the principles of good commissioning*• Much more professional procurement approach• Improving engagement of users*• Improved commissioning to meet the needs of BME communities*• Increased consultation with children & young people*
‘The State of Social Care in England , 2005-06’
‘Failure of Commissioning’
Social Care: ‘progress remains gradual’*:
• Focus on outputs, not outcomes• Extent and form of engagement varies considerably*• Focus on specific groups – rather than whole population*• Limited Market Analysis and Development*• Little “Commissioning for Quality”*• New initiatives represent small investment of total resources*• Few Councils focusing on people who fund their own care – or those
excluded from services by high eligibility criteria*
*The State of Social Care in England, 2005-06’
‘An unfair playing field’
The indictment has been set out often:• Lack of awareness amongst commissioners of the Third Sector• Inconsistency of procurement and regulatory practices• Great variation in when/whether to use grants or contracts• Burden of disproportionate procurement practices – pre-qualification
requirements, guarantees/bonds• Poor funding practice: lack of full cost recovery > ‘subsidy’• Poor funding practice: short-termism = barrier to investment “Most TSOs have not seen any general improvement in funding practices
since 2002, and in some cases funding practices are perceived to haveworsened”
• Burden of disproportionate monitoring
‘Working with the Third Sector’ National Audit Office June 2005
‘An unfair playing field’
‘An unfair playing field’
Re-launching Commissioning
Vision + direction set out in:– Commissioning Framework (July)– Practice-Based Commissioning Guidance
(November)– NHS Contract – hospitals (December)– Care Resource Utilisation – demand
management (December– Commissioning Framework for Health,
Care & Well-being (March - consultation)
To follow:– Guidance on ‘Free Choice’ (Spring)– “Choice Framework” (late-Spring, for
consultation)– NHS Contract – hospitals & out-of-hospital
services, including Third Sector (Autumn 2007 for 2008/09)
Vision for Commissioning:
An approach to Commissioning which …
• Is based on systematic needs assessment – individuals,groups, communities, populations
• Puts people at the centre• Takes decisions at the right levels• Uses evidence & information• Prioritises health improvement & wellbeing• Targets inequalities in access & health• Commissions appropriate, responsive and effective services
which sustain people’s health, dignity & independence• Offers choice – of provider, setting, treatment, to self-care• Provides value for money• Procures effectively & fairly
Vision for Commissioning
Commissioners who …
• Can assess need systematically• Listen to individuals & communities – especially those who are often
not heard• Commission for outcomes & outputs• Understand & use the levers available to them:
– Care Resource & Utilisation– Contracts– Incentives– Market development (Third Sector, IS, etc)
• Are capable & competent & multidisciplinary• Can build effective partnerships
‘Towards a fair playing field’
Recognised as a key issue in ‘Health Reform in England: update andcommissioning framework”:
• “PCTs will work with existing and potential providers to ensure theyunderstand the services required by the local population and theopportunities to develop new services, to meet unmet needs, or to improvethe quality of service”
• “We recognise that establishing new services … can have additional costsor higher risks … a commissioning model based on patient choice andtariff alone may not always be sufficient to secure the development of newservices…”
• “There are a number of approaches PCTs could choose to adopt toreduce the risk for providers and consequently make the provision of newservices more attractive to existing providers or new entrants, includingthose from the third sector.”
‘Towards a fair playing field’
Health Reform in England: update and commissioning framework”:• Pay a supplement to tariff – start-up allowance or supplement• Provide guarantees within the contract• Reduce the capital investment required from the provider• Commitment to develop & use appropriate contractual framework
But …• PCT must be able to make a sound case• Any incentive must be strictly time limited• Transparency & auditability• Process for awarding the incentive must be open to any willing provider
‘Towards a fair playing field’:Commissioning Health & Well-being
Problem: providers are sometimes unwilling or unable to provide new and innovative services
Solution:• Commissioning focused on outcomes
• Wider range of providers
• Develop effective, strong partnerships with providers
• Transparent and fair procurement
• More innovative provision, tailored to the needs of individuals (engage providers inneeds assessments)
• Intelligent decommissioning
And the review of the regulatory system (The future of regulation of health and
adult social care in England, consultation closed 28 Feb 2007)
‘Towards a fair playing field’:Commissioning Health & Well-being
Proposals include:• Commissioning for outcomes & outputs• Active market shaping role for PCTs & LAs• Build awareness & understanding of the role & potential contribution of all
providers, including Third Sector (and within TSO, smaller organisations)• Better information to help people (including self-funders) choose• Local provider forum (potential + current)• Engagement of providers in Strategic Needs Assessment• Publication of SNA• Joint review of available providers following SNA – ensure sufficient range
of services & providers to ensure genuine choices for users• Signalling of intentions in PCT Prospectus
‘Towards a fair playing field’:Commissioning Health & Well-being
• Fair & open procurement and contractual processes which areproportionate, neutral between different types of providers andtransparent on pricing
• Address ‘full cost recovery’ through transparency on pricing andallowing providers to frame realistic, economic tenders
• ‘Fair and reasonable trading’ – contract length & risk apportionment• Encourage entry – use the incentives in the ‘July Commissioning
Framework’• Clarity about the distinction between grants and legally-binding
contracts & the role each has to play• National contract template(s) – building on the work of the Third
Sector Commissioning Taskforce
‘Towards a fair playing field’:Next steps
• Consultation on the H&W Commissioning Framework• Development of contract templates• DH to work with OTS and other Departments to align, over
time, approaches to commissioning• ‘Unbundling’ appropriate tariffs, or developing local tariffs• Active programme of commissioner development
Appendix 22.
NWW Good Practice Guide on the Contribution of Applied Psychologists to Improving Access for Psychological Therapies
(Summary and recommendations)
Good Practice Guide on the Contribution of Applied Psychologists to Improving Access for Psychological
Therapies
Guidance for psychologists, managers and commissioners produced by the IAPT Group of the New Ways of Working for
Applied Psychologists Project
Comments to:
Graham Turpin
Clinical Psychology Unit,
Department of Psychology
University of Sheffield
Western bank
Sheffield, S10 2TN
III Executive summary/ Quick Guide Introduction Ensuring adequate access to psychological therapies for people consulting their GPs
in primary care is a key government priority as demonstrated by the Improving
Access to Psychological Therapies Programme (MHChoice, 2007). Service users will
obtain choice about the kinds of interventions (e.g. medication vs psychological
therapy) that they require, and the provision of effective interventions to treat anxiety
and depression has the potential for economic savings both in the form of reduced
incapacity benefits, and offsetting costs associated with prescribing, diagnostic
assessment of unexplained symptoms, briefer inpatient stays etc.
Better access to psychological therapies is associated with redesigning primary care
mental health services to follow a stepped care model whereby patients assess least
intrusive interventions, in a timely fashion but are stepped up to more intensive
interventions or down depending on progress and need.
The purpose of this report is to outline some of the processes and examples of positive
practice involved in designing and implementing IAPT services. In particular, it
focuses on the contributions that applied psychologists, working with other staff and
through provider organisations, can make to the success of the IAPT Programme. The
report was co-ordinated by the NWW IAPT sub-group, and consists of a series of
chapters commissioned from experts within the area of psychological therapies. In
addition, a series of positive practice exemplars are included to illustrate how applied
psychologists have contributed to service innovation and improvement.
Contents of the Report
Introduction to the policy context and the development of the IAPT Programme. This
provides the policy background to the development of the IAPT programme and
outlines crucial information for those services contemplating service redesign.
Perspectives from all four nations within the UK are covered.
Graham Turpin and Roslyn Hope
The general contributions that applied psychologists can make to the challenge of service innovation and redesign in expanding access to psychological therapies. Many trusts are appointing psychologists to Directors of Psychological Therapies:
these appointments are usually at Board level. This contribution provides examples
and illustrations that applied psychologists that can make to progressing a multi-
professional approach to improving the governance and training of psychological
therapies and awareness throughout the entire organisation.
Kay MacDonald and Keith Millar
Care pathways and the service users journey: providing integrated services and commissioning? A method describing care pathways for users of mental health
services is reviewed. The integrated care pathways approach provides a focus for
determining which psychological interventions are required, together with the
different contributions and roles of mental health staff. It could also assist in the
costing and resourcing of services.
Roger Paxton, Rolland Self, Mike Lucock
Innovation in supporting community and primary care mental health. This discusses
innovative practice that can support improving access within primary care. A
particular focus is how psychologists can enhance the skills of GPs and other primary
care staff. Interventions including staff training, guided self-help, computerised CBT,
brief protocolised therapies are reviewed.
John Cape
Innovation and the provision of psychological therapies. Many users presenting with
common health problems may required more intensive therapies and may need to be
stepped up from primary care to secondary care services. This chapter reviews the
provision of these more intensive psychological interventions, typically employed in
the research trials upon which much of NICE guidance is based.
John Cape
Clinical governance, risk and the management of psychological therapy services: how can applied psychologists contribute? Psychological therapy services comprise more
than just the provision of therapy. This contribution deals with issues of governance,
training, supervision, performance management and outcomes, audit, etc. and how
psychologists, together with other senior members of the therapies team can maintain
and enhance service quality.
Robina Barry
Contribution of psychologists both to evidence-based practice and practice-based evidence. Ensuring services are well-evaluated and enable the collation of practice-based evidence to inform the development of future clinical guidelines. A review of
different research and evaluation approaches to psychological therapies is provided.
Michael Barkham
Implications for the psychology workforce: new roles, education and training, career pathways and the roles of consultant psychologists. Service redesign will require
consideration of new roles (e.g. low intensity practitioners), plus the need to upskill
existing staff in order to deliver the IAPT programme. The consequences of these
training needs for both education providers and commissioners is dealt with.
Graham Turpin and Roslyn Hope
Ensuring added value: commissioning advice for those securing applied psychology services. What does psychology add to IAPT services and what should commissioners expect of consultant psychologists? Although applied psychologists are usually
positioned with service providers, they may also act as a useful source of advice to
those responsible for commissioning services involving psychological therapies.
Tim Cate and Claire Mcguire
Overview of the impact of IAPT on the profession of applied psychology: opportunities and challenges. This final section assess the impact of the IAPT
programme on the future of the applied psychology profession. Although the
programme may create unprecedented opportunities for psychologists to engage with
widening access to psychological therapies, there are also important impacts,
especially for psychologists working outwith therapy provision. It will be important
for commissioners to recognise the range and diverse contributions that psychologists
make to users, carers and families spanning a broad range of care groups from mental
through to physical health, and across the age span. A summary of the potential
contribution of applied psychologists to the NHS reform agenda is summarised below.
IMPROVED CLIENT EXPERIENCE
(Health, well-being and functioning of individuals, families and communities)
Value for money • Ability to assess and formulate complex
problems
• Effective therapies and therapists
• Therapy innovations and service redesign
• Working through other staff (Nurses, GPs,
OTs, Graduate Workers, Psychology
Assistants etc) to broaden delivery of
therapies
• Leading and disseminating psychological
knowledge within teams
• Education and training psychologists and
other staff through the organisation
• Offsetting costs of psychological burden
and unexplained symptoms within
medical and inpatient care
• Attending to the psychological needs of
staff and organisations
• Advising on HR issues
Standards • Knowledge of wide range of interventions
and competencies
• Knowledge of professional accreditation
• Expertise around clinical governance and
risk
• Audit and service evaluation
• Promoting ethical practice
• Expertise around supervision and training
supervisors
• Providing specialist supervision to other
staff (e.g. psychiatrists, nurse specialists,
counsellors, etc.)
• Critical thinkers and problem solvers
• Flexibility in roles and working across care
groups and health problems
• Ability to think organisationally and to
support other staff
• Supporting Trust Boards in delivering
business plans
• Ensuring that standards and knowledge are
regularly updated through R&D
User Perspective & Choice • Knowledge of wide range of therapies
and therapists
• Working with users to promote
understanding of range of
psychological approaches in order to
achieve informed choice
• Promoting well-beiig, psycho-
education and self-help
• Providing individually tailored
psychological formulations
• Helping organisations to understand
users’ needs and their social context
• Championing a psychosocial
understanding of both physical and
mental health
• Supporting user agendas and
promoting social inclusion
Commissioning • Advising commissioners on needs
assessments, effective interventions
and outcomes
• Knowledge of a wide range of
psychological interventions, not
restricted to a single therapeutic
modality
• Knowledge of psychological issues
and disorders across the age range
• Integrating mental and physical
health needs
• Providing a bio-psychosocial
approach
• Helping to understand health issues
and impacts within families
• Helping to understand health issues
from a community perspective
• Addressing user perspectives,
recovery and social inclusion
POTENTIAL CONTRIBUTION OF APPLIED PSYCHOLOGISTS TO IMPLEMENTING
NHS REFORM
CONCLUSIONS AND AREAS FOR FURTHER CONSIDERATION
RECOMMENDATIONS FOR PSYCHOLOGISTS: 1. IAPT presents an opportunity to enhance the quality of psychological
therapies to service users within the NHS through expanding capacity and ensuring access to effective and appropriate therapies, as recommended within NICE guidelines.
2. For this to be successful, however, psychologists will have to embrace strong
partnership working with other professions in promoting service innovation and redesign.
3. Psychologists need to lead in the promotion of new service models (i.e.
stepped care) and the specification and development of integrated care pathways, which meet the varied and complex needs of service users.
4. Psychologists may need to re-evaluate their approach to assessments and
triage to ensure that they meet the individual requirements of service users, are safe but also allow for sufficient access and do not contribute to bottle necks within the system.
5. Psychologists have a responsibility to work with local communities to ensure
that psychological therapy services provide a range of interventions that are culturally appropriate and accessible by all members of the community.
RECOMMENDATIONS FOR COMMISSIONERS AND PROVIDERS: 6. Service redesign is key to the successful implementation of the IAPT
programme and psychologists have important contributions to offer in helping services innovate and change.
7. Psychologists have a major role to play in implementing this programme and
should be essential to its success. Accordingly, consideration should be given to the role of Consultant Psychologists in providing leadership at both the organisational level (i.e. Trust Boards) and within clinical teams.
8. A full range of interventions extending from guided self-help to the provision
of formal therapy should be readily available within primary care and delivered by a range of practitioners (e.g. nurses, counsellors, graduate workers, voluntary sector employees). Psychologists have important roles in supporting such staff by the provision of expert consultancy, training, supervision, clinical governance and research/evaluation within psychological therapies.
9. For people with more complex or more intractable problems, there should be easy routes of access between primary and secondary care to ensure that these individuals receive more specialist psychological therapies, and with greater continuity.
10. Psychologists have a particular role to play alongside other senior staff in
ensuring good clinical governance, and the safe and competent practice of all workers involved in the delivery of psychological therapy services.
11. The success of the IAPT programme will rest on its ability to demonstrate
good clinical outcomes. Psychologists have an important role in advising local services as to routine clinical data collection, and how to guarantee and monitor good and appropriate clinical outcomes.
12. In addition to outcome measurement, it will be important to ensure that the
IAPT programme remains up to date, and reflects developments in clinical guidelines, and contributes to the future evidence base supporting a potentially wide range of psychological therapies. It will be important that psychologists have the opportunity to employ their research skills and are actively involved in the evaluation of both national and local initiatives.
13. Psychologists can make useful and important contributions to the
commissioning process by advising commissioners on aspects of needs assessment within local populations, specifying service models and availability of effective therapies, defining clinical outcomes and their measurement, and ensuring safe practise through clinical governance.
14. Psychologists also bring with them alternative perspectives to healthcare
problems which transcend the traditional biomedical model and help to promote more community and socially inclusive policies, which incorporate a greater holistic view of service users and carers, including for example family and parenting issues, employment, housing and community integration, and social cohesion.
15. It is important to recognise the breadth of psychologists’ contributions to
social and health care, and that many psychologists work in settings away from primary care, with client groups not necessarily represented within the IAPT programme (e.g. psychoses, personality disorder, people with learning disabilities or brain injury) and make major contributions through consultancy, neuropsychological and functional assessments, staff and organisational interventions, which are beyond the traditional role of the psychological therapist.
16. It will be important that recent attention given to primary mental healthcare
does not detract from the contribution that psychologists may make in their other roles and interventions supporting services outwith primary care mental health. This also applies to the resources that support these services.
RECOMMENDATIONS FOR SHAS AND EDUCATION AND TRAINING COMMISSIONERS:
17. However, if capacity and access is to be truly enhanced, significant additional
resources will be required both in establishing additional services and the training of new staff.
RECOMMENDATIONS FOR THE BRITISH PSYCHOLOGICAL SOCIETY AND EMPLOYERS: 18. The BPS through New Ways of Working for Applied Psychologists should
consider supporting the establishment of new roles (i.e. such as formally trained psychology assistants) in order to enhance the contribution that psychologists (i.e. qualified and assistants) can make to enhancing capacity and access. It will be important to ensure that any new workers practise safely and this will require clarity around organisational structures, supervision and appropriate regulation.
19. It will also be essential that any new role is sustainable, integrates with career
structures for both psychologists and other work roles within psychological therapy services, and allows for transferable recognition of training and experience for those wishing to go on and enter doctoral training as a psychologist.
20. The BPS through its post-qualification registers should assist psychologists in
specifying the range and level of expertise in psychological therapies that they possess. Similarly, pre-registration training should result in clear and assessed competences (e.g. within CBT) which support the IAPT programme and other roles that psychologists adopt.
21. Finally, that the BPS promotes the IAPT programme by supporting and
informing its members of this development, helping to promote new standards of training and upholding standards of regulation.
22. In addition, the BPS should seek to advise and inform the public of the
benefits of psychological therapies and the contributions that psychologists can make to all aspects of health care.
Graham Turpin, Director, Professional Standards Unit, Division of Clinical Psychology, British psychological Society. Roslyn Hope Director, National Workforce Programme, CSIP
Appendix 23.
NWW Organising, Managing, and Leading Psychological Services (Summary and recommendations)
NEW WAYS OF WORKING
FOR APPLIED PSYCHOLOGISTS
Organising, Managing, and Leading Psychological Services
The content of this document incorporates the views of the British
Psychological Society (BPS), National Institute for Mental Health in England
(NIMHE) New Ways of Working Project Group for Organising, Leading, and
Managing Psychological Services, and applied psychologists, from pre-
doctorate trainee to executive level.
All professional groups are clarifying their roles and contribution to delivering
person centred care. Applied psychologists represent an extensively trained,
scarce resource that is diverse in roles and function across the whole health
care system, providing services beyond traditional mental health and learning
disability services into primary care and the acute sector.
The recommendations made in this document were developed for Applied
Psychologists but the themes will be applicable to other professional groups,
as strong leadership is needed across all professional groups. New Ways of
Working will mean a stronger focus on multi-disciplinary situational and task
leadership in the context of a strong Capable Teams approach to service
delivery. Professional Leadership for Applied Psychology requires strategic
and operational leadership at the highest levels across the health and social
care. Moreover, delivering on the Well-being and Happiness agenda will
require strategic access to Applied Psychological expertise.
This document is for the guidance of leaders and commissioners who will be
addressing the governance requirements of services which will be developing
in a variety of new settings, provided by people in new roles. People who use
services may be interested particularly in the context of becoming members of
foundation trusts and using the opportunities afforded by becoming governors
to press trusts to deliver the improving access to psychological therapies
agenda. Last but not least, applied psychologists and other health
professionals with specialist training in psychological approaches need to
consider the professional regulation and clinical leadership arrangements
which will best support changing practice and the development of the next
generation of effective psychological therapies.
quality psychological therapies and services are made more readily available
to users and carers. To this end, they have been made in the form of
recommendations to the major parties involved in the commissioning and
delivery of psychological services, those concerned with commissioning and
delivering the training of applied psychologists and people who use services.
People Organising and Leading Psychological Services • There is a need to ensure there is Board level strategic and systemic
clinical leadership for psychological services
• Leaders of psychological services should ensure that service users and
carers are involved in the design, delivery and evaluation of services.
• There is a need to ensure succession-planning and mentoring
processes are in place to develop future key leaders.
• In all continuing professional development of applied psychologists, the
development of leadership qualities and competencies should be
addressed.
People Commissioning Psychological Services • There is a need to ensure that there is a high level of understanding
about psychological therapies/services in those involved in
commissioning such services.
• There is a need to ensure that commissioned psychological services
are well led and that governance arrangements are in place to ensure
staff providing psychological services are appropriately trained,
supervised and regulated.
• Service commissioning should be based on an assessment of the
psychological health needs of the population including physical health
• Service users and carers should be involved in the commissioning as
well as design, delivery and evaluation of psychological services.
People Providing Training in Psychological Therapies • There is a need for pre-qualification programmes to select people with
leadership potential are part of the programme.
• Pre-qualification Doctoral programme should include the development
of leadership and team-working competencies.
• Multi professional leadership development programmes that
incorporate action learning sets, mentorship arrangements, exposure
to innovative leaders, as well as theoretical inputs should be developed
and commissioned.
Table 3: Leadership Development Framework
Leadership Development Tasks
Executive
Band 8(d) –
9
Leadership development of others
Mentoring – including peer mentoring and mentoring to
others
Succession planning
Policy Leadership
Strategic Planning
Consultant
Band 8(c) –
(d)
Mentoring – including peer mentoring and mentoring to
others
Differentiation into tripartite role – clinical, professional,
managerial
Application of skills, lead for psychology at organisational
level
Support leadership role and function of executive
leadership
Identification of leadership skills and needs at speciality /
service level
Leadership development, with attention being given to
potential successors from 8(a)–(b) banded staff, supporting
equal opportunities
Setting future direction for specialty / niche market /
professional subgroup / team
Policy Leadership
Principal
Band 8(a) –
(b)
Mentoring – including peer mentoring and mentoring to
others
Identification of leadership skills in others (individuals)
Support leadership development of others
Align learning experience to future leadership needs
Leadership consultation across one or more settings
Clinical
Psychologist
Band 7
Mentoring – including peer mentoring and mentoring to
others
Consolidate skills
Broaden repertoire and extend application of leadership
skills
Future career planning
Wider range of practical experience (across settings)
Role model to others
Longer term projects
Proactive identification of opportunities
Pre-
Qualification
Band 6
Personal leadership profile
Increase awareness of impact on others and system
Develop strengths and strengthen areas of need
Scenario discussions with mentor
Experiential learning on placement
Feedback from multiple perspectives
Develop political & organisational awareness
Knowledge of other professional groups
SELECTION
STAGE
Selection criteria to include section on leadership potential
Appendix 24.
NWW new roles project group (Summary and recommendations)
British Psychological Society and
National Institute for Mental Health in England
New Ways of Working
for Applied Psychologists
FINAL REPORT
of the
NEW ROLES PROJECT GROUP
July 2007
A. Summary
The New Roles Project Group set out to consider what roles, career structures,
training and supervision arrangements should be available to psychology graduates
working in (mental) health services, taking into account the available evidence
concerning the effectiveness of existing pre-qualification roles and emerging new
roles. In addition, the capacity available in terms of supply and training resources to
significantly increase the numbers of psychological practitioners through new roles
was considered. Based on its work and discussions with a range of stakeholder
groups, and with reference to a vision for the development of psychological services
that takes into account health policy determinants, a strategy for delivery and
organisational structures, the Project Group has concluded that there needs to be
significant investment in pre-qualification roles and supporting systems. This includes
the establishment of a distinct career pathway incorporating three levels of pre-
qualification psychologists that are appropriately remunerated, supported and
regulated. A pre-doctorate academic framework will need to be developed in
partnership with the providers of current doctorate in applied psychology programmes
to support this expansion of new roles. The Project Group also recommends the
development of a new professional grouping of ‘Psychological Therapist’, along with
a career pathway, to be located within established psychological services departments
to help meet the demand-supply gap for psychological therapies.
D. Recommendations
Based on its work and discussions with a range of stakeholder groups, the New Roles
Project Group makes the following recommendations for consideration:
i. A distinct career pathway for pre-qualification psychologists should be
established that is linked to and articulates with the pathway for applied
psychologists.
ii. A broader base of three levels of pre-qualification psychologist posts should
be developed within this career framework: Psychology Assistant, Senior
Psychology Assistant, and Psychology Associate (Footnote 1, page 13).
iii. These new roles should be regulated within the proposed regulatory
framework under the auspices of the BPS and/or Health Professions Council.
iv. The new roles should be realistically and fairly remunerated in order to
provide attractive, alternative career pathways that are stable and sustainable
and encourage diversity and inclusion.
v. A training framework incorporating awards at post-graduate certificate, post-
graduate diploma, and masters-level should be provided to support the pre-
qualification career framework.
vi. The training framework should be developed, as far as possible, in
partnership with institutions currently accredited by the BPS to provide
applied psychology programmes.
vii. A potentially new professional grouping of Psychological Therapist along
with a career pathway should be developed that is located within established
psychological services departments/directorates.
Appendix 25.
NWW Training models in applied psychology (Summary and recommendations)
NEW WAYS OF WORKING
FOR APPLIED PSYCHOLOGISTS
TRAINING MODELS IN APPLIED PSYCHOLOGY IN HEALTH AND SOCIAL CARE
EXECUTIVE SUMMARY A Training Model Group was assembled with representation from all applied
psychology Divisions and major Boards of the BPS as well as service users and
commissioners. The remit of the group was as follows:
1. to review current training models in applied psychology, strengths and
weaknesses, including current capacity and application rates, BME and gender
ratios
2. to generate some radical alternatives which address overarching NWW themes
such as inclusion, increasing access to psychological therapies and capacity
building, service user perspectives, unification of applied psychology training
routes, flexibility, Accreditation of Prior Experience and Learning, step-
on/step-off pathways
3. to consider the undergraduate curriculum and what constitutes the Graduate
Basis for Registration
4. to develop criteria for evaluating training models
• Some of the drivers for change considered by the group included unification of
training routes, increased inclusion of psychology graduates in health and social
care roles, and integration of new roles into training pathways.
• The group assembled summaries of current applied psychology training models
associated with the BPS Divisions and evaluated these in terms of strengths and
weaknesses.
• By an iterative process of progressive consultation with Divisions and their
training communities, the group developed a number of radical new training
models. These were tested out through the process of robust debate and
consultation. Ultimately this has resulted in the drawing out of a number of key
principles:
1. a progressive, pre-doctoral training pathway for psychology graduates that
populate NHS pay bands 4 to 6 needs to be developed, that leads directly into
doctoral training (this should not serve to exclude other, flexible and diverse
routes into doctoral training); such a development would make a significant
contribution to the NHS workforce by providing capacity and competences
relevant to Improving Access to Psychological Therapies and other health
improvement programmes whilst creating inherent clinical governance,
accountability and supervisory structures which would protect the public interest;
2. existing doctoral applied psychology training courses should offer training for this
pre-doctoral pathway that is relevant to these roles and which provides a
progressive, coherent curriculum integrating with doctoral training;
commissioners of training should be encouraged to fund such developments,
although not at the cost of reducing doctoral commissions;
3. the Membership and Professional Training Board of the BPS should develop
accreditation mechanisms and criteria for such pre-doctoral training;
4. the applied Divisions and their training committees should explore jointly areas of
their curricula where generic or unified training might be feasible; and
5. existing applied psychology training courses should provide an increased
emphasis on supervisory and leadership skills.
These principles should form the basis for further dialogue with the Boards of the
BPS, training commissioners and NHS employers.
RECOMMENDATIONS There is widespread concern in the clinical training community that the NWW
Training Model Project represents a significant threat to doctoral qualifications and
appointments in clinical psychology. It is therefore important that such concerns are
addressed. It is essential that NHS commissioners of training and NHS employers do
not take the NWW project and its outcomes as a license to compromise future
doctoral training commissions.
As indicated in section 6 of this document, of all the new models reviewed, New
Roles “A” was considered to have the most to commend it. However, although it
represents even less unification of training than the Kinderman model, we recognise
that at the present time there is substantial resistance to even a single year of applied
generic training. This resistance arises not just from the clinical training community,
but also other from other applied Divisions. There appears to be less resistance to the
general concept of the development of specific pre-doctoral stages and some are
interested in the prospect of developing training programmes for such stages. Clearly
the Divisions and their training communities need to be persuaded that there is
significant overlap and that some degree of unification is justified. More evidence of
the degree of overlap (or otherwise) could be obtained. The Membership and
Professional Training Board of the BPS would be in the best position to undertake
such a project. In the meantime, all applied training courses, and particularly those
located within the same HEI, should be encouraged to explore joint training strategies
in relation to both curriculum delivery and practice placements.
In view of the arguments for a more structured pre-doctoral pathway and associated
training, existing applied psychology training courses should be encouraged to
develop training programmes for assistant and associate psychologists, which are
relevant to their roles, but which also represent a coherent training progression from
undergraduate to doctoral level. NHS Commissioners of training should be
encouraged to commission pilot projects of this kind. Ultimately the BPS Membership
and Professional Training Board should be encouraged to develop curricula, learning
outcomes and accreditation criteria for such pre-doctoral training. It is recognised by
the project group that such pre-chartership training has hitherto been considered
outwith the scope of MPTB’s accreditation activity.
There has been much debate and a recent white paper addressing the issue of statutory
regulation of applied psychology, and, in this particular context, pre-qualification and
training grades. No clear proposals with regard to the latter have emerged. It is
imperative that robust mechanisms for the regulation of pre-doctoral appointments in
applied psychology are developed and implemented.
At the present time, Doctoral clinical psychology training courses are heavily
(although not exclusively) dependent on a consistent supply of assistant psychologists
from whom they select for postgraduate clinical training. There is no national
oversight of the supply of such posts and this is a potential weakness. Equally, any
move towards a staged pre-doctoral pathway into doctoral training would require a
degree of central oversight and strategic planning to ensure supply. The Annual
meeting of the NIMHE/BPS Workforce Planning Group would be an appropriate
forum to consider how such central influence might be achieved.
The recent DfES document “Review of the Functions and Contributions of
Educational Psychologists (EPs)” produced through the University of Manchester,
recommends that “professional organisations representing EPs should begin
discussions about the possible eventual merger of the two professions, child clinical
and educational psychologists”. Given that educational psychologists will be working
alongside child clinical psychologists in the community and in educational settings, it
would be helpful in the meanwhile to explore ways in which the two professions
could work jointly and in a more complementary fashion.
In view of this the New Ways of Working in Applied Psychology Training Model
Project Group recommends the setting up of a working group from the Division of
Clinical Psychology and the Division of Educational and Child Psychology including
representatives from both Training Committees to explore the possibilities of moving
towards an integrated training.
The NWW Training Model Project Group has discussed the nature of GBR and its
role as the gateway into applied psychology. GBR is strongly endorsed as an essential
prerequisite for postgraduate training and post-qualification practice in applied
psychology and it is imperative that the regulation and accreditation of the
undergraduate curriculum is maintained by the BPS. Nevertheless, concern has been
expressed at the apparent absence of engagement between the QE Committee that
reviews the curriculum and the applied Divisions. Much better representation from
applied psychology should be included on this committee. Moreover, a specific
project to explore the extent to which topics and competences relevant to pre-
registration practice in health and social care settings could be included should be
initiated.
SUMMARY OF RECOMMENDATIONS The following recommendations are put forward for consideration.
1. The established three-year doctoral training model in clinical psychology and,
more latterly, in other areas of applied psychology, is robust, has a proven
track record and remains the flagship of applied psychology training: any
alternative developments should not be viewed as a substitute for doctoral
training
2. Existing applied psychology training courses should be encouraged to explore
shared, common modules and shared placement opportunities (where these are
relevant) with other applied psychology training courses within their host
institution
3. The BPS Membership and Professional Training Board should be asked to
initiate a project to identify commonalities, complementary areas of practice
and differences between the applied Divisions in their training curricula and
learning outcomes.
4. If significant differences emerge from such a project, these should be clearly
articulated to the public and healthcare commissioners
5. Existing applied psychology training courses should be encouraged to develop
training programmes for assistant and associate psychologists, which are
relevant to their roles, but which also represent a coherent training progression
from undergraduate to doctoral level
6. MPTB should develop accreditation criteria and processes for such pre-
chartership courses
7. A joint DH/BPS project should be initiated under the aegis of the joint
Workforce Planning Group to explore the strategic development of pre-
doctoral posts in NHS Trusts, which is responsive to national workforce and
training requirements as well as local need.
8. It is imperative that robust pre-registration regulatory mechanisms are pursued
jointly by the BPS and the DH, and implemented
9. A Membership and Professional Training Board/GTiCP/Division of
Educational and Child Psychology and Training Committee working group
should be set up to explore joint training possibilities between Child Clinical
and Educational Psychology
10. The Psychology Education Board should be asked to initiate a working group
with specific representation from all applied Divisions to review the objectives
of GBR and the Qualifying Examination curriculum as a preparation for
applied psychology training and practice.
Appendix 26.
NWW Working psychologically in teams (Summary and recommendations)
NEW WAYS OF WORKING
FOR APPLIED PSYCHOLOGISTS
WORKING PSYCHOLOGICALLY IN TEAMS
Summary and key messages • The aim of this document is to provide an update on our understanding of
how teams work and how their effectiveness can be maximised. It was developed as part of the NIMHE New Ways of Working Initiative and so has a bias towards mental health services. Nonetheless, it provides positive practice and guidance on effective teamworking for application in a variety of contexts. It aims to have some relevance to any team member wanting to work using psychological principles.
• Psychologists have important roles to play in achieving improved outcomes from teamworking. These include helping to achieve optimal team design and operation, effective individual service planning, peer consultation processes, reflective practice, the effective involvement of users and carers, teaching, training, research, evaluation and development.
• Recent policy and practice developments concerning team working mean that psychologists are required to adopt new ways of working. These are determined by local contexts and include some new and specific challenges. It often requires that psychologists become further integrated into teams.
• The issue of psychologists’ integration in teams is a hot one for psychologists and is often determined by local capacity for psychology input. Stakeholders showed an overwhelming preference for the integration of psychologists within teams but only if psychologists retained their unique identity and contribution (e.g. offering an authoritative and constructive counter-balance to the “medical model”).
• Psychologists have a wider role in providing consultancy to organisations on organisational and systems improvement (e.g. leadership and teamwork development) but their competence and confidence to assume these roles cannot be assumed.
• Definition of teams need to be clear and widely understood and differentiated from other descriptions of group working such as networks and communities of interest.
• There is good evidence for positive outcomes from teamworking but benefits will not be achieved without premeditated design of teams based upon research on what promotes effective teamworking.
• Effective teamworking is associated with o clear and achievable objectives, o differentiated, diverse and clear roles, o a need for members to work together to achieve shared objectives, o the necessary authority, autonomy and resources to achieve these
objectives, o a capacity for effective dialogue. This means effective processes for
decision making, being able to engage in constructive conflict and if complex decision making is involved the team needs to be small enough (no larger than 8 or 9 people).
o expectations of excellence, o opportunities to review what the team is trying to achieve, how it is
going about it and what needs to change o clear and effective leadership.
• Dedicated effort is required to improve team working within local whole systems. Tried-and-tested service improvement approaches are available to support this and should be more widely applied.
• Teams exist within complex systems and an understanding of how change and development occurs within such systems is important when aiming to improve outcomes.
• At team level leadership is about creating the conditions that enable the team to do its job; building and maintaining the team as a performing unit; and coaching and supporting the team to success. Leadership capacity is dispersed within complex systems and leadership roles should be determined by context and the demands of the task at hand, not position. It is the quality of the relationship between leader and follower that has most influence on performance-relevant attitudes and behaviour.
• Teams are working with greater reliance on virtual methods of working. Research in this area suggests that the need to consciously design and support teams to be effective is amplified in these contexts with an even greater need to build trust and shared understanding of ways of working among team members.
Key messages Psychologists should be actively involved in the design, operation and evaluation of teams making use of appropriate research evidence (e.g. with respect to team size, composition, and process). This work should be informed by an understanding of the teams’ role in the wider context of the local system of care, an understanding of how change within complex systems occurs and awareness of forthcoming developments in new roles and work practices (e.g. increased virtual teamworking). Psychologists should seek to integrate their work within teams in a way that continues to promote their unique contribution to the care and treatment of service users. Psychologists should seek to develop their role in contributing to the improved effectiveness of services through process consultancy at systems level, peer consultation and supervision, leadership, and the promotion of effective roles for users and carers. The achievement of effective person-centred planning should be a key marker for the success of this contribution.
