Have targets improved performance in the English NHS?
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ABSTRACT:
SUBMITTER: Bevan G
PROVIDER: S-EPMC1370980 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:OBJECTIVES:To examine the association between financial performance as measured by operating margin (surplus/deficit as a proportion of turnover) and clinical outcomes in English National Health Service (NHS) trusts. SETTING:Longitudinal, observational study in 149 acute NHS trusts in England between the financial years 2011 and 2016. PARTICIPANTS:Our analysis focused on outcomes at individual NHS Trust-level (composed of one or more acute hospitals). PRIMARY AND SECONDARY OUTCOMES:Outcome measures included readmissions, inpatient satisfaction score and the following process measures: emergency department (Accident and Emergency (A&E)) waiting time targets, cancer referral and treatment targets and delayed transfers of care (DTOCs). RESULTS:There was a progressive increase in the proportion of trusts in financial deficit: 22% in 2011, 27% in 2012, 28% in 2013, 51% in 2014, 68% in 2015 and 91% in 2016. In linear regression analyses, there was no significant association between operating margin and clinical outcomes (readmission rate or inpatient satisfaction score). There was, however, a significant association between operating margin and process measures (DTOCs, A&E breaches and cancer waiting time targets). Between the best and worst financially performing Trusts, there was an approximately 2-fold increase in A&E breaches and DTOCs overall although this variation decreased over the 6 years. Between the best and worst performing trusts on cancer targets, the magnitude of difference was smaller (1.16 and 1.15-fold), although the variation slowly rose during the 6 years. CONCLUSIONS:Operating margins in English NHS trusts progressively worsened during 2011-2016, and this change was associated with poorer performance on several process measures but not with hospital readmissions or inpatient satisfaction. Significant variation exists between the best and worst financially performing Trusts. Further research is needed to examine the causal nature of relationships between financial performance, process measures and outcomes.
| S-EPMC6352807 | biostudies-other
Project description:ObjectivesNumerous papers have measured hospital efficiency, mainly using a technique known as data envelopment analysis (DEA). A shortcoming of this technique is that the number of outputs for each hospital generally outstrips the number of hospitals. In this paper, we propose an alternative approach, involving the use of explicit weights to combine diverse outputs into a single index, thereby avoiding the need for DEA.MethodsHospital productivity is measured as the ratio of outputs to inputs. Outputs capture quantity and quality of care for hospital patients; inputs include staff, equipment, and capital resources applied to patient care. Ordinary least squares regression is used to analyse why output and productivity varies between hospitals. We assess whether results are sensitive to consideration of quality.ResultsHospital productivity varies substantially across hospitals but is highly correlated year on year. Allowing for quality has little impact on relative productivity. We find that productivity is lower in hospitals with greater financial autonomy, and where a large proportion of income derives from education, research and development, and training activities. Hospitals treating greater proportions of children or elderly patients also tend to be less productive.ConclusionsWe have set out a means of assessing hospital productivity that captures their multiple outputs and inputs. We find substantial variation in productivity among English hospitals, suggesting scope for productivity improvement.
| S-EPMC4361750 | biostudies-literature
Project description:We investigate the extent to which small hospitals are associated with lower quality. We first take a patient perspective, and test if, controlling for casemix, patients admitted to small hospitals receive lower quality than those admitted to larger hospitals. We then investigate if differences in quality between large and small hospitals can be explained by hospital characteristics such as hospital type and staffing. We use a range of quality measures including hospital mortality rates (overall and for specific conditions), hospital acquired infection rates, waiting times for emergency patients, and patient perceptions of the care they receive. We find that small hospitals, with fewer than 400 beds, are generally not associated with lower quality before or after controlling for hospital characteristics. The only exception is heart attack mortality, which is generally higher in small hospitals.
| S-EPMC7768184 | biostudies-literature
Project description:Systems and processes for prescribing, supplying and administering inpatient medications can have substantial impact on medication administration errors (MAEs). However, little is known about the medication systems and processes currently used within the English National Health Service (NHS). This presents a challenge for developing NHS-wide interventions to increase medication safety. We therefore conducted a cross-sectional postal census of medication systems and processes in English NHS hospitals to address this knowledge gap.The chief pharmacist at each of all 165 acute NHS trusts was invited to complete a questionnaire for medical and surgical wards in their main hospital (July 2011). We report here the findings relating to medication systems and processes, based on 18 closed questions plus one open question about local medication safety initiatives. Non-respondents were posted another questionnaire (August 2011), and then emailed (October 2011).One hundred (61% of NHS trusts) questionnaires were returned. Most hospitals used paper-based prescribing on the majority of medical and surgical inpatient wards (87% of hospitals), patient bedside medication lockers (92%), patients' own drugs (89%) and 'one-stop dispensing' medication labelled with administration instructions for use at discharge as well as during the inpatient stay (85%). Less prevalent were the use of ward pharmacy technicians (62% of hospitals) or pharmacists (58%) to order medications on the majority of wards. Only 65% of hospitals used drug trolleys; 50% used patient-specific inpatient supplies on the majority of wards. Only one hospital had a pharmacy open 24 hours, but all had access to an on-call pharmacist. None reported use of unit-dose dispensing; 7% used an electronic drug cabinet in some ward areas. Overall, 85% of hospitals had a double-checking policy for intravenous medication and 58% for other specified drugs. "Do not disturb" tabards/overalls were routinely used during nurses' drug rounds on at least one ward in 59% of hospitals.Inter- and intra-hospital variations in medication systems and processes exist, even within the English NHS; future research should focus on investigating their potential effects on nurses' workflow and MAEs, and developing NHS-wide interventions to reduce MAEs.
| S-EPMC3943404 | biostudies-other
Project description:Health care systems in OECD countries are increasingly facing economic challenges and funding pressures. These normally demand interventions (political, financial and organisational) aimed at improving the efficiency of the health system as a whole and its single components. In 2009, the English NHS Chief Executive, Sir David Nicholson, warned that a potential funding gap of £20 billion should be met by extensive efficiency savings by March 2015. Our study investigates possible drivers of differential Trust performance (productivity) for the financial years 2010/11-2012/13.Following accounting practice, we define Productivity as the ratio of Outputs over Inputs. We analyse variation in both Total Factor and Labour Productivity using ordinary least squares regressions. We explicitly included in our analysis factors of differential performance highlighted in the Nicholson challenge as the sources were the efficiency savings should come from. Explanatory variables include efficiency in resource use measures, Trust and patient characteristics, and quality of care.We find that larger Trusts and Foundation Trusts are associated with lower productivity, as are those treating a greater proportion of both older and/or younger patients. Surprisingly treating more patients in their last year of life is associated with higher Labour Productivity.
| S-EPMC5540600 | biostudies-literature
Project description:ObjectivesTo understand organisational technology adoption (initiation, adoption decision, implementation) by looking at the different types of innovation knowledge used during this process.DesignQualitative, multisite, comparative case study design.SettingOne primary care and 11 acute care organisations (trusts) across all health regions in England in the context of infection prevention and control. PARTICIPANTS AND DATA ANALYSIS: 121 semistructured individual and group interviews with 109 informants, involving clinical and non-clinical staff from all organisational levels and various professional groups. Documentary evidence and field notes were also used. 38 technology adoption processes were analysed using an integrated approach combining inductive and deductive reasoning.Main findingsThose involved in the process variably accessed three types of innovation knowledge: 'awareness' (information that an innovation exists), 'principles' (information about an innovation's functioning principles) and 'how-to' (information required to use an innovation properly at individual and organisational levels). Centralised (national, government-led) and local sources were used to obtain this knowledge. Localised professional networks were preferred sources for all three types of knowledge. Professional backgrounds influenced an asymmetric attention to different types of innovation knowledge. When less attention was given to 'how-to' compared with 'principles' knowledge at the early stages of the process, this contributed to 12 cases of incomplete implementation or discontinuance after initial adoption.ConclusionsPotential adopters and change agents often overlooked or undervalued 'how-to' knowledge. Balancing 'principles' and 'how-to' knowledge early in the innovation process enhanced successful technology adoption and implementation by considering efficacy as well as strategic, structural and cultural fit with the organisation's context. This learning is critical given the policy emphasis for health organisations to be innovation-ready.
| S-EPMC3329608 | biostudies-literature
Project description:Recent substantive reforms to the English National Health Service expanded patient choice and encouraged hospitals to compete within a market with fixed prices. This study investigates whether these reforms led to improvements in hospital quality. We use a difference-in-difference-style estimator to test whether hospital quality (measured using mortality from acute myocardial infarction) improved more quickly in more competitive markets after these reforms came into force in 2006. We find that after the reforms were implemented, mortality fell (i.e. quality improved) for patients living in more competitive markets. Our results suggest that hospital competition can lead to improvements in hospital quality.
| S-EPMC4373154 | biostudies-other
Project description:BACKGROUND:Prescribing high doses of methotrexate increases the potentially fatal risk of toxicity. To minimise risk, it is recommended that only 2.5 mg tablets are used. AIM:To describe trends in GP prescribing of methotrexate over time; the harm associated with methotrexate errors at a national level; ascertain variation between practices and clinical commissioning groups (CCGs) in their implementation of the safety guidance; and map current variations at CCG and practice level. DESIGN AND SETTING:A retrospective cohort study of English GP prescribing data (August 2010-April 2018), and data acquired via freedom of information (FOI) requests. METHOD:The main outcome measures were: variation in ratio of non-adherent/adherent prescribing, geographically and over time, between practices and CCGs; and description of responses to FOI requests. RESULTS:Of 7349 practices in England, 1689 prescribed both 2.5 mg and 10 mg tablets to individual patients in 2017, breaching national guidance. In April 2018, 697 practices (?90th percentile) prescribed >14.3% of all methotrexate as 10 mg tablets, likewise breaching national guidance. The 66 practices at ?99th percentile gave >52.4% of all prescribed methotrexate in the form of 10 mg tablets. The prescribing of 10 mg tablets fell during the study period, with 10 mg tablets as a proportion of all prescribed methotrexate tablets falling from 9.1% to 3.4%. Twenty-one deaths caused by methotrexate poisoning were reported from 1993-2017 in England and Wales. CONCLUSION:The prevalence of unsafe methotrexate prescribing has reduced but remains common, with substantial variation between practices and CCGs. The authors recommend investment in better strategies around implementation. As 21 deaths that occurred from 1993-2017 in England and Wales were attributed to methotrexate poisoning, the coroners' reports for these deaths should be reviewed to identify recurring themes.
| S-EPMC7311108 | biostudies-literature
Project description:OBJECTIVES:Since April 2015, Clinical Commissioning Groups (CCGs) have taken on the responsibility to commission primary care services. The aim of this paper is to analyse how CCGs have responded to this new responsibility and to identify challenges and factors that facilitated or inhibited achievement of integrated care systems. DESIGN:We undertook an exploratory approach, combining data from interviews and national telephone surveys, with analysis of policy documents and case studies in four CCGs. Data were analysed using thematic content analysis. SETTING/PARTICIPANTS:We reviewed 147 CCG application documents and conducted two national telephone surveys with CCGs (n=49?and n=21). We interviewed 6 senior policymakers and 42 CCG staff who were involved in primary care co-commissioning (general practitioners and managers). We observed 74 primary care commissioning committee meetings and their subgroups (approx. 111?hours). RESULTS:CCGs in our case studies focused their primary care commissioning activities on developing strategic plans, 'new' primary care initiatives, and dealing with legacy work. Many plans focused on incentivising and supporting practices to work together and provide a broad range of services. There was a clear focus on ensuring the sustainability of general practice. Our respondents expressed mixed views as to what new collaborative service models, such as the new models of care and sustainability and transformation partnerships (STPs), would mean for the future of primary care and the impact they could have on CCGs and their members. CONCLUSIONS:There is a disconnect between locally based primary care and the wider system. One of the major challenges we identified is the lack of knowledge and expertise in the field of primary care at STP level. While primary care commissioning by CCGs seems to be supporting local collaborations between practices, there is some way to go before this is translated into broader integration initiatives across wider footprints.
| S-EPMC6500348 | biostudies-literature
Project description:IntroductionHospital-acquired infection with COVID-19 (HAI) has reduced from 14.3% to 4.2% over the last year, but substantial differences still exist between English NHS hospital trusts.MethodsWe assessed rates of HAI, comparing NHS hospital trusts using airborne respiratory protection (RPE, eg FFP3 masks) for all staff, as a marker of measures to reduce airborne spread, against those using mostly droplet precautions (eg surgical masks).Results/discussionRPE use was associated with a 33% reduction in HAI odds in the Delta wave, and 21% in the Alpha wave (p<0.00001). We recommend all hospitals make airborne mitigations a priority.
| S-EPMC8631043 | biostudies-literature