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Health economics and patient safety

2 Feb

Health economics is a field of study concerned with the efficient use of resources within the health and social care sector. Efficiency is measured as a combination of patient health outcomes (such as the number of detected cancers, lives saved or quality adjusted life years (QALYs)), with the resource input (costs for treatment etc.).  Health economics not only involves looking at the cost of a healthcare intervention, technology or programme being studied, but also the effectiveness of it. An economic evaluation can be made from different perspectives: that of the health and social care provider (i.e. NHS), the stakeholder, or from a societal perspective, among others. Given the fixed budget the NHS faces, resources should be spent as efficiently as possible.

The more patient safety measures that are used in health and social care, the higher the cost. Therefore, policymakers need guidance on what patient safety interventions to implement to maximise health, care and economic gains. This is not questioning the necessity of patient safety measures themselves, but trying to identify the most efficient use of the existing resources to increase the benefit for patients. Health economics uses different types of evaluations to estimate the effects on the population and the cost to the NHS of the intervention being studied.

Building on success: Safety Informatics

1 Feb

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Digital technologies are becoming more commonplace within the NHS and in our daily lives, producing rich data on all aspects of our health and care. Connecting the data which is held in, for example, smartphones (such as step counters) and our own Electronic Health Records in primary and secondary care, can help us to gain a deep understanding of patient safety issues and the factors that increase risks of harm.

The Safety Informatics theme will continue its work from the first NIHR Greater Manchester PSTRC, using the wealth of health data which is collected about us, to help prevent harm in our everyday healthcare experiences. One example of the work taking place in Safety Informatics theme is the ACTION intervention, which uses Electronic Health Record data to give feedback to healthcare professionals in Greater Manchester on prescribing safety and management of long term conditions, which creates a ‘learning health system’. The theme will also work on the surveillance of system-wide diagnostic error; patient-led monitoring of test results; and monitoring late effects of cancer treatment.

Find out more on the Safety Informatics web page.

Self-harm in children and adolescents

1 Feb

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Self-harm is any act of self-poisoning or self-injury whether intentional or not. Self-harm is the strongest risk factor for possible future suicide, with suicide being the second most common cause of death before the age of 25 worldwide.

In recent years, there has been a rise in suicide rates in children and adolescents, as well as a marked increase in psychological distress. The purpose of this study was to identify how the rates of self-harm have changed, and how these changes compare in different genders, as well as among different age groups. The Clinical Practice Research Datalink (CPRD) database was used to identify 16,912 records of children or adolescents presenting to their GP after self-harming between 2001 and 2014. Researchers then looked at what proportion had been referred to mental health services and what drugs, if any, were prescribed in the 12 months following the self-harm.

The most notable trends were:

  • A 68% increase in incidence of self-harm in girls aged 13-16
  • Those who lived in socially deprived areas were 23% less likely to be referred in the 12 months following self-harm
  • Children and adolescents who self-harmed were at increased risk:
    • 9 times more likely to die of unnatural causes
    • 17 times more likely to die by suicide
    • 34 times more likely to die through alcohol or drug poisoning.

 Read more in the full paper in BMJ, or the plain English publication summary.

How do I get more involved in my patient safety?

1 Feb

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We have been working together with patients, carers, members of the public, GPs and pharmacists to design a PSTRC patient safety guide for patients and carers. This will be a useful resource to help answer key questions about primary care patient safety and to identify points where patients and carers can make their own care safer.

The guide consists of a short booklet, website and cue card prompts which people can use flexibly:

  • to plan for a consultation
  • as a memory aid
  • to help make the most of the time a person has with a healthcare professional
  • to support their own care at home.

As part of this project, the PSTRC has held co-design events which have brought together members of the public, patients, carers, GPs and pharmacists to discuss how everyone can work together to make care safer. Discussions have focused on key points in the care pathway and actions that each person could identify to improve their patient safety with the priorities that were identified for their own care. These discussions were then used to develop and refine the guide.

Since completing the initial development stage of the patient safety guide, work has been taking place with key national stakeholders to further refine the guide and the centre will continue to co-develop the project and the testing of it with patients, carers and healthcare professionals.

If you’re interested in hearing more about the guide, or to find out more about future co-design events, please contact Rebecca Morris at rebecca.morris@manchester.ac.uk.

Putting patient safety first

4 Dec

by Maria Panagioti, Senior Research Fellow

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Delivering safe healthcare to patients and preventing patient harm is an international priority. Despite this, patient safety incidents are not uncommon. Around 10 per cent of patients experience a harmful patient safety incident whilst being treated. Such harmful incidents could be due to actions of healthcare professionals, healthcare system failures or a combination of both. Medication errors, misdiagnosis, wrong-site surgery, hospital-acquired infections and in-hospital falls are all examples of serious patient safety incidents which can result in patient harm.

While eliminating patient harm is a desirable goal, in practice it may not always be possible. A certain level of harm is considered inevitable because harm cannot always be predicted. For example, some adverse drug reactions occur in the absence of any error in the medication process and without the possibility of early detection.

Focusing on prevention

This understanding has recently led researchers and policymakers to focus on reducing preventable harm. Although full consensus about the nature of preventable harm has not yet been reached, most working definitions include the idea that preventable harm is identifiable, in that it can be attributed to medical care and modifiable in that it’s possible to avoid by adapting a process or adhering to guidelines. The focus on preventable harm could help policy makers and healthcare practitioners to devise more efficient and reliable plans to predict and prevent patient harm.

There has been a lack of clarity in the literature about the prevalence and main types of preventable harm – and how often severe harm such as death and severe injuries are likely to occur. In response to the need to better understand preventable harm, the General Medical Council commissioned our team to undertake a large systematic review and meta-analysis to understand the nature of preventable patient harm across healthcare settings including hospitals, primary care and specialty settings. The aim of this review is to help the GMC and stakeholders get a better understanding of types, causes and patterns of harm – with a view to identifying ways of mitigating them.

Letting numbers do the talking

We reviewed 149 published studies through this work and our findings in relation to the importance and impact of preventable patient harm were striking:

  • Six in 100 patients experience preventable harm and 13% of this preventable harm leads to permanent disability or patient death.
  • Medication incidents such as errors in ordering, prescribing and administering medication, and misdiagnoses are the main causes of preventable patient harm.
  • Preventable patient harm might also be higher in certain medical specialities such as surgery.

These findings provide useful direction on areas where regulators, the NHS and Government should invest to reduce preventable patient harm. For example, investment in interventions to reduce medication errors (particularly at the stages of prescribing and administration of medication) and preventing misdiagnoses would be encouraged by our findings.

In line with our findings, the importance of improving medication safety is fully recognised by the World Health Organisation who have recently identified Medication Without Harm as the theme for their third Global Safety Challenge. Given the large number of studies we reviewed, the quality and depth of data on preventable patient harm is relatively low. We need to invest in better research and reporting practices to understand which types of patient harm clinicians and healthcare systems can prevent.

In recognition of the importance of patient safety research, and following on from previous research undertaken in Manchester and London already having an impact on NHS frontline services, the NIHR announced funding of three new NIHR PSTRCs. Work began in August at the Centres – located in London, Manchester and Leeds – and their aim is to turn patient safety discoveries into practice.

By understanding the nature of preventable patient harm we can work towards eliminating it – saving lives and reducing unnecessary medical interventions. Investing in reducing key sources of preventable harm and improving reporting standards of future research studies on preventability of patient harm could be a major contribution to the safe care of patients.

What makes a ‘good’ GP?

5 Apr

by Golda Gibson, member of the Greater Manchester PSTRC Research User Group

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My guess is that for every person there will be a slightly different answer. We all want them to be knowledgeable, to know when something might be going wrong with us and to act decisively thus protecting us from further harm. Where we may differ will be in our personal relationship with our GP, what is perhaps important for one will not necessarily be the same for another. Within us we all have what are known as ‘trigger points’, areas controlled by our emotions, past memories good and bad of how we were related to in a given situation, the ‘building blocks’ of our emotional development that affect how we behave in many circumstances and those momentous moments when we can actually act objectively. You will all be aware of that instantaneous moment when you meet someone for the first time – and dislike them!!! How can that be? It is not THAT person that is the problem, it is our response to past negative experiences which that person has now triggered. This can happen between family, friends, colleagues, the person in the street and yes, with your doctor, he/she too is just another human being with all the ‘baggage’ we all carry around with us each day.  They and we, can be reactive, defensive, introverted, extroverted. They and we, can have home problems, family problems, car problems, even late night problems, but what we want in our exchanges is for our healthcare professional (and us) to be able to ‘place’ those problems where they belong.

When we go to the GP or any healthcare professional for that matter we are asking to be ‘made better’, we are unable to be ‘objective’ about ourselves. This childlike position is vulnerable and it is in this very situation when, if we are not received in a positive away the relationship can falter. What we are looking for is respect for our lack of knowledge, concern for our anxieties, interest in our suffering and empathic understanding of how we feel and why.

Are there such GPs about? Probably not that many but I am very lucky to have found one.

Four years ago when I first became ill my diagnoses floored me. ME!!! – (not M.E.) the one who exercised regularly, ate healthily, kept control over my weight and was still working in her 71st year in a very exacting job, I had become chronically ill, my body had let me down and all that NHS propaganda about the need for a healthy lifestyle hadn’t worked. To make matters even worse, twelve days after my diagnoses my husband had a stroke. In less than two weeks I had become a patient and a carer, my career was over and my whole world had changed irretrievably.

I met my GP not at the point of diagnoses but shortly after when treatment was being started and I was given an urgent appointment. His first words to me on entering his room were …’I’m so sorry’. Those were the first kind words I’d had said to me and they penetrated through this shocked state I was in. Without being fully aware of it I had made a mental note that day that this was the doctor I was going to deal with, this was a ‘feeling’ man, someone who without a word from me had recognised my anguish and made it his own, our ’emotional baggage’ had not got in the way of our first exchange, we were accepting of each other, I was vulnerable, sad, totally overwhelmed and angry, add to that my  ‘feisty’ personality and my anger could have destroyed the moment but his warmth towards me quietened me.  

During that first eighteen months he always made a 4-6 week follow-up appointment for me before I left his surgery, even though there were times I felt that perhaps I didn’t need it. He became my advocate, guiding me, advising me, listening to my concerns and always ready to respond. When treatment with one clinician or another wasn’t up to standard he responded. He never judged me, never made me feel I was a ‘difficult patient’ although I’m sure others might and have!  I ask questions and I expect answers and I know when I was being ‘talked down to’ with rubbish. My GP is never patronising, always and without exception he is pleased to see me, he likes me and I can tell. When I enter his office, time is mine, there is no clock saying ‘time up’, I am made to feel that I have as much time as I need.

As time went on my own condition worsened and also that of my husband. Through numerous ‘urgent’ moments my doctor was always there, guiding, advising and supporting. When I couldn’t get appointments to see him he gave me a ‘hotline’ that allowed me to make direct contact with him should I need it and a promise that he would always ‘fit me in’ should an appointment be necessary. He also connected me to a new innovative community caring system where I am able to make contact with a Nurse Practitioner directly on the day I need it if I became unwell and found it difficult to care for my husband.

My husband who was not initially with him but with another practice, is not very mobile, it is difficult for me to get him to the surgery, impossible at his previous surgery as they were on a main road next to traffic lights with no parking area whatsoever. My doctor has said to me more than once he would call and see ‘H’ at home if it would be easier for me! I have also known him just to phone me to ask how I am when he had not seen me for a while. Very rare qualities.

Some months ago I received an email from one of the doctor ‘comics’ that are delivered to the practices around the country and also electronically. In it an article asked if there was a deserving GP in your practice that was worthy of being nominated for a national champion award for the care of R.A patients. This was my chance to get my wonderful doctor recognised and acknowledged for his exceptional care to me and all his patients. I then had to set up a plan whereby I enlisted the help of the Assistant Practice Manager who in turn sought help from one of the other GPs in the practice to fill in a part of the form I couldn’t due to not being privy to that particular information, and then it was my turn to get my chance (only one) to write about this wonderful man. I knew it had to be written with a passion that conveyed just who he is and what he is to his patients. As I said, I was only going to get this one chance and they had only given me 400 words in which to do it!! There would be many practices and patients nationally who would be submitting their own nominee and there were only ten championship awards to be had in the whole of the country, my writing had to ‘stand out’, it had to make the reader ‘feel’ as I did – AND WE MANAGED IT – HE GOT THE AWARD!!! The ceremony took place at the House of Commons on the 2nd November and the awards were given by the Prime Minister Mrs Theresa May.

Afterwards he wrote me the most beautiful thank you letter in which he told me that the personal qualities I bestow upon him are really a reflection of myself. Doesn’t that just tell you what kind of a man he is. I am extremely fortunate and blessed to have such a doctor. In this crazy 21st century NHS, with reductions and shortages in just about everything, when talking (the same story) to just one more person makes you want to tear your hair out and you begin feeling as though it is you who are the problem. When you hear yourself getting sharp and snappy on the phone to one or other department and no one is actually listening and even if they listen and promise that what you’re asking for will get done – it then doesn’t get acted upon. When I reach that rock bottom moment I have my GP.

The ‘triple aim’: a reality check

27 Jan

by Jonathan Stokes, Research Associate in the Centre for Health Economics at The University of Manchester

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In December, I completed the final exam (or ‘viva’) for my PhD, which was funded by the NIHR Greater Manchester PSTRC. In the discussion section of my thesis, I presented an argument that my examiners suggested I should explore further, so I’m using this blog post to try and record some initial thoughts, which I hope to turn into an academic paper at some point (so feel free to post any feedback you have below).

So, my argument, briefly, was this:

  • Health systems are recognised to have a so-called ‘triple aim’, aiming to improve health and satisfaction of patients, while reducing costs. With the move towards ‘integrated care’, policymakers argue that integration can improve all triple-aim outcomes simultaneously.
  • In the NHS, integrated care is defined around the patient’s feeling of joined-up care (i.e. around the outcome of satisfaction). However, policymakers, when setting out the aims of their integrated care models aim primarily to reduce costs, usually by reducing emergency hospital admissions (probably unsurprising given the ‘NHS crisis’ currently being covered in the media).
  • But the literature tells us that the ‘triple aim’ goals are quite complexly interlinked, so achieving one does not necessarily have a beneficial effect on all of the others. For example, the highest patient satisfaction (good) is associated with the highest overall healthcare expenditure (bad), and may be also those experiencing worse health outcomes, e.g. a higher mortality rate (very bad).
  • Therefore, there is a potential conflict between the patient-level (the feeling of more joined up care for the patient) and system-level (reducing costs) goals of integrated care in the NHS, and potentially a need to prioritise aims.

Basically, there is little evidence that the ideal scenario of not having to pay for improvements in care quality is plausible (note: that doesn’t mean we can’t have this improvement, it just implies that we would need to invest more in our health system to get it). And, if we design interventions that address the NHS definition of integration and increase satisfaction with care, then we won’t necessarily meet the pressing system aims of reducing costs in the current NHS funding crisis.

So, to my mind, if we want to contain costs, this would mean that the patient satisfaction aim (while still important, and should continue to be measured) should be bumped down the priority. This is partly because people who are healthier tend to be more satisfied in any case (so it is partially a secondary outcome of better health and should take care of itself if people get better health outcomes), but also because in a tax-funded system like the NHS, where the overarching values are delivering equity and social justice, sustainability of the system is more important than preferences of the individual (i.e. ‘consumer-focused’ healthcare). Especially when aiming primarily for satisfaction of the individual harms the system.

To try and explain why this might be, imagine that if we’re primarily aiming to improve satisfaction with care, implementing an intervention where we gave everyone a dram of whisky as they waited for their appointment might send satisfaction rates through the roof, but it would cost a fortune and might not do people’s health a lot of good.

Healthcare is a complicated process (which is why it takes so long to train healthcare professionals, who in fact never stop receiving training during their working lives). One of the ‘market failures’ in healthcare (i.e. why a normal economic free-market system, where the consumer decides, doesn’t work) is ‘information asymmetry’ (i.e. the expert knows more than others, so can make the more informed decisions). While this asymmetry is clearly in patients’ favour in some aspects (e.g. experience of disease/ experience of using health services/ treatment burden etc.), it favours the physician/expert in others (e.g. treatment course in many cases/ health system setup or organisation/ cost of care etc.). The patient is therefore not likely to make the most informed decision when it comes to overall health system costs.

In view of this, I think there’s an interesting debate to be had about the role of ‘patient-centred’ care more widely, and how this fits with our system goals. For example, I went to a seminar the other day where an NHS Vanguard programme talked about how they were shifting their approach in patient care to one where they ask the patients to define their goals, asking them ‘What matters to you?’. But, before that, we’d had a talk from NHS England about the national metrics that the Vanguards would be assessed on, centred on system goals (again, primarily about reducing avoidable emergency hospital admissions). This got me thinking: what if the patient’s goal is something that doesn’t affect our system goals whatsoever, or is even completely contrary to these? If it was in the USA, the patients themselves (or their health insurer) would pay for the option and it wouldn’t matter so much, but in a tax-funded system there is more need to think resourcefully at this wider system level (and try being poor and getting decent healthcare in the USA if you think that’s the way to go instead).

The role of the patient in influencing/defining research priorities could be another debate. For example, the PSTRC and wider NIHR funders are very focused on Public and Patient Involvement (PPI) in research. But, what if the researcher (while employing common sense, and not purely as a stereotypical ivory-tower-type) has access to more knowledge about where the current knowledge gaps are, and which questions are possible to answer and how? Is it a good use of resources to pay for the ‘lay perspective’ in all cases (or at all)? (But, of course, this is just one simplified question in the debate of the role of PPI in influencing and defining research priorities, the balance of which I hope to explore further in a future post).

In sum, I think some of the assumptions we make (in good faith, I’m sure), about the aims and delivery of health services, and research to support these services, are still open to debate. While we dwell on ideally achieving all outcomes, we neglect the reality of the need for trade-offs and priority setting. But, I’d be interested in hearing your thoughts.