Health Care Evaluation: Appropriateness and adequacy of services and their acceptability to consumers and providers

Patient involvement in the design and development of health services, not just as service users, is becoming more widespread from the individual level complaint or letter of satisfaction to lay-membership on Trust boards and decision-making groups. Ensuring patient and public involvement in the management of healthcare organisations is a core standard for clinical governance.

Different service users will have different ideas of appropriateness and adequacy of services, and unless there are given standards of service to benchmark against, knowing whether a service is adequate or acceptable on the basis of local opinion can be difficult. Therefore the context in which patient experience or satisfaction data is being collected and analysed must be made clear (for example, someone with low expectations of health services may be much more easily pleased than someone who has previously had very good experience of health service provision). Cultural beliefs and practices, age, gender, communication skills and education level will also affect people’s experiences of health care.

Patient experience

To date in the NHS, patient feedback has focused largely on patient experience including:

• Was the hospital environment clean?
• Were you treated with privacy and dignity at all times?
• Were signs within the hospital clear?
• Did you get a choice about your time of appointment?
• Were waiting times acceptable?
• Did you receive sufficient information regarding treatment and choices made available to you?

Such data is usually collected by survey and in some cases more detailed information gathered by follow-up telephone call. Surveys can be carried out nationally, for example the National Patient Survey programme www.nhssurveys.org, and locally. National surveys are available in multiple languages.

Other local information on patient experience is collected either through Patient Advice and Liaison Services, letters to the Chief Executive or other members of staff as well as complaints reported to external agencies such as MPs, Healthcare Commission, Health and Scrutiny Committee. The number of complaints, as well as serious untoward incidents, are routinely reported to Trust management and actions in response are monitored with the ultimate aim of leading to service improvements.

Acceptability and safety of services to patients also forms part of assessments by external quality assurance agencies such as the Healthcare Commission as part of the annual health check, and the Postgraduate Medical Education and Training Board as part of inspections of medical training. Results of these reports are made available to the public.

Recent developments which also publicise patient experience information include websites such as www.nhs.uk/servicedirectories whereby patients can look up their local hospitals and see how other patients rated their experience for given areas of care along with any Healthcare Commission assessments. As payment for hospital services in the UK now follows the patient under Payment by Results, this has implications for both providers and commissioners of services as patients may be put off attending a hospital with poor reviews, and commissioners would seek to purchase care from a more acceptable provider, thus ultimately leading to a fall in funding for that poorly rated provider.

Patient reported outcomes

To date information regarding outcomes of treatment from the patient’s perspective have not been made routinely available. The new standard NHS contract for acute services, introduced in April 2008, includes a requirement in Schedule 5 to report from April 2009 on patient-reported outcome measures (PROMs). PROMs aim to provide a service user’s perspective on clinical outcomes and are already in use by non-NHS healthcare organisations. PROMs are used to derive measures of the outcomes of specific interventions and changes in patient’s health status.

PROMs employ short, self-completed questionnaires which measure the patient’s health status or health-related quality of life at a single point in time. PROMs comprise condition-specific or generic instruments to gather socio-demographic data, information regarding the patient’s general health, co-morbidities and length of time with the condition. ^[19] A study in 2004 by the LSHTM piloted PROMs with 2400 patients at 24 sites and concluded that PROMs were cost-effective and patients willing to participate. ^[20]

The information provided by PROMs can be used to:

• assess the relative clinical quality of providers of elective procedures, for clinicians, managers and commissioners benchmarking their own performance, for regulators, clinical audit and for patients and GPs exercising choice. Appropriate adjustments are applied to the data to ensure comparability by accounting for differences in risk and case-mix. ^[21]
• research what works. Efficacy and cost-effectiveness of different technical approaches to care can be evaluated using PROMs in association with other measures that assess what would have happened to patients in the absence of treatment or with alternative treatment.
• assess referral thresholds. PROMs data used to establish whether referrals for elective procedures are appropriate by examining variation in baseline PROMs scores across the country and comparing against benchmarks. ^[22]
  From April 2009, use of PROMs for four elective procedures are mandated^[23]:

Mandatory PROMs from April 2009

Patients are asked to self-complete the questionnaires without assistance on the day of admission. Patients who are considered incapable of completing PROMs may be excluded from the data collection process (as judged by staff members) though any reasons for exclusion must be documented. Reasons may include problems with literacy, eyesight, first language not English, cognitive impairment or another reason. Patients will subsequently be asked to complete a post-operative PROM at an appropriate time after the intervention (sent via the post), which is likely to be 3 months for groin hernia repair and varicose vein surgery, and 6 months for hip and knee replacements.

As well as the four PROMs mandated as part of the 2009 contract, further PROMs have been systematically reviewed to assess their reliability. These PROMs relate to conditions rather than specific interventions. ^[24]

References

• [19] Department of Health, December 2007, Annexe of the new Standard NHS Contract for Acute Services: Guidance on the Routine Collection of Patient Reported Outcome Measures (PROMs)
• [20] London School of Hygiene and Tropical Medicine, Patient-reported outcome measures Ribeiro J R Soc Med.2007; 100: 397
• [21] For example, PROMs could be stratified by severity of presenting condition rather than trying to compare PROMs relating to different baseline levels of morbidity.
• [22] http://www.glasgows.co.uk/proms/index.html Patient reported outcome measures homepage
• [23] http://www.dh.gov.uk/en/Publicationsandstatistics/Bulletins/theweek/DH_0... The week, issue 54, Department of Health, 11-17 July 2008
• [24] Report to the Department of Health, November 2006, by the National Centre for Health Outcomes Development- structured review of chronic conditions. Patient Reported Health Instruments Group, Oxford University. http://phi.uhce.ox.ac.uk/pdf/ChronicConditions/DH_REVIEWS_NOVEMBER_2007.pdf

© Rosalind Blackwood 2009