Integration, funding and resource flows in the care system
Market analysis and system management
Quality measurement and productivity and efficiency analysis
Quality measurement and productivity and efficiency analysis. This theme considers how we measure what is being delivered for the money spent on health and social care. In the current economic climate it is particularly important that we are able to identify and monitor changes in quality, efficiency and productivity. Our work is intended to inform efficiency improvements and outcome-based commissioning and to guide service provision within and across the health and social care sectors.
Workstream 3: Quality measurement and productivity and efficiency analysis - 2018 Projects
1. Determinants of provider responsiveness to financial incentives to improve quality and efficiency
Project lead: Nils GutackerContext and problem statement
Best Practice Tariffs (BPTs) are designed to improve the quality and efficiency of hospital care by incentivising providers to adopt evidence-based care processes. Our previous analysis under the 2016-2017 ESHCRU programme has shown that many BPTs (e.g. those incentivising day case treatment) are, on average, effective in changing behaviour but that hospitals differ substantially in how much they respond to the incentive; with some not responding at all. This implies missed opportunities to improve care, and may imply sub-optimal design of the financial incentives. To date little is known about why providers in the NHS respond differently to financial incentives.
Project aims
We investigate i) whether the speed and magnitude of practice changes incentivised by BPTs is associated with observable hospital characteristics such as pre-policy profit margin, overall budget impact, ownership and practice style; and ii) whether hospitals converge/diverge over time in their adoption of the incentivised processes and so increase/decrease inequalities.
Quality measurement and productivity and efficiency analysis - 2016-2017 Projects
1. Quality of care, staff job satisfaction and workforce stability
Project lead: Julien Forder, Raphael WittenbergContext and problem statement
Social care is a highly labour-intensive industry but little is known about the relationship between workforce characteristics and quality of care. There are a range of policies that could potentially affect the functioning of the social care labour market and in turn quality (and cost) of care. Minimum wage, qualification and training, regulations regarding workload are examples of relevant policies.
Project aims
The overall aim of this study is to investigate the effects of labour market dynamics in social care in terms of the impact on the quality and sustainability of care services. In particular, we propose to assess:
- whether there are direct links between social care labour market characteristics (including wage rates/conditions of care staff, turnover rates etc.) and (a) quality of care (of both care homes and home care), and (b) care home closures;
- the effect of increases in the National Minimum Wage (in particular on the share of staff employed on zero-hour contracts);
- the use of zero hours contracts and other employment conditions and how this affects staff turnover in the care sector (with implications for quality); and
- the determinants of job satisfaction in a comparative analysis of three sectors characterised by low pay levels and/or high stress levels: social care, retail trade and primary/secondary school education.
2. Evaluating the intended and unintended consequences of best practice tariffs on patient health outcomes and provider behaviour
Project lead: Nils GutackerContext and problem statement
Policy makers increasingly rely on pay-for-performance (P4P) schemes to incentivise healthcare providers to improve quality and contain costs. This research will contribute to the evidence base on the effectiveness and cost-effectiveness of P4P schemes, and thus inform the design of future P4P schemes in the English NHS.
Project aims
The objective of this research is to assess the intended and unintended effects of BPTs on patient outcomes and provider behaviour and contrast those to the additional costs of the schemes. It will analyse a large set of BPTs introduced since 2009 that are implemented nationally and rely on administrative data. This broad view will help us shed light on
- whether BPTs are effective in what they are set out to do (i.e. improve processes or outcomes) and whether there are spill-overs to non-incentivised outcomes,
- whether their effectiveness differs by provider characteristics and past performance,
- whether changes in BPT design, e.g. increases in bonus payments, had measurable effects,
- whether the BPTs are a cost-effective use of resources,
- and whether there are particular design elements that are associated with cost-effectiveness, e.g. the choice between specifying improved processes or outcomes
3. Incentive schemes to increase the number of people diagnosed with dementia: an evaluation of the effects, costs and unintended consequences
Project lead: Anne MasonContext and problem statement
The need for effective community care that supports patients and carers to live independently is a high policy concern. Dementia is devastating long-term condition, managed predominantly in the community and requiring integrated health and social care. GPs are uniquely placed to co-ordinate care for people with dementia and their carers. The Quality and Outcomes Framework (QOF) dementia review is an annual health check for patients and their carers, in which GPs identify and help to address their needs for support. The project will identify the costs and consequences of these schemes and, thereby, help inform the design of policies aimed at boosting the diagnostic rate, as results will be generalizable to other financial schemes.
Project aims
The project aims to assess the individual and collective impacts of financial incentive schemes designed to increase the number of people diagnosed with dementia.
We will assess the effects on prevalence and on the number of people subsequently treated under the dementia QOF. We will also estimate the cost of the schemes and seek to identify unintended consequences, such as poorer access to services or misdiagnosis.
4. Higher quality primary care for dementia: the effects on risk of care home placement
Project lead: Anne MasonContext and problem statement
Care home placement is a defining event in the lives of dementia patients and their carers, and placement following an acute hospital admission is an indication that the care process has failed. Investigation of how such placements may be avoided has important implications for patients, commissioners and policymakers.
The research will provide a clearer picture of the quality of care provided by GPs for their dementia patients (and carers). Information on the aspects of care associated with a lower risk of care home placement, and the most effective ways to support carers of people with dementia, could be used to refine the QOF or other incentive schemes.
Project aims
Our objectives are to address the following research questions:
- What care do people with dementia and their carers receive during the QOF dementia review and how is this care integrated across settings?
- How does the care provided by GPs align with expectations articulated in the QOF?
- Which components of integrated care are effective in reducing the risk of care home placement following acute hospital admission?
5. Variations in costs and outcomes under the National Tariff Payment System for mental health services in England
Project lead: Rowena JacobsContext and problem statement
A new prospective method of funding mental health services, the National Tariff Payment System (formerly known as Payment by Results (PbR)), is being rolled out in England. This research will analyse the impact of the National Tariff Payment System on mental health providers in terms of variations in a) costs and b) outcomes.
Project aims
In order for a payment system such as the National Tariff to work effectively, it needs to group patients into a manageable number of clusters which are intended to be both (a) clinically meaningful and (b) economically homogenous within each grouping, i.e. patients utilise approximately the same amount of resources (costs). Validating the clusters with regard to their homogeneity is important both with a view to the costs as well as to the combination of idiosyncratic needs.
We will examine:
- Are the average costs per cluster a reasonable estimate for the patients assigned to them?
- What are the distributions of cluster costs for providers over time?
- Are patients within one cluster similar enough to be described by their cluster label and treated in the same care pathway?
- What is the variation in outcomes for providers across clusters?
Quality measurement and productivity and efficiency analysis - 2013-2015 Projects
1. Measuring variations in costs following hip fracture
Project lead: Andrew StreetContext
Measuring the productivity of interventions that cut across traditional health and social care boundaries remains challenging. This project promises to provide greater insight into the drivers of productivity by focussing on the patient care pathway for specific conditions. Thus far, we have concentrated on evaluating the management of care for patients who suffer hip fracture. This condition was chosen for analysis because (i) there is robust data, (ii) a significant interplay between H&SC sectors, (iii) it accounts for around £2 billion in H&SC costs which is around 2% of the total NHS healthcare budget, and (iv) it affects a frail elderly population which is set to increase as demographics change.
Project aims
Our objective is to analyse the variation in costs and length of stay for hospitals across the patient care pathway for hip fracture, from emergency admission, to hospital stay and follow-up outpatient appointments. We map costs to each step and explain variation in costs due to: i) socio-demographic characteristics and clinical conditions of the patient, and ii) characteristics of the providers of care. By looking in detail at the complete care pathway, we are able to identify which factors are most associated with best practice, and inform policy about what configurations are more likely to yield efficiency gains.
2. Social care productivity
Project lead: Julien ForderContext
There are apparent differences in how productivity is defined and measured in the health and social care sectors. Moreover the construction of accurate and comprehensive productivity measures requires accurate and comprehensive data. Our work to date has provided the conceptual framework and foundation for further empirical work on productivity to be undertaken.
The value of information about productivity lies in motivating improvements in productivity by commissioners, providers, and regulators. National trends can tell us about how productivity changes year-on-year but productivity information is particularly useful where it is disaggregated into service type, service-user group and locality. To be valuable, productivity assessment needs to reflect strategic goals for social care and also account for all relevant factors.
Currently ONS statistics appear to indicate that the national productivity trend in adult social care (ASC) is downwards. The national trend is calculated as the change in the total (cost-weighted) volume of ASC service divided by the change in the volume of inputs (deflated expenditure). Volume measures (e.g. resident-weeks or hours of home care) do not fully reflect the value of ‘outputs’ of ASC. They do not account for changes in the nature of the population served or the outcomes achieved for that population.
Project aims
The aim of this project is to:
- Incorporate both outcome and case-mix/severity-of-need adjustments in productivity measurement
- Estimate productivity rates over time and by service type, group and locality
The project will use these estimates to compare trends and comment on potential improvements in SC productivity.
3. Higher quality primary care for people with dementia: the effects on hospital admissions
Project lead: Anne MasonContext and problem statement
In 2000, the Audit Commission published evidence of poor assessments and treatment for dementia, with little joint health and social care planning and working (Audit Commission 2000). Only half of GPs believed it important to look actively for signs of dementia and to make an early diagnosis. A range of policy measures were introduced in response, and since 2006/7 GP practices have been paid to identify and review patients with dementia as part of the Quality and Outcomes Framework (QOF). The reviews are a type of health check, and are designed to address the support needs of carer and patient.
Compared with their peers, people with dementia are at a higher risk of depression, and are less likely to report physical conditions. Therefore, the QOF health check for people with dementia should increase the level of care received in primary care settings, and increase outpatient and planned inpatient care. Insofar as it has a preventative effect, the health check may also reduce the rate of unplanned hospital admissions. If carer burden is appropriately managed, the probability that people with dementia enter a care home may also change, but the direction of change is difficult to predict. Practice performance on this QOF indicator is sufficiently variable to allow these hypothesised effects to be tested empirically (see Figure).
Project aims
To test whether the quality of care provided by the GP practice is associated with:
- Q1: Higher levels of planned hospital admissions
- Q2: Lower levels of unplanned hospital admissions
- Q3: Shorter stays for patients who are hospitalised
- Q4: Probability of discharge to a care home
We will test whether the quality of care provided by GP practices influences the level of hospital admissions, and whether it has an impact on length of stay and discharge destination for those who are admitted. The work will add to knowledge of the link between primary and secondary care and between health and social care. It will help to highlight where resources should be invested in order to address the growing demand for care by those suffering from dementia and it can also help inform future developments of the QOF.