[e-drug] Measuring NHS productivity

["Joao Carapinha" <carapinhaj@therapy.wits.ac.za>]

E-DRUG: Measuring NHS productivity 
------------------------------

Colleagues:

Below is an interesting article which discusses how the performance of a
healthcare system should be measured. Inevitably difficulties will arise
depending on what is being measured and the perspective (assumptions)
adopted when measuring. Ideally, any measurement should aim to balance
clinical outcomes, humanistic outcomes and economic outcomes. The
article reminds us of the challenges we face in South Africa. 

Regards
Joco Carapinha
carapinhaj@therapy.wits.ac.za

http://bmj.bmjjournals.com/cgi/content/full/330/7498/975?etoc 

Measuring NHS productivity 

How much health for the pound, not how many events for the pound 
The October 2004 report from the UK Office for National Statistics (ONS)
invites potentially harmful misunderstandings.1

The report concludes that NHS productivity declined by 3-8%
(depending on the method of calculation) between 1995 and 2003.
"Production of what?" is the key question here. If we ask the wrong
question the answer may lead us to the wrong policy conclusion. 
The job of the health service is to produce health to relieve suffering.
In the words of National Academy of Sciences in the United States, "The
purpose of the health care system is to reduce continually the burden of
illness, injury, and disability, and to improve the health status and
function of the people..."2

Ideally, the term productivity, as applied to the NHS, ought to refer
to the ratio of inputs (such as labour, capital, and supplies) to that
output, not just counts of activities. 

Of course the burden of illness, injury, and disability is very hard to
measure, and so we use surrogates when we assess healthcare systems,
whence the hazard. But the difficulty of assessing productivity is no
excuse for using misleading shortcuts. By definition, holding inputs
constant, the aim of a more productive healthcare system is to offer
more health than a less productive one. Useful measurements ought to
help us understand how well the NHS is achieving that aim. The
measurements offered by the ONS do not do that; they merely describe its
activities. 

The ONS calculates productivity as a ratio of inputs to outputs,
defining outputs as a weighted average of 16 types of care activity,
such as hospital cases, visits to doctors, and ambulance journeys. The
weights reflect some view of the importance of each output. For example,
the output index of the ONS weights an inpatient treatment 14 times as
heavily as an outpatient treatment. The measurement takes no account,
however, of the degree to which those events accomplish their
purpose - healing. For example, it does not assess improvement in the mix
of these so called outputs, such as when innovations in care allow
patients to be treated successfully in outpatient settings rather than
in the hospital. To its credit, the ONS notes carefully that "the output
estimates do not capture quality change."1

Its interpreters need to show equal caution. 
Measuring productivity without regard to quality or value is a risky
foundation for wise policy. In globally competitive markets
manufacturing and service companies that take that route often find
themselves in deep trouble, because their customers know better. Think
about the assertion of one UK newspaper columnist who wrote of the ONS
report, "Whether quality should properly be counted in the value for
money calculations is open to question."3

Will she feel the same when she buys her next car, refrigerator, or
restaurant meal? Probably not. In fact objective assessments supported or done by the Nuffield Trust,4 the Royal College of Physicians,5 and several university research groups have confirmed reductions in
waits and delays, improvements in reliability and outcomes of care for
cancer, heart disease, and probably orthopaedics, and smoother flow in
emergency departments in the NHS between 1995 and 2003.6

Moreover, primary care access, in particular, has soared during this
period, and innovations in non-visit care, especially NHS Direct, make
the United Kingdom an international pioneer. Other areas are lagging
behind including smoking rates, obesity, and standardised population
death rates.7 and need to be tackled. 

When the Labour government set about to improve the NHS through its
modernisation process, politicians had every reason to believe - although
they might not have recognised it - that the form of productivity measured
by the ONS would and should fall. They were investing more moneyraising
inputs for sure, and were consciously changing the nature, quality, and
intent of the units of service that the ONS report is counting as
"outputs." Appropriate resources and sound improvements to the process
should and did have the effect of making care far more effective, far
more valuable, for patients. 

The NHS faces major hurdles and is engaged in risky innovations such as
foundation trusts; the new, performance based contract for general
practitioners; a massive investment in information technology; and some
dabbling in health care imported from offshore organisations. These
innovations are far more consequential than changes in the type of
productivity reported by the ONS, and they need to be carefully managed,
treated as social experiments, adjusted as time passes, and assessed
objectively. Their proper assessment requires that policy makers rely
not on simple, potentially misleading metrics of numerical throughput
but rather seek answers to the tougher and far more important question
of value for money. The people of the UK should be not asking, "How many
events for the pound?" but rather, "How much health for the pound?" At
least, that is what they should ask if they desire an NHS that can keep
them healthy and safe at an affordable price for as long as is feasible.

Donald M Berwick, president, Institute for Healthcare Improvement, 20
University Road, Cambridge MA 02138, USA