Health Quality Indicators, Value of Health: Accounting for Quality Change Aileen Simkins, Department of Health Co-Director of the Atkinson Review

Context UK measurement of public service healthcare output and productivity – Part 2 Quality adjustments to series for healthcare output described earlier by Chris Little Quality adjustments developed by DH; used by ONS in Health Productivity article but not in National Accounts Development programme

ONS Health Productivity Oct 2004

DH Press Release Oct 04 John Reid (Secretary of State for Health) says “ it is absurd to measure NHS output without taking account of quality”

Quality as part of NHS Output How many domains of quality? –Health gain –Patient experience What can we measure? How can we link quality measures to the NHS output index? How should we weight different aspects of quality? How valid is a partial story?

DH Work on Quality Adjusted Output York/NIESR research commissioned 2004 Parallel DH work during 2005 DH paper Accounting for Quality Change published Dec 2005, with research report Used in 2nd ONS Health Productivity article Feb 2006

Accounting for Quality Change Average over last 5 years: Value of health 1.5% Value weight for statins 0.81% York/NIESR adjustment0.17% Patient experience* 0.07% Blood pressure control *0.05% Heart attack survival 0.01% Total **2.68% Quality adjusted output growth 6.29%

ONS Health Productivity 2006

York/NIESR Research 0.17% Ideal method is value weighted output index, not cost weighted activity index Algebra takes account of multiple aspects of quality and their value to patients – e.g. health gain (QALYs) Interim formula uses cost weights with mortality after hospital treatment + estimate for health gain if not dead Waiting time – interim formula measures as deferred benefit (discounted)

Quality Adjusted Life Years Ideally we want to measure the area under the curve Before and after measures are a reasonable approximation (?)

Value Weight for Statins 0.81% Statin prescriptions rising fast (so positive output growth in CWAI) Value per prescription, in QALYs, can be shown to be greater than cost Work based on epidemiological research – lives saved, less morbidity Value weight is £115 v cost £30 (assuming £30,000 per QALY) So using value weight raises output growth even further

Improving blood pressure control 0.05% GP Contract Quality and Outcomes Framework First data set Sept 2005 – no time series yet QRESEARCH data on 400+ practices (3m patients) – quarterly measures of many QOF indicators, pre-contract Prevalence rates and comorbidity rates Examined data for blood pressure and cholesterol control

Hypertension: blood pressure control

Key results Jan 2002 – Oct 2004 CHD Blood pressure control Jan % Blood pressure control Oct % Annual rate of increase10.4% Hypertension Blood pressure control Oct % Blood pressure control July % Annual rate of increase22.4%

Overall GP Quality Adjustment Most patients (86%) don’t have CHD or hypertension – assume no change in quality Patients with hypertension and/or CHD also see GP for other illnesses – weight as equally important as CHD/hypertension, no change Patients with CHD need wider treatment than blood pressure control – weight BP as 1/3 Result: 1.1% a year for GMS as a whole Raises NHS output by 0.14% a year

Patient Experience 0.07% Survey programme set up NHS Plan 2000 Operated by Healthcare Commission PSA target for national improvement in measured patient experience Separate surveys for inpatients, outpatients, primary care, A&E – with 2 data sets each Many questions; 5 domains

Patient Experience Data

Value of Health 1.5% Biggest single element; used first for education Does not depend on NHS data – same every year Atkinson Report Principle C ‘account should be taken of the complementarity between public and private output, allowing for the increased real value of public services in an economy with rising real GDP’ E.g ‘rising real wage rates mean we attach a higher valuation to days lost through sickness absence’

Establishing the Principles UKCeMGA consultation paper Sept 2006 Framework for quality adjustment – based on Atkinson Report Arguments on public/private complementarity – two way Effect depends on specific channels of influence in each area of public spending DH will await outcome of consultation and further clarity

DH Development Work Aiming for AfQC 2 in winter 2006/7 Improvements on volume series (hospital, GP) ? Use ‘avoidable deaths’ instead of ’30 day mortality Discussion of functional form – additive not multiplicative, how to weight different domains Wider, longer analysis of primary care clinical outcomes Re-analysis of patient experience New quality indicators (e.g. discharge to normal residence after stroke) New value weight for smoking cessation Progress on routine measurement of patient reported outcomes

Value and Validity of Quality Adjusted Output Measures Focus on attributable impact on outcomes and quality change Data incomplete; biased towards areas of attention / improvement Development work by DH – partial? Techniques new, untried, difficult UKCeMGA in position to set standards, lead development work, assure independent view External consultation important – health Nov 06 based on Dec 05 paper