1c Health Care Evaluation

Question 1

What is a Health needs assessment (HNA)?

Answer 1

A systematic method of identifying the unmet health and healthcare needs of a population, and making changes to meet those unmet needs.

A HNA may focus on specific diseases, population groups, procedures or interventions.

Question 2

What is “need” in relation to a health needs assessment?

Answer 2

The population’s ability to benefit from health care interventions.

A need for health is not the same as a need in a HNA as a need for health also includes health problems where there is no realistic or available treatment and thus does not inform the planning of health care services.

Question 3

What are the three main approaches to a health needs assessment?

Answer 3

Epidemiological. This approach considers the epidemiology of the condition, current service provision, and the effectiveness and cost-effectiveness of interventions and services.

Comparative. This approach compares service provision between different populations. Large variations in service use may be influenced by a number of factors, and not just differing needs.

Corporate. This approach is based on eliciting the views of stakeholders - which may include professionals, patients and service users, the public and politicians - on what services are needed. Elements of the corporate approach (i.e. community engagement and user involvement) are important in informing local policy.

Question 4

What is the difference between a JSNA and a HNA?

Answer 4

need to find out

Question 5

Why may current services identified in a health needs assessment need to change?

Answer 5

Inequalities in outcomes
Local sensitivities
Changing demographic patterns or disease trends
Availability of new treatments
Changing expectations

Question 6

What are the main steps of a health needs assessment?

Answer 6

There is no clear predefined process, but these steps give a suggested outline.

Step 1: Getting started
Early stakeholder involvement to identifying who will carry out which elements of the assessment, and ensuring engagement of all parties. This stage should include:
* Identifying the population of interest - is it defined by geography, illness, social experience or setting
* Identifying the key stakeholders
* Identifying what resources are available

Step 2: Identify health priorities
Gather data describing the population of interest (quantitative and qualitative data), to give a detailed picture of health needs.
* Consider collecting data on similar localities to allow comparisons of need.
* Review current levels of service provision(e.g. infrastructure and workforce/skill, effectiveness)

Step 3: Identify priorities for change.
Identify key issues
Develop priorities for action based on:
* Size and severity impact
* Availability of effective and acceptable interventions and actions
* Local commissioning priorities and partnership arrangements

Steps 4 and 5:
Implement the changes
Develop a monitoring and evaluation strategy
Measure the impact of the changes in services.

Question 7

What is the inverse care law?

Answer 7

The availability of good medical care tends to vary inversely with the need for it in the population served.

This operates more completely where medical care is most exposed to market forces, and less to where such exposure is reduced.”

Question 8

In what ways can service use be measured?

Answer 8

Service-based activity, such as GP referral rates, bed occupancy, intervention rates

Population-based activity such as prescriptions, immunisation coverage, surgical rates

Question 9

What factors may impact health care service utilisation?

Answer 9

Statistical factors (incomplete data, bias, etc)

Demand factors (age/sex composition, morbidity rate, illness behaviour)

Supply factors (availability of services, professional judgement); which are usually the main reason for variation in use of services.

Question 10

What factors may impact health care service demand?

Answer 10

Illness behaviour (itself influenced by age, gender, education, socioeconomic class)

Knowledge of services

Influences from the media

Supply of services, which is itself influenced by the use of guidelines, and evidence of clinical and cost-effectiveness.

Question 11

What is a Participatory needs assessment?

Answer 11

A way of understanding the health needs of a local population including needs relating to the wider determinants of health, such as housing, crime, employment and education.

Professionals and local people form a partnership to identify community needs, set priorities and develop an action plan.

The overall aim of the participatory needs assessment is to understand the health needs of the community from their own perspective rather than from the provider or commissioner’s view point.

Question 12

Which sources of information may be used in a participatory needs assessment?

Answer 12

Informal discussions with voluntary or community groups
Focus groups
Interviews with key informants and service users/patients
Household surveys
Relevant local documents about the neighbourhood or community
Observations undertaken in homes and neighbourhoods
Community mapping

Question 13

What are the outcomes of a participatory needs assessment?

Answer 13

Information is analysed and presented to include a description of the community, the wider determinants of health that impact on the community, quality and level of health and social services available to the community as well as any relevant local or national policies impacting on the health needs of the community.

The information gathered is then reviewed with all participants who then prioritise their health needs, using ranking if needed. Any programmes suggested as part of the improvement programme must be acceptable to the community and also sustainable in the longer term.

Question 14

What are the basic principles required for any needs assessment?

Answer 14

Any programmes suggested as part of the improvement programme must be acceptable to the community and also sustainable in the longer term.

Aims and objectives of the needs assessment should be set out at the beginning of the work

Timescales should be set in advance an allow sufficient time to be spent gathering data to ensure that as many members of the community as possible have the chance to participate.

Question 15

How can you ensure that you have adequate community involvement in your participatory health needs assessment?

Answer 15

Rifkin describes a checklist for assessing the levels of participation in community development projects such as participatory needs assessment:

Definition of health needs and how needs were identified
* How were health needs identified?
* Did the identification include only health service needs or other health needs?
* What role if any was foreseen for community people in conducting the needs assessment and in analysing health needs?
* Were surveys used? Who designed the surveys and who conducted them?
* Were the surveys used merely to get information or also to initiate discussions with various possible beneficiaries?
* Were potential beneficiaries involved in analysing results?

Use of results
* Was the assessment used to further involve the beneficiaries in future plans and programmes?
* Was only one assessment made or is it an exercise for change, review and further involvement of community in programme plans?
* How were the results of the assessment used in the planning of the programme?

Who contributed / participated
* If community people were involved in the assessment did they continue to be involved in the implementation?
* Was it able to include various representatives from the wide range of possible beneficiaries for which the health programme was intended?

Question 16

What is the benefit of a participatory needs assessment over a traditional health needs assessment?

Answer 16

Provide an opportunity for the views and voices of those not normally heard to be taken into account (ethnic minority groups, young people, homeless people etc). In a normal health needs assessment, the views of such groups would normally only be heard if they had raised issues formally.

Participatory needs assessment may link to or complement epidemiological (or other) needs assessment, particularly in relation to service planning and does not have to be a stand alone piece of work.

Question 17

What are the measures of supply?

Answer 17

Measures of supply indicate the amount of care that can be made available and include:

Staffing: consultants, total doctors, total nurses, managers and can be considered in terms of whole time equivalents and skill mix
Beds available: available bed-days = no. of beds x no. of days in period (it is important to just count staffed beds not total beds)
Equipment: e.g. MRI scanners, operating theatres
Budget: surplus, debt, funds available for investment, other sources of income
Waiting times

These measures can be used in isolation or combination, examples of combination measures include:
WTE nurses / beds available
consultants / operating theatre
total doctors / beds available
funds available per bed

Question 18

What are the measures of demand?

Answer 18

Measures of demand indicate the quantity of health services the population wants. This may be legitimate need as well as desired demand:

Inpatient admissions
Hospital catchment population - The number of people who fall within the catchment area of a healthcare provider. This will be affected by a number of factors such as: distance from the service user to the healthcare provider, ease of access, ambulance transfer time, range of services provided at each institution, quality and standards of care.
The average length of stay (ALOS): may be a reflection of the complexity of case mix (demand) or indeed poor discharge planning (supply)
Waiting times

These measures can also be used in isolation or combination, examples of combination measures include:
Admissions per 1000 catchment population
Hospital bed days demanded (= number of admissions during period x ALOS)

Question 19

Why may inpatient admissions be an inaccurate marker for health service demand?

Answer 19

May reflect a high demand, but may also reflect:

A lack of alternative services
The health status of a community
A varied case-mix, for example, admissions are likely to be high in an elderly, deprived population.
The admission threshold by the hospital or community staff

Question 20

What are the supply and demand targets for healthcare organisations in the UK?

Answer 20

Maintain a referral to treatment maximum wait for non-emergency care of 18 weeks

Maintain an outpatient appointment attendance within two weeks of an urgent GP referral for suspected cancer

Maintain a maximum waiting time of two months from urgent referral to treatment for all cancers

Maintain a four hour maximum wait in A&E from arrival to admission, transfer or discharge

Maintain that ambulances responding to category A calls resulting in an emergency response arrive within 8 minutes

Maintain that operations cancelled for non-clinical reasons on or after the day of admission are rescheduled within 28 days

Question 21

Which data do local authorities use to monitor and comapre healthcare trusts?

Answer 21

National Supply and demand targets (such as the 4 hour A&E waiting time)
Throughput (patients per bed in a given period of time)
The average length of stay in the over 65s age group compared to the under 65s age group
New to follow-up appointments ratio in outpatient services
Percentage occupancy (= bed days demanded / bed days available x 100)

Question 22

Which aspects of healthcare systems can be assessed?

Answer 22

Effectiveness – the benefits of healthcare measured by improvements in health

Efficiency – relates the cost of healthcare to the outputs or benefits obtained

Acceptability – the social, psychological and ethical acceptability regarding the way people are treated in relation to healthcare

Equity - the fair distribution of healthcare amongst individuals or groups

Question 23

What are the main types of healthcare evaluation?

Answer 23

Formative evaluation - Evaluation during a healthcare intervention, so the findings of the evaluation inform the ongoing programme

Summative evaluation - Evaluation at the end of a programme

Question 24

What is the difference between prospective and retrospective healthcare evaluation?

Answer 24

Evaluating on a prospective basis has the advantage of ensuring that data collection can be adequately planned and hence be specific to the question posed (as opposed to retrospective data dredging for proxy indicators) as well as being more likely to be complete.

Prospective evaluation processes can be built in as an intrinsic part of a service or project (usually ensuring that systems are designed to support the ongoing process of review).

Question 25

What should any objectives identified during a healthcare system evaluation be?

Answer 25

SMART

Specific – effectiveness/efficiency/acceptability/equity
Measurable
Achievable – are objectives achievable
Realistic (can objectives realistically be achieved within available resources?)
Time- when do you want to achieve objectives by?

Question 26

What are the steps in healthcare system evaluation?

Answer 26

Generally, it is best to pick a framework, but the chosen framework will depend on the intervention or system you are evaluating, in general:

Decide on the role of the evaluation
Pick a study design
Pick which measures you will use
Decide how and when you will collect data

Question 27

Give an example of a framework for healthcare evaluation.

Answer 27

Donabedian
E.g. evaluating a programme
Structure/inputs > process > outputs > outcomes

Black
E.g. priority setting
Effectiveness (efficacy), efficiency, equity, humanity

Maxwell
E.g. a screening programme
Effectiveness (efficacy), efficiency, equity, access, acceptability, appropriateness

Question 28

What are the different types of study designs that may be used in healthcare evaluation?

Answer 28

Randomised Trials
* Randomised control trial
Non-Randomised Trials:
* Cohort studies
* Case-control studies
Ecological studies
Descriptive studies
Health technology assessment
Qualitative studies

Question 29

What are the advantages and disadvantages of a randomised control trial?

Answer 29

Advantages:
Removes confounders

Disadvantages:
Expensive to run
Not always practical

Question 30

What are the advantages and disadvantages of a case-control trial?

Answer 30

Advantages:
Good for rare disease

Disadvantages:
Control group selection is a major form of bias

Question 31

What are the advantages and disadvantages of a randomised control trial?

Answer 31

Advantages:
Cheap
Quick
Useful for studying the impact of health policy

Disadvantages:
Crude
Less sensitive

Question 32

What is a Health technology assessment?

Answer 32

Examines what technology can best deliver benefits to a particular patient or population group.

It assesses the cost-effectiveness of treatments against current or next-best treatments.

Question 33

Examples of measures during a healthcare evaluation.

Answer 33

Question 34

What are common problems that can occur during healthcare evaluation?

Answer 34

There are several problems which can arise when undertaking evaluation in practice, including:

How the evaluation will sit within national and local policy context (it can be difficult to isolate an intervention or programme from the context within which it operates)
Politics - Some stakeholders may have biases towards which outcomes should be reported
Practicalities - finance, time, resources, level of detail required, being able to measure what you want to measure
Research versus practice - ensuring that the evaluation is undertaken in a rigorous and robust way can sometimes be compromised by the practicalities of running a service
The evaluation should go beyond being just an audit - ideally it should relate the separate parts of the evaluation framework to each other e.g. input to outcomes as opposed to just reviewing whether processes are occurring as they should be
Assessment - it can be difficult to measure what you want to measure in practice
The evaluation may be wider than existing performance management processes requiring the collection of additional data.

Question 35

What is health as defined by the WHO?

Answer 35

A state of complete physical, mental and social well-being, and not merely the absence of disease.

Question 36

What are the two key elements of health?

Answer 36

Health status - Health can be considered in terms of a person’s body structure and function and the presence or absence of disease or signs

Quality of life - Their symptoms and what they can and cannot do i.e. the extent to which the condition affects the person’s normal life.

Question 37

What is healthcare?

Answer 37

Health care is the prevention, treatment, and management of illness and the preservation of health through the services offered by health care organisations and professionals.

It includes all the goods and services designed to promote health, including “preventive, curative and palliative interventions, whether directed to individuals or to populations”.

Question 38

In what ways can health status be measured?

Answer 38

Health status can be measured using pathological and clinical measures and is usually observed by clinicians or measured using instruments.

Types of disease measurement include:
Signs e.g. Blood pressure, X-ray findings, Tumour size
Symptoms
Co-morbidity - Charlson Index, ICED- index of co-existing disease, adverse events (pain, readmission, complications).

Question 39

What is health-related quality of life?

Answer 39

Quality of life is a measure of the difference between the hopes and expectations of the individual and the individual’s present experience.

Health-related quality of life is primarily concerned with those factors which fall within the spheres of influence of health care providers and health care systems.

Question 40

What are health-related quality-of-life measures and give an example of each type?

Answer 40

Measures of health-related quality of life.

They can be applicable across different types of diseases, medical treatments and demographic/cultural groups or they may relate only to specific diseases, interventions or population groups.

Generic tools:
Short form (SF)-36
WHOQOL
EuroQoL (EQ5D)
Nottingham health profile (NHP)
Sickness Impact Profile (SIP)

Disease-specific:
Asthma Quality of Life Questionnaire
PROMS - Measures for hip and knee replacement and varicose veins
Warwick Edinburgh score (Mental health measures)

Population-specific:
The Child Health and Illness Profile/CHIP

Question 41

What are Population health outcome indicators and who publishes this data?

Answer 41

They are measures the effect of health care on health status at a population level i.e. it is aggregated data.

They may reflect a state of health at a point in time, a change in a health state over a period of time; or change in health status as a result of an intervention.

In England, data on population health outcome indicators are published by the Health and Social Care Information Centre, Public Health England, Care Quality Commission and other agencies such as Dr Foster Health Intelligence Unit.

At a national level, health outcomes achieved for the population of England are published through the NHS Outcomes Framework and the Public Health Outcomes Framework. The Adult Social Care Outcomes Framework also published social care outcomes.

Question 42

Give an example of health outcome data.

Answer 42

Controlled high blood pressure in patients with hypertension – the intended outcome being fewer complications and sequelae of disease in patients with better-controlled blood pressure, i.e. a better health outcome

Deaths within 30 days of emergency admission to hospital for stroke – the intended outcome is to avoid mortality in patients with stroke and a low mortality rate within 30 days of admission would suggest that the management and treatment of stroke is good.

Question 43

What are Deprivation scores?

Answer 43

Deprivation scores can be ascribed to an area or population to give a picture of its social and economic status.

Question 44

Can deprivation scores be used to ascertain individual outcomes?

Answer 44

No, it is ecological data and so ascribing an area’s characteristics to the individual can lead to ecological fallacy.

Question 45

What deprivation scores are used in the UK?

Answer 45

National statistics socio-economic Classification (NSSEC)
Index of Multiple Deprivation
Jarman score
DETR 2000
Townsend Material Deprivation Score
Carstairs

Question 46

What factors make up deprivation scores?

Answer 46

Income
Occupation
Years of education
Housing
Ownership of various goods such as car, washing machine etc.

Question 47

What are the pros and cons of the Index of Multiple Deprivation (deprivation measure)?

Answer 47

Pros:
Can be aggregated by population-weighted averages.
A broad range of measures

Cons:
Cannot make direct comparisons between 2015 IMD and previous version because scores are calculated differently by year.
Can only comment on relative rank differences between years.

Question 48

What are the pros and cons of Jarman score (deprivation measure)?

Answer 48

Pros:
Can be used for small areas.
Diverse range of measures.

Cons:
Differences between wards are masked.
Data is linked to last census (2001) so can be out of date.
Does not indicate the proportion of people in an area who are deprived.
Biased towards urban population.

Question 49

What are the pros and cons of DETR 2000 (deprivation measure)?

Answer 49

Pros:
Data is updateable
Can distinguish between different aspects of deprivation.
Gives the proportion of people that are deprived for the income and employment domains.

Cons:
Some domains (housing) derived from only a few data sources.
Variables are weighted differently though justification is not clear.
Access score is more reflective of rural rather than urban need.
Data is not available below ward level.
District averages are applied to ward level in some instances.

Question 50

What are the pros and cons of Townsend Material Deprivation Score?

Answer 50

Pros:
Can be used to look at small areas.
Highly correlated with measures of ill-health.
Easy to calculate because sum of standardised scores.

Cons:
Data can be out of date as linked to last census- particularly in terms of housing tenure.
Does not indicate the proportion of people in an area who are deprived.
Better indicator of deprivation in urban areas that rural areas.

Question 51

What are the pros and cons of Carstairs (deprivation measure)

Answer 51

Pros:
Based on census so allow objective results for whole population.
Can be used to look at small areas.
For an outcome such as low birthweight, Carstairs scores have been shown to perform better than individual social class in describing the extent of inequalities in the population.

Cons:
Data can be out of date as linked to last census- particularly in terms of housing tenure.
Better indicator of deprivation in urban areas that rural areas.

Question 52

What is the difference between quality assessment and quality assurance?

Answer 52

Quality assessment is the data collection and analysis through which the degree of conformity to predetermined standards and criteria are exemplified.

Quality assurance is the process of guaranteeing quality.
If quality indicators are being measured and quality standards are reached, through the quality management process, then quality assurance can be given.

Question 53

What is a quality management system?

Answer 53

A systme of policies and protocoles then

Question 54

What are the key components of a quality management system?

Answer 54

Indicators of success in the early, mid and end stages of an intervention or programme. Such indicators need to be reported and fed back into the loop so that quality improvements can be made continually.

Question 55

Give an example of a healthcare quality assessment.

Answer 55

Healthcare organisations’ performance against national targets and indicators

GPs - performance as measured by quality outcomes framework

Question 56

Give an example of health quality assurance.

Answer 56

Some examples of quality assurance.

National Cancer Screening programmes quality assurance guidelines.
NICE guidance and Health Technology Assessments

Question 57

What is clinical governance?

Answer 57

Clinical governance is the quality management system for ensuring clinical quality within an organisation, for example, ensuring that processes/policies/protocols are in place to ensure that the correct kidney is removed and that these processes/policies/protocols are put in action to ensure good clinical outcomes and to maximise patient safety.

Question 58

What are the challenges of setting clincal standards?

Answer 58

Whilst clinical guidelines set out appropriate steps in a patient pathway usually based on systematic reviews of evidence, actually assessing clinical outputs in terms of quality is difficult. It is difficult to know what to benchmark against – should it be average performance or should there be a threshold? Should there be a minimum safe standard that many will achieve or an aspiring standards of excellence?

Question 59

What criteria should any set standard have?

Answer 59

It must be clear how they can be achieved by individuals
It must be an achievable standard

Question 60

What are Equality, Inequality, Equity and Inequity?

Answer 60

Equality = sameness

       Inequality   =   unequal

       Equity         =   fairness

       Inequity      =   unfair or unjust

Question 61

What are the three acceptable reasons for patient care for the same condition differing?

Answer 61

Effective care: clinical evidence supports different treatments

Preference-sensitive care: where alternative valid treatment options are available and variations are caused by patients exercising choice

Supply-sensitive care: variations reflect the different availability of alternative treatment approaches.

Question 62

In what way can healthcare inequalities be measured?

Answer 62

Measuring health need (measuring demand through health needs assessment - see section ‘Participatory needs assessment’)

Measuring access to health care (measuring supply and demand) health care use e.g. avoidable admissions, barriers to admission e.g. waiting lists, patients’ perceptions of healthcare provision

Measuring quality of health care (see section ‘Principles of evaluation’).

Question 63

What is the The Gini co-efficient?

Answer 63

The Gini-coefficient of inequality is a commonly cited measure of inequality and is shown by a Lorenz curve of income distribution.

The Lorenz curve (B) plots the share of cumulative income enjoyed by the relative share of the population – on the curve shown below, 40% of the population obtains 20% of the total income.

Curve (A) is the line of total equality whereby 40% of the population obtain 40% of the total income.

The difference between the 2 curves, the Gini-coefficient, indicates the degree of inequality of distribution. A co-efficient of 0 reflects complete equality whilst 1 indicates complete inequality.

Question 64

What is the difference between vertical and horizontal equity?

Answer 64

Horizontal equity refers to equity between people with the same health care needs, whilst vertical equity refers to those with unequal needs who should receive different or unequal health care.

Vertical inequity can be justified in healthcare if morally relevant factors are causing this.

Question 65

What are the morally relevant and irrelevant factors in vertical equity?

Answer 65

Moral:
Need
Ability to benefit
Autonomy
Deservingness

Immoral:
Age/sex
Ethnicity
Income, class
Disability, genetics

Question 66

What is a clinical audit?

Answer 66

Clinical audit is the review of a process or practice or outcomes against a pre-agreed set of standards and forms part of the quality improvement process.

It is central to improving quality standards within healthcare and is an important part of maintaining high standards and patient safety.

Clinical audit should form an intrinsic part of clinical activity - it should not be a one-off random process and should be conducted regularly to monitor for improvements (or failures) in clinical practice.

Clinical audit is a key pillar of clinical governance and should be carried out by all healthcare staff.

Question 67

What are the stages of a clincal audit?

Answer 67

Stage 1: Preparing for audit:
* Define the purpose of the audit
* Involve service users in the audit process
* Provide the necessary structures for the audit
* Identify the resources required for undertaking the audit (people, skills, training, funding, equipment)
* Include service user involvement where appropriate

Stage 2: Selecting audit criteria
Criteria must explicitly define what is being measured and must represent elements of care which can be measured objectively. Criteria must be valid and appropriate.
Criteria can be selected from:
* Guidelines (e.g. NICE guidelines)
* Standards based on professional or consensus opinion
* Service user-defined measures (e.g. outcome measures)
* Set performance levels
* Care pathways

Stage 3: Measuring level of performance
Planning data collection:
* Inclusion criteria – i.e. who should be included in the audit (with any exceptions to be noted)
* Which healthcare professionals should be included in the audit i.e. who provides the patient’s care for the audit
* Sample size
* The time period over which the criteria apply
* Data sources to use - consider retrospective versus prospective collection
Plan data analysis
* Consider and plan for any data protection issues

Stage 4: Making improvements
* Disseminating results
* Changing behaviours

Stage 5: Sustaining improvement
* Regular audit
* Clinical performance indicators

Question 68

Give an example of a national audit programme

Answer 68

Sentinel Stroke National Audit Programme (SSNAP)
National Emergency Laparotomy Audit (NELA)

Question 69

What is a confidential enquiry and what is its purpose?

Answer 69

Confidential enquiries are “confidential” in that details of the patients/cases remain anonymous, though reports of overall findings are published.

The purpose of a confidential enquiry is to detect areas of deficiency in clinical practice and devise recommendations to resolve them. Enquiries can also make suggestions for future research programmes.

Most confidential enquiries to date (at both national and local level) are related to investigating deaths, to establish whether anything could have been done to prevent the deaths through better clinical care.

Confidential enquiries are “confidential” in that details of the patients/cases remain anonymous, though reports of overall findings are published.

Question 70

What is the difference between a confidential enquiry and an audit?

Answer 70

The confidential enquiry process goes beyond that of audit, in that the details of each death or incident are critically reviewed by a team of experts to establish whether clinical standards met (similar to the audit process) and also that the right clinical decisions were made in the circumstances (audit is unlikely to include this aspect).

Question 71

Give an example of a national confidential enquiry?

Answer 71

England’s recent national-level confidential enquiries include:

National Confidential Enquiry into Patient Outcome and Death (NCEPOD) - Sepsis (2015). Care for patients aged 16 years or older with sepsis was reviewed. Areas where the clinical and organisational care of these patients care might have been improved were identified.

MBRRACE-UK Perinatal Confidential Enquiry Report – Term, Singleton, Normally-formed, Antepartum Stillbirth (2015). Cases were reviewed in detail against national care guidelines by a panel of clinicians, including midwives, obstetricians and pathologists who considered every aspect of the care.

National Confidential Inquiry into Suicide and Homicide (NCISH) by people with mental illness (2015). The report presents findings from 2003 to 2013 and highlights areas of health care where safety should be strengthened across a range of organisations.

Question 72

What is a Local Confidential enquiry?

Answer 72

Confidential enquiries can also be conducted at a local level in a similar way whereby a panel of locally appointed experts review clinical practice to ascertain whether any deaths or adverse events were avoidable.

Recommendations for action are then made and implemented. Examples of local confidential enquiries include drug related deaths.

Question 73

What is a consensus method?

Answer 73

Consensus methods provide a means of synthesising information. Their main purpose is to define levels of agreement on controversial subjects.

The 3 best-known consensus techniques are:
* Delphi process
* Nominal group technique
* Consensus development conference

Question 74

What is the Delphi process?

Answer 74

The Delphi method is a systematic interactive way of gaining opinions/forecasts from a panel of independent experts over 2 or more rounds. It is a type of consensus method which does not require face-to-face meetings.

The Delphi process aims to determine the extent to which experts or lay people agree about a given issue and with each other and in areas where they disagree, achieve a consensus opinion. Delphi technique is usually conducted through questionnaires.

Where focus groups purposely use group dynamics to generate debate on a topic, Delphi methods maintain anonymity of the participants, even after the study.

Question 75

What are the stages in the Delphi process?

Answer 75

The following steps outline how to undertake a Delphi study:

1. Design the questionnaire
2. Invite participants to take part
3. Send out first round of questionnaire (see example below)
4. Analyse responses from round 1 questionnaire
5. Prepare the second round questionnaire
6. Send out second round questionnaire (see example below)
7. Analyse responses from round 2 questionnaire
8. Design the third round questionnaire. For the third round, the second questionnaire is repeated but incorporates scores from the second questionnaire results. This gives participants a chance to see how the rest of the group prioritised the areas and if the participant then wants to change their opinion on the basis of the group consensus, has the opportunity to do so.
9. Analyse the results of the third round questionnaire for agreement and degree of consensus
10. Report findings

Question 76

What are the Strengths and weaknesses of the Delphi technique?

Answer 76

Strengths:
A rapid consensus can be achieved
Participants do not have to be in the same room together to reach agreement
Individuals are able to express their own opinions as opposed to “Group think”
Can include a wide range of expertise
Relatively low cost to administer and analyse
There is the potential to gain large quantities of data
Offers a method which can be used where data are lacking

Weaknesses:
Does not cope well with widely differing opinions or large changes in opinions (paradigm shifts)
The facilitator’s view may dominate in the analysis
Differing opinions may not be sufficiently investigated
Can be time-consuming
Needs high participant motivation
Success of the method depends on the quality of the participants
The written response format may be less suitable for some potential respondents

Question 77

Which white paper made outlined plans to make the patient experience more of a measurable outcome in care?

Answer 77

Equity and excellence: Liberating the NHS, a white paper published in July 2010, which outlined plans to make patient experience a measurable outcome of care, along with introducing a ‘no decision about me without me’ ethos set a clear direction of a greater focus on acceptability of healthcare services. Including patient experience as a measurable outcome of care in the NHS Outcomes Framework (and other initiatives) has also drawn attention to this aspect of care at all levels within healthcare organisations.

Question 78

What are some examples of patient experience measures?

Answer 78

Friends and Family Test
‘I’ statements
GP Patient Survey
Care Quality Commission patient experience surveys
Patient complaints and compliments (Through the Patient Advice and Liaison Service)

Question 79

What is NHS choices?

Answer 79

A website where patients can look up their local hospitals and see how other patients rated their experience for given areas of care along with any Care Quality Commission assessments.

Question 80

How are patient experience measures used?

Answer 80

NHS Choice - Patient can look at results
NHS e-Referral Service - Patients can select where they are referred to
Payment by Results - Makes up some of the criteria involved in resource allocation.

Question 81

What are patient-reported outcomes (PROMs)

Answer 81

Patient Reported Outcome Measures (PROMs) assess the quality of care delivered to NHS patients from the patient perspective.

Question 82

What are the uses of patient-reported outcomes (PROMs)

Answer 82

Allow comparison of the relative clinical quality of providers of elective procedures, for clinicians, managers, commissioners, regulators, clinical audits, patients and GPs.

Gives a better understanding of what works. The efficacy and cost-effectiveness of different technical approaches.

Assess referral thresholds. PROMs data used to establish whether referrals for elective procedures are appropriate.

Question 83

Which patient-reported outcomes (PROMs) are mandated in England and how are these performed?

Answer 83

Primary Unilateral Hip Replacement
Oxford Hip Score

Primary Unilateral Knee Replacement
Oxford Knee Score

Groin Hernia Repair
None

Varicose Vein Procedures
Aberdeen Varicose Vein Questionnaire

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.

Patients are subsequently 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.

Question 84

What are the different types of disease prevention?

Answer 84

Primary = Prevent
Secondary = Screen
Tertiary = Treat

Primordial prevention - Seeks to prevent the risk factors for disease. For example, a child seeing their parents smoke cigarettes may wrongly consider this a good lifestyle choice for later in life: advising parents to quit smoking in such circumstances can be considered primordial prevention.

Primary prevention - Prevention of disease through the control of exposure to risk factors. Strategies for primary prevention include population-wide strategies and targeted, high-risk strategies focusing on population sub-groups. For example, careful weight control prevents obesity which in itself is a risk factor for many conditions including heart disease and diabetes.

Secondary prevention - The application of available measures to detect early departures from health and to introduce appropriate treatment and interventions. Screening is a major component of secondary prevention for example, cervical screening for women to detect early changes which may go on to lead to cancer of the cervix.

Tertiary prevention - the application of measures to reduce or eliminate long-term impairments and disabilities, minimising suffering caused by existing departures from good health and to promote the patient’s adjustments to his/her condition. For example, a person identified as having type 2 diabetes will have regular blood glucose checks to monitor control of their diabetes and prevent complications of the disease.

Question 85

What are the two general approaches to prevention, and what are the pros and cons of each type?

Answer 85

There are two approaches to prevention - targeting a whole population whether they are exposed to risk factors or not, or tackling only those identified as being high risk.

Question 86

What is the prevention paradox?

Answer 86

Aka the Rose hypothesis (1992)

Since diseases are rare, most individuals who adopt a behaviour designed to lower their risk of disease will not benefit directly, although a few individuals may benefit enormously.

For example, any one person’s decision to lose weight may only have a small impact on that person’s risk of disease in the near future, but if many people each lose a little weight, this may have a substantial impact on the community’s obesity-related disorders.

Question 87

What are the advantages and disadvantages of targeting high-risk patients with prevention rather than population-level techniques?

Answer 87

Advantages:
May be more cost-effective than population-wide approaches
Those who are identified as being high risk may be more motivated to change their behaviour than the whole of society
Easier for health professionals to promote change on an individual basis
Individuals are usually aware of their exposure to adverse risk, whereas in society not everyone will have been exposed
Society prefers focusing on individuals to change rather than a whole population

Disadvantages:
Can be expensive to identify and treat those at increased risk
Fails to address public health problems arising from small but widespread risks that may be substantial
Ignores the point that a large number of people exposed to a small risk may generate more cases than a small number of people exposed to a large risk
Tends to medicalise prevention
Strategies for the individual tend to be either palliative or temporary
Does not focus on what influences behaviour
Does not tend to predict an individual’s change in risk
May have little overall impact on control of disease

Question 88

What are the advantages and disadvantages of population-level prevention rather than targeting high-risk patients?

Answer 88

Advantages:
Recognises that society influences individual behaviour
Risk reduction can be achieved at population rather than individual level
In situations where there is a dose-response relationship in terms of risk and exposure, shifting the entire population distribution towards lower levels of exposure is effective.

Disadvantages:
Is less effective in situations where there is not a dose-response relationship in terms of risk and exposure.

Question 89

Overall are population-level techniques or high-risk targeting better for disease prevention?

Answer 89

Both have their own positives and negatives. Whilst the high-risk approach seemingly has many more disadvantages compared to the population approach, the prevention paradox reduces the effectiveness of the population approach, therefore a combination of population and high-risk approaches is usually most effective.

Question 90

How are high-risk patients for prevention identified?

Answer 90

Screening
Genetic testing
Analytical studies linking risk factors and disease and ecological studies to identify groups

Question 91

What is a health impact assessment?

Answer 91

Health Impact Assessment (HIA) is a combination of procedures, methods and tools by which a policy, programme or plan may be judged as to its potential effects on the health of the population and the distribution of those effects within the population.

HIA is a decision-making tool and is designed to take account of the wide range of potential effects that a proposal may have on a target population. It considers relevant evidence, takes into account opinions, analyses the potential health impacts of the proposal to enable informed decision making.

Question 92

What are the different types of health impact assessment and which is the most useful?

Answer 92

Prospectively, concurrently or retrospectively.

Prospective HIA is usually the most useful as health impacts can be considered before commitments made.

Question 93

What are the uses of a health impact assessment?

Answer 93

The design and development of a policy or strategy
The commissioning of services
Resource allocation
Community participation and service user involvement
Community development and planning
Preparing funding bids

Question 94

What are the steps in a health impact assessment?

Answer 94

1) Screening: a selection process which assesses policies, programmes and projects for their potential to affect the health of the population. It offers a systematic way of deciding whether a HIA is worth doing. Considerations during screening include:
* Economic issues - size of the project and the population affected; and the costs of the project and their distribution
* Outcome issues - nature of potential health impacts of the project; likely nature and extent of disruption caused to communities by the project; existence of potentially cumulative impacts
* Epidemiological issues - degree of certainty (risk) of health impacts; likely frequency (incidence/prevalence) of potential health impacts; likely severity of potential health impacts; size of any probable health service impacts; likely consistency of “expert” and “community” perceptions of probability, frequency and severity of impacts.

2) Scoping: usually a steering group encompassing all the organisations involved will be formed and will set the boundaries for appraisal of health impacts. They will also agree the way in which the appraisal will be managed and allocate responsibility for decision-making.

3) Appraisal: this is the main part of the HIA and can be rapid, intermediate or comprehensive. To ensure that the views of local communities are heard a comprehensive HIA is the most effective. Appraisal includes analysing the policy, programme or project; profiling the affected population; identifying and characterising the potential health impacts, looking at the evidence base and making recommendations for the management of the impacts.

4) Presenting results: unless total consensus is reached, results should be presented as a range of options.

5) Decision-making: The ultimate result will be an agreed set of recommendations made by the steering group for modifying the project such that its health impacts are optimised.

6) Implementing, monitoring and evaluating: impacts of HIA processes are monitored to enhance the evidence base for future HIAs. Outcome evaluation is constrained by the fact that negative impacts which have been successfully avoided due to the modification of the project will not be clearly identifiable. Other beneficial outcomes include better partnership working.

Question 95

What is a quantitative risk assessment (QRA)?

Answer 95

A more formal, quantitative form of impact assessment is often referred to as quantitative risk assessment (QRA). By convention, this is described as having four stages:

Hazard identification
Based on review of scientific literature, including toxicological studies and epidemiology, as available.

Exposure-response assessment
Again based on toxicological and/ or epidemiological data, usually entailing extrapolation of exposure-response curve, and giving rise to uncertainties with respect to thresholds/ intercepts; shape of the exposure-response (extrapolation); and the relationship between risk, intensity and duration of exposure.

Exposure assessment
Direct measurement is often difficult or costly, so this is often based on indirect, semi-quantitative assessment using: type of exposure, duration, intensity etc. An exposure matrix may be produced that estimates exposure levels for various population groups defined by location, age etc.

Risk characterisation
This summarises patterns of risk based on information from Steps 2 and 3 above.
QRA draws on all the available evidence, requires little or no new measurement, and generates results which are statistically stable. But estimates are indirect (both with respect to exposure & health impacts), and typically many assumptions are necessary (e.g. extrapolations across dose ranges, sometimes from one species to another etc).

Question 96

What is an environmental impact assessment?

Answer 96

An (EIA) is an assessment of the possible impact of a programme or project on the natural environment. The assessment ensures that decision makers consider any possible environmental impacts prior to deciding whether to proceed with a project.

Environmental impact assessment enables environmental factors to be given due weight, along with economic or social factors. It helps to promote a sustainable pattern of physical development and land and property use in cities, towns and the countryside.

Question 97

What are the steps of an environmental impact assessment?

Answer 97

An environemtal impact assessment has the same steps as a health impact assessment.

Screening
Scoping
Appraisal
Presenting results
Decision-making
Implementing
Monitoring and evaluating

Question 98

When might an environemntal impact assessment be done?

Answer 98

Examples of EIAs include those undertaken in relation to proposals for building new dams, constructing new run ways or on a more local scale, a town by-pass.

Question 99

When and why are environemtla impact assessments mandatory?

Answer 99

European Union legislation on EIA of the effects of projects on the environment was introduced in 1985 and was amended in 1997, 2003 and in 2009.

For some types of project EIA is a mandatory part of the planning process whereas for other projects, EIAs are only required if the particular project in question is judged likely to give rise to significant environmental effects (screening stage of the process).