Health Quality Indicators, Value of Health: Accounting for Quality Change Aileen Simkins, Department of Health Co-Direct

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

2. 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

3. ONS Health Productivity Oct 2004

4. 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”

5. 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?

6. 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

7. Accounting for Quality Change Average over last 5 years: • Value of health 1.5% • Value weight for statins 0.81% • York/NIESR adjustment 0.17% • Patient experience* 0.07% • Blood pressure control * 0.05% • Heart attack survival 0.01% Total ** 2.68% Quality adjusted output growth 6.29%

8. ONS Health Productivity 2006

9. 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)

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

11. 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

12. 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

13. Hypertension: blood pressure control

14. Key results Jan 2002 – Oct 2004 CHD Blood pressure control Jan 02 60.4% Blood pressure control Oct 04 78.3% Annual rate of increase 10.4% Hypertension Blood pressure control Oct 01 44.6% Blood pressure control July 04 63.0% Annual rate of increase 22.4%

15. 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

16. 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

17. Patient Experience Data

18. 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’

19. 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

20. 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

21. 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