Transcript The role of the public in quality assurance for family

The role of the public in quality
assurance for family practice
Amanda Howe
MA MEd MD FRCGP
Professor of Primary Care
University of East Anglia, Norwich, U.K.
Norfolk – not far from Europe ...
NORWICH
- EAST OF
CAMBRIDGE
-Close to
BELGIUM
- MED SCHOOL
OPENED 2002
School of Medicine, Health Policy and Practice, University of EAST ANGLIA
Outline
• give an overview from current developments in U.K.
• show specific policy examples from service and
research evaluations
• share theoretical and practical frameworks for
evaluating approaches to public involvement
• examine ways in which public involvement can be
measured and evaluated for its effectiveness in
improving quality at practice level
Concepts and definitions (1)
• ‘Quality’
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Evaluation of a service or relationship
Involves making comparisons / judgements
People may value differently
‘Comes at a price’, e.g. offset against quantity
• Quality indicators – specific measurable
elements of practice that can be used to assess
quality
• Quality assurance – implies a ‘guarantee’ that the
public’s expectations will be met to a ‘good enough’
standard, and that improvements will occur
Concepts and definitions (2)
• ‘The public’
– Anyone who is not an expert, employee, or has
other involvement in the relevant service
– Those who choose to put their views
– Those sampled to represent others
• In health services context
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Not health professionals or managers
Those speaking on behalf of patients
Patients themselves (cf users, consumers, clients)
Those who have volunteered to play certain roles
Rationale for public involvement
“Engaging and listening to the public will
• provide responsive services in keeping with local needs
• encourage staff to look at service delivery from the patient
perspective
• improve accountability and openness
• encourage listening, learning and improving as key features of
the organisational culture
The key aims of the strategy must therefore be to:
• Enable patients and their carers to be fully informed about
treatment, condition and care
• Support patient choice and informed decision making
• Encourage a lay perspective in service planning
• Help health professionals to be more responsive to the needs
and preference of service users”.
Patient and Public Involvement Strategy, Norfolk University Teaching Hospital, 2004
Framework – ‘Arnstein’s ladder’
Empowerment: true power sharing, giving autonomy to the
previously dependent
Participation:
• direct - in which the people actively attempt to influence policy
making by direct interaction with the decision makers
• indirect - includes other mechanisms by which people take part
in the democratic process, e.g. voting, affiliating to political party
that best represents their views on health care delivery
Consumer Satisfaction: involve users in the process of evaluation
of the services they receive
Consultation:
• user opinions sought on issues related to their health services
Health Education:
• aims to change attitudes and behaviour as well as increasing
knowledge.
Information: aims to increase knowledge - flow mostly one way from
the health care provider to the health care user.
•Arnstein, S.R. (1969), 'A ladder of participation', Journal of the American Institute of Planners, 35, 216-224.
Methods of evaluation used
• Questionnaires and surveys
• Interviews / focus groups
Plus for research evaluation of impacts :• Meetings observation
• Numbers and profile of those recruited
• Time charts / resource use
• Evidence of impacts in the organisation / on services
• Evidence of new roles played by lay people
• * examples mostly at organisational level
School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH
Case 1: Primary Care Trusts
“PCTs are required, under section 11 of the Health and Social Care Act
2001, to make arrangements to involve and consult patients and the
public in: • Planning services
• Developing and considering proposals for changes in the way those
services are provided
• Decisions to be made that affect how those services operate
Strengthening accountability: involving patients and the public”, sets out:
• What the duty of Public and Patient Involvement (PPI) means for PCTs
• How to do a baseline assessment
• How to construct a patient and public involvement strategy
• How to integrate PPI into the planning process
• The importance of working in partnerships
• Managing the consultation process, eg with specific groups, hard to
reach groups, staff, and dealing with conflict
• The overall scheme of PPI systems in the New NHS”.
Evaluation of public involvement in Primary Care Groups in London
Will Anderson, Dominique Florin, Lesley Mountford and Steve Gillam, The King's Fund 2002
Early findings
NHS organisations are not designed to learn from public voices.
Public involvement work will achieve little if investment in
methods of involvement is not matched by attention to internal
mechanisms of learning and change.
Formal decision-making processes only take public views
seriously if there are strong advocates for those views within
them. However, organisations and their members and officers
are open to influence in many other informal ways, which
public voices should exploit.
Whatever the approach, change is only likely if public involvement
work connects in some way to existing organisational interests,
where change is already on the agenda.
School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH
Case 2 : the Expert Patient Programme
Aims:
Promote awareness and create an expectation that patient
expertise is a central component in the delivery of care to
people with chronic illness
Establish a programme for developing user-led self-management
courses
Integrate the EPP into existing NHS provision of health care
across UK, and provide organisational support
Promote health professionals’ knowledge and understanding
about the benefits for them as well as for patients of user-led
self-management programmes.
Work closely with the leading patient representative bodies and
main health professional bodies to provide consistency
Assessing the Process of Embedding EPP in the NHS (NCPCRD, 2004)
Early findings
“Finding sufficient participants to undertake the self-management
courses was problematic, and remains the biggest challenge
for the pilot phase”
“More than one day a week is devoted to dealing with EPP. An
assistant to the PCT lead deals with phone enquiries from
patients, explains the EPP course and maintains a database –
they currently have a waiting list of 30 patients, and they have
six voluntary tutors so are developing flexibility...”
“Lack of experience of dealing with patients – some respondents
are not used to dealing directly with participants and
discussing health and illness matters”
School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH
Other national examples
• National Patient Safety Agency – safety as one parameter of
quality (along with access, effectiveness, and satisfaction) anonymous reporting of lapses and adverse events
• Strong public input through scoping, panel membership, media
• SURESTART – community based early intervention into
deprived families
• Health promotion
• R&D user involvement ‘essential’ for most funders
n.b. PROBLEM – of national policy biasing objective evaluation
School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH
Evidence of outcomes
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A lot of activity but ...
Research into effectiveness of lay involvement
3 site case study
Allowing stakeholders to explore their own
definitions of measures of ‘effectiveness’
• Stakeholder interviews, focus groups, observation
• Including organisational leads, patients, and
community interface
• Results .....
School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH
Public involvement in quality assurance
of family practice
Practice level
Patient surveys e.g. GPAS
- achievement on seven subscales including access,
technical care,
communication, interpersonal care, trust,
knowledge of the patient,
and nursing care
- global sum score, comparison
across practices
Patient participation groups
Volunteers for support
Consultation level
CQI / PEI - operationalise
‘quality’ in terms of two
principal core values of
general practice, focussing
on ‘patient-centredness’
and ‘holism’.
OPTION – shared decision
making
Consultation analysis – e.g.
patient centredness
CARE – empathy
School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH
A practice checklist for public
involvement in quality
Does the team ....?
Does the practice ...?
Aim to develop a dialogue with
its population and patients
outside routine care
Audit consultations with
validated patient-led tools
Survey patients on a regular
basis to seek their views on
aspects of service
Encourage patient involvement
in service, education and
research
Seek to include the ‘hard to
reach’
Advertise opportunities for
patients to play new roles
Support patient groups running
their own contribution
Respond to feedback and
demonstrate change
Have an ethos of patient –
centredness and self
questioning
Engage with community health
initiatives
Delegate time for members to
contribute to PPI initiatives
School of Medicine, Health Policy and Practice, INSTITUTE OF HEALTH
The role of the public in quality
assurance for family practice
Amanda Howe
MA MEd MD FRCGP
Professor of Primary Care
University of East Anglia, Norwich, U.K.