From black bag to black box: will computers improve the NHS?
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Computer Systems↗
Biomedical subjects
L J Donaldson
Publications and source records attributed to L J Donaldson.
Cost effectiveness of a single-function treatment center for cataract surgery.
PURPOSE: To compare the clinical and cost effectiveness of two models for cataract treatment: a single-function Cataract Treatment Centre (CTC) and a general ophthalmology service. SETTING: Cataract Treatment Centre and the general ophthalmology service at Sunderland Eye Infirmary, Sunderland, United Kingdom. METHODS: Two hundred patients were studied using two models of care: 100 in the CTC and 100 in the general ophthalmology service. Outcome measures were best corrected visual at 3 months postoperatively or at discharge and occurrence of surgery-related complications. All direct costs to the National Health Service were identified, measure, and assessed. RESULTS: Clinical outcomes in the two groups were similar. The average cost per patient was 496.90 pounds ($760.25) at the CTC and 566.34 pounds ($866.50) at the general ophthalmology service. The cost per patient treated as a day case in the general service group was 495.84 pounds ($758.63). Thus, treatment at the CTC was more cost effective than in the mixed service group and as cost effective as in the day case subgroup. CONCLUSIONS: Depending on local circumstances, day care must be delivered more cost effectively in a single-function center than in a general ophthalmology service. We recommend day care using local anesthesia and protocols for assessment, surgery, and follow-up.
Anesthesia↗
Outcome of criminal investigation into allegations of sexual abuse.
The aim was to study the outcome of criminal investigation into allegations of sexual abuse made by 160 children assessed over a two year period in a specialist paediatric unit in the North of England. In all, 141 of the 160 children (88%) were female, and 99 (62%) were aged under 12 years. There were 145 males and nine females named by children in allegations of sexual abuse. Fathers formed the largest single group of alleged male perpetrators (56/176). None of the nine alleged female abusers was prosecuted. Of the 145 males, 57 reached trial; 49 were convicted, an 86% conviction rate of those sent to trial and a rate of proven sexual offence (including cautions) of 44% (54/124) among men originally interviewed by the police. Twenty five per cent of children (17/68) who could have testified did so, most giving evidence against someone who was known to them. Pragmatic selection of cases for prosecution resulted in an outcome highly vindicating of the decision to prosecute. The possible effects of this process are discussed.
Adolescent↗
Cancer mortality among local authority pest control officers in England and Wales.
OBJECTIVE: To examine cancer mortality by tumour site among local authority pest control officers. METHODS: Prospective mortality study, and follow up to the end of 1994, of 1485 male pest control officers aged between 17 and 69 and employed in 296 local authorities in England and Wales for at least six months between January 1980 and April 1984. Observed numbers of deaths were compared with those expected on the basis of the rates for relevant calendar year, cause, sex, and age specific groups for England and Wales. RESULTS: 200 deaths occurred during the follow up period of which 65 were certified as due to malignant neoplasms. No tumour type showed significantly more deaths than expected. Total all cause, lung cancer, and respiratory disease mortality were significantly lower than expected. CONCLUSIONS: 15 year follow up of a group of men handling a wide range of pesticides did not show any significant risk of cancer. This may be partially explained by the healthy worker effect and also the limited power of the study to detect significant increases in the less common tumours. Further long term follow up of this cohort will continue. Chemical control of pests that can cause human disease and can contaminate food and water has been, and will continue to be, a major public health measure. It is important to ensure that the health of those applying pesticides is not at excess risk. Negative results are important.
Adolescent↗
Improving the quality of health care through contracting: a study of health authority practice.
OBJECTIVES: To investigate approaches of district health authorities to quality in contracting. DESIGN: Descriptive survey. SETTING: All district health authorities in one health region of England in a National Health Service accounting year. MATERIAL: 129 quality specifications used in contracting for services in six specialties (eight general quality specifications and 121 service specific quality specifications) MAIN MEASURES: Evaluation of the use of quality specifications; their scope and content in relation to established criteria of healthcare quality. RESULTS: Most district health authorities developed quality specifications which would be applicable to their local hospital. When purchasing care outside their boundaries they adopted the quality specifications developed by other health authorities. The service specific quality specifications were more limited in scope than the general quality specifications. The quality of clinical care was referred to in 75% of general and 43% of service specific quality specifications. Both types of specification considered quality issues in superficial and broad terms only. Established features of quality improvement were rarely included. Prerequisites to ensure provider accountability and satisfactory delivery of service specifications were not routinely included in contracts. CONCLUSION: Quality specifications within service contracts are commonly used by health authorities. This study shows that their use of this approach to quality improvement is inconsistent and unlikely to achieve desired quality goals. Continued reliance on the current approach is holding back a more fundamental debate on how to create effective management of quality improvement through the interaction between purchasers and providers of health care.
Contract Services↗
Nomenclature of health care organisations: the extent of public understanding.
Health care systems in many parts of the world are undergoing organisational change. In Britain, the establishment of new organisations following the National health Service (NHS) reforms of 1990 has led to a change and a greater diversity in the nomenclature of health bodies. An important but often overlooked consequence of such change is the extent to which the public, as consumers of services, can recognise health organisations by their names. We investigated this in a study in the North east of England in early 1994. Eleven hundred respondents were asked to identify their local health authority, acute hospital and community health service provider. Mean scores for correct identification were: health authorities (or consortia of health authorities) 32%; acute hospitals 36%; community units 19%. Worst performing organisations scored very high 'don't know' responses: worst performing health authority 52%; acute hospitals 59%; community unit 48%. This survey demonstrates that the names chosen for themselves by health care organisations can convey little meaning to the public. This is an area which needs attention if health care systems are to create a culture in which they regard their patients as informed consumers.
Attitude to Health↗
The reporting of in-patient suicides: identifying the problem.
Fifty in-patient suicides occurring in an English health region over the five-year period 1987-91 were identified from two data sources: the Regional Health Authority's records of untoward incident reports and coroners' records. An analysis of the quality of incident investigations conducted locally was carried out. The people who committed suicide were more often men, with a similar sex distribution in the study population to suicides in the community. Male in-patient suicides (mean age, 40 years) were younger than females (mean age 58 years). There was a high incidence of violent methods and around a third of the deaths occurred in the week after admission. More than half the deaths had occurred outside hospital. The health service's untoward incident reporting system seriously under-enumerated cases of in-patient suicide. Even when notifications were made, they appeared to be of variable quality and few demonstrated a comprehensive investigation and action plan.
Adult↗
The doctor's dilemma.
The close relationship between expenditure on health care and the countless individual judgements made by doctors for their patients means that any discussion about rationing must involve the process of clinical decision-making. Increasingly, doctors are being drawn into rationing by two powerful forces. Firstly, through the corporate responsibilities of those working within a managed health care system in which organisational objectives and budgetary constraints are agreed and specified in a much more explicit way than ever before. Secondly, by the professionally-led movement towards more clinically effective practice. These, in combination, are leading towards a fundamental review of the nature and ethical basis of clinical practice in which the duty of doctors to individual patients must be balanced against the wider considerations.
Cost-Benefit Analysis↗
Limb reduction defects in the northern region of England 1985-92.
STUDY OBJECTIVE: To test the hypothesis that children born to mothers living near the sea are at increased risk of limb reduction defects. DESIGN: Descriptive data analysis. SETTING: The northern health region of England. PATIENTS: All children born between 1 January 1985 and 31 December 1992 in the northern region of England with isolated limb reduction defects. MAIN RESULTS: The birth prevalence of isolated limb reduction defects was not affected by the distance the mother lived from the sea. There was some evidence of space-time clustering, but there was no evidence of statistically significant variation in the occurrence of the condition with sex, time of birth (monthly or yearly), or county of birth. CONCLUSIONS: There is no evidence that children born to mothers living near the sea are at increased risk of limb reduction defects.
Cluster Analysis↗
Press coverage of the Cleveland child sexual abuse enquiry: a source of public enlightenment?
BACKGROUND: The objective of this study was to assess national and local newspaper reporting of events considered by a Public Enquiry which investigated a major crisis involving child protection services. The Judicial Enquiry, held in Cleveland, North East England, examined the actions of statutory bodies and the professionals working within them following the diagnosis of suspected sexual abuse in 121 children. METHODS: This is a descriptive study using analysis of legal transcripts and newspaper reports. The data involved a total of 216,360 lines of transcript evidence given by 111 witnesses and lawyers representing them at the Judicial Enquiry which lasted 74 days; together with 344,899 words in reports covering 17 newspapers (seven local and ten national). The main outcome measures were based on the volume and type of newspaper coverage including that for each witness' and lawyer's evidence. A coverage index related the amount of newspaper reporting to the extent of evidence given. RESULTS: The highest coverage of any single day of the Enquiry in both local and national newspapers occurred when Dr Marietta Higgs (one of the two principal paediatricians involved) made her first appearance. However, the highest interest (coverage index) was shown in evidence given by lawyers for the parents and the least in evidence given by public bodies. The evidence of witnesses was used very selectively by the press in emotive headlines to imply blame or support for the main protagonists or their actions. This sustained several lines of reporting: criticism of the doctors and social workers, inter-professional conflicts, damage and wrong-doing to the families and the search for someone to blame. CONCLUSIONS: The Cleveland crisis occupied newspaper headlines in the United Kingdom for more than a year. Much of the newspaper coverage took an adversarial approach which sought to apportion blame and take sides. The press appeared to report negative issues which were newsworthy and did not give a balanced view. Broader policy issues, which formed an important part of the Enquiry report's influence on subsequent child protection legislation, were largely ignored.
Child↗
Is it possible to catch leukaemia from a cat?
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Animals↗
Doctors with problems in an NHS workforce.
OBJECTIVES: To describe the incidence, nature, and implications of serious disciplinary problems among the medical staff of a large NHS hospital workforce. DESIGN: Descriptive study with analysis of case records. SETTING: Northern Health Region, an administrative area within the NHS covering a population of three million. SUBJECTS: Forty nine hospital doctors: 46 consultants and three associate specialists. MAIN OUTCOME MEASURES: The nature of the problems encountered within the doctors' practice, and the types of action taken by the employing authority. RESULTS: Over a five year period concerns serious enough to warrant the consideration of disciplinary action were raised about 6% of all senior medical staff (49/850). Ninety six types of problem were encountered, and were categorised as poor attitude and disruptive or irresponsible behaviour (32), lack of commitment to duties (21), poor skills and inadequate knowledge (19), dishonesty (11), sexual matters (seven), disorganised practice and poor communication with colleagues (five), and other problems (one). Twenty five of the 49 doctors retired or left the employer's service, whereas 21 remained in employment after counselling or under supervision. CONCLUSIONS: Existing procedures for hospital doctors within the NHS are inadequate to deal with serious problems. Dealing with such problems requires experience, objectivity, and a willingness to tolerate unpleasantness and criticism. Because most consultants' contracts are now held by NHS trust hospitals, however, those who had developed skill over the years in handling these complex issues are now no longer involved.
Adult↗
Lanterns in the jungle: is the NHS driven by the wrong kind of efficiency?
The performance of the National Health Service is assessed in part by an Efficiency Index (EI) which is applied to the service as a whole as well as to individual health authorities. The EI relates increases in the amount of patient care activity to increases in total expenditure. The index can give a misleading impression of performance, creates perverse incentives and is at odds with the overall strategy of the health service which is to place greater emphasis on the promotion of health and to provide more care in primary and community-based settings. The philosophy, validity and appropriateness of the EI are discussed.
Community Health Services↗
Is health care a commodity: how will purchasing improve the National Health Service?
Through the reforms to the National Health Service in 1990 an internal market for public health care provision in the United Kingdom was introduced. As part of this new system of care, responsibility for purchasing of health care was separated from that for its provision. The new purchasing function, undertaken by district health authorities and fundholding general practices, has created the opportunity for improvements in health and higher standards of care to be achieved through new and explicit mechanisms. However, the purchasing function has not yet realized its full potential to achieve beneficial change, partly because traditional behaviours have not yet adapted to the new system of care and partly because specific aspects of the internal market are creating barriers and perverse incentives. This paper discusses these issues and identifies the important barriers which have still to be overcome if purchasing is to be the driving force for change in the new National Health Service.
Contract Services↗
Maintaining excellence: the preservation and development of specialised services.
The advent of the Tomlinson inquiry draws attention to the need to strike a balance between market led and planned approaches to health care delivery. This is important not just for hospital rationalisation but also for the preservation and development of services which are provided in a smaller number of hospitals. Specialised services are often in the forefront of raising standards of care and introducing new developments and innovations. They are the only option for a small number of patients with serious illnesses. In the internal market for health care provision created by the 1990 NHS reforms more sophisticated and flexible mechanisms must be found to provide stability for specialised services while at the same time enabling the benefits of purchaser choice and provider competition to be realised.
Delivery of Health Care↗
Eight years' experience of clinical activity in an outpatient fracture clinic.
Major changes to the method of planning and provision of health care in Britain have led to the introduction of contracts as the main means through which services are procured. Never before has the need for accurate and comprehensive clinical information been greater. Yet comprehensive outpatient information, though planned, is not yet available, and there is relatively little experience of such systems which have been introduced in individual localities. Fracture clinic patients are an important group of outpatient, not least because interventions are often undertaken as an integral part of the outpatient episode. This is relevant for estimating resource use and for pricing, but until now has been 'hidden' work as far as conventional information systems are concerned. This study describes the establishment and manifestation of a clinical information system based on a fracture clinic serving the majority of a population of 850,000. Information was gathered over 8 years on 61,635 patients, who had 72,984 diagnoses and received 93,878 treatments. An information system of the type described in this study can be of great value as part of the contracting process (for both purchasers and providers of orthopaedic services), as a basis for clinical audit and research, and to facilitate undergraduate and postgraduate teaching.
Adolescent↗
Clinical complaints and their handling: a time for change?
OBJECTIVES: To assess the performance of the hospital complaints procedure for complaints proceeding to peer review and the quality of responses to complainants. DESIGN: Retrospective study of data on clinical complaints proceeding to peer review during 1986-91 from clinical records, correspondence, reports of the complaints investigations, and expert review of written responses to complainants. SETTING: Northern Regional Health Authority, covering three million people. SUBJECTS: All 71 clinical complaints investigated to the third stage of the hospital complaints procedure and a sample of 65 written responses to complainants. MAIN MEASURES: Characteristics, duration, and outcome of complaints; findings of peer review; and quality of written responses at various stages in the procedure as evaluated by an expert panel against eight agreed criteria. RESULTS: The median duration of a complaint investigated through all stages of the procedure was 381 days. The longest median stages were those involving attempted resolution locally (131 days) and in which peer review was being arranged (113 days). More complaints alleging failure of communication were upheld by peer review (46/59, 78%) than those alleging misapplication of clinical skills (20/98, 20%) or failure to initiate appropriate investigations or treatment (8/32, 25%). Written responses commonly fell below the standards agreed by the expert panel. CONCLUSIONS: The hospital complaints procedure takes too long and its final peer review stage may not demonstrate sufficient impartiality. The written responses suggest that criticism is not welcomed as a way of improving service. IMPLICATION: The clinical complaints procedure needs to be reformed to ensure true accountability to patients.
Data Collection↗