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The role of the public in quality assurance for family practice

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Title: The role of the public in quality assurance for family practice


1
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.


2
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
3
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

4
Concepts and definitions (1)
  • Quality
  • 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 publics expectations will be met to a good
    enough standard, and that improvements will
    occur

5
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
  • 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

6
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
7
Framework Arnsteins 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.

8
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
9
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
10
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
11
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)
12
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
13
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
  • RD 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
14
Evidence of outcomes
  • 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
15
Public involvement in quality assurance of
family practice
  • Practice level
  • Patient surveys e.g. GPAS
  • - achievement on seven sub-scales including
    access, technical care, communication,
    inter-personal 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
16
A practice checklist for public involvement in
quality
  • Does the team ....?
  • 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
  • Does the practice ...?
  • 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
17
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.
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