Title: The role of the public in quality assurance for family practice
1The 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.
2Norfolk 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
3Outline
- 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
4Concepts 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
5Concepts 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
6Rationale 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
7Framework 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.
8Methods 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
9Case 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
10Early 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
11Case 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)
12Early 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
13Other 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
14Evidence 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
15Public 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
16A 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
17The 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.