Use of economic evidence in the design of Health Improvement Programmes (HImPs)

Introduction 1. In recent years considerable efforts have been made to increase the evidence base for decision making within the NHS. Under the NHS R&D Programme a sizeable percentage of NHS resources have been spent on research, one of the largest programmes of research being in the field of health technology assessment. 2. However, whilst the generation of more research evidence is important, mechanisms still need to be developed to increase its use in NHS decision making. The NHS White Paper of 1997 (paragraph 7.5) pointed out that “there are unjustifiable variations in the application of evidence on clinical and cost-effectiveness”. 3. The concept of the Health Improvement Programme (HImP) was first introduced in “The New NHS. Modern: Dependable” (NHS Executive, 1997). This white paper gave the lead responsibility to health authorities to provide a framework for health and social care provision through multi-agency partnership and in collaboration with the public. One of the main aims of the HImP is to produce action plans based on evidence to address local and national priorities. HImPs cover a three year long cycle and are revised annually. The second phase HImPs ran from April 2000 to April 2003 and these are the focus of this project. 4. To date, a small number of reviews of HImPs have been conducted (Abbott et al, 2000, Arora et at 1999 & 2000, Carruthers et al, 1999) but there has been limited exploration of the role of evidence in relation to the HImP, and no specific effort has been made to examine whether the HImP has proved to be a useful vehicle in arranging provision of care to improve the health of the population, given resource constraints. This report explores the evidence base of these second phase HImPs with particular reference to the contribution of economic evidence. Methods 5. In order to examine the use of evidence in the design of HImPs, a threestage project was undertaken. First, a survey of all English health authorities was conducted to elicit HImP leaders’ views on the use of evidence in the design of their own HImP. Second, 10 individuals involved in the HImP and who worked for different health authorities were interviewed to explore their views on the HImP, the role of evidence and the impact of the HImP. Third, a random sample of 25% of all 2000-2003 HImP documents from the health authorities in England were reviewed in order to investigate whether the health care priorities chosen reflect government objectives and whether there was any evidence of the use of economic evidence in the production of the HImP documents. Findings 6. The main findings were that, first, HImPs are seen as having multiple objectives. Whereas the improvement of health is viewed as the prime objective, other important objectives are to reduce health inequalities and to develop partnerships. 7. Second, the notion of evidence is interpreted broadly. Namely, data drawn from classical research studies and published in the literature, do not encompass the range of inputs to the design of a HImP. Many of the inputs relate to national guidance and local professional opinion, which in turn might be based on data from research studies. 8. Third, basic concepts of economics are well understood, if not always applied. This is partly because the level of access to economic analyses and economics expertise was low. Even where economic studies did exist, it was not clear how they could be interpreted and used. 9. Fourth, local constraints greatly influence the development of HImPs. These constraints include time limitations, lack of certain expertise and the need for political acceptability. These often restricted the extent of the search for, interpretation and use of economic evidence. 10. Finally, most importantly, national guidance from National Service Frameworks (NSFs) and the National Institute for Clinical Excellence (NICE) s very influential in the design of HImPs. Given the constraints at the local level, national guidance was assumed to have a sound evidence base and was usually followed, although sometimes adapted in the light of local circumstances. Therefore, the use of national guidance may be the best route to improving the evidence base of HImPs. Research and policy implications 11. The results of this research lend considerable support to a number of research and policy implications, many of which are already underway. The ain implications are: (i) the evidence base of national guidance should be maintained, if not strengthened; (ii) efforts should continue to generate, synthesise and disseminate evidence on a national level; (iii) quantifiable targets (for health improvement) and the role for evidence in priority setting need to be stressed; (iv) the local role in assembling evidence needs to be clearly defined and adequately resourced; (v) efforts to educate health care professionals in evidence-based medicine and economics should be maintained, or strengthened; (vi) more research should be undertaken into the cost-effectiveness of broader socio-economic interventions to improve health. 12. Finally, the research and policy implications of this study also need to be reviewed in the light of the recently announced organisational changes in the NHS, especially the creation of strategic health authorities and the developing role of PCGs/Ts. In particular, it will be important to ensure that PCGs/Ts have the resources and expertise to gather, synthesise and interpret evidence, including economic evidence. Introduction In recent years considerable efforts have been made to increase the evidence base for decision making within the NHS. Under the NHS R&D Programme a sizeable percentage of NHS resources have been spent on research, one of the largest programmes of research being in the field of health technology assessment. In addition, institutions such as the NHS Centre for Reviews and Dissemination, the Cochrane Collaboration and the National Coordinating Centre for Health Technology Assessment have greatly contributed to the communication of research findings to the NHS. The NHS white paper of 1997 (para 7.5) pointed out that “there are unjustifiable variations in the application of evidence on clinical and cost-effectiveness” (NHS Executive, 1997). This view is echoed by several surveys of NHS decision-makers (Crump et al, 2000, Drummond et al, 1997; Duthie et al, 1999) which showed a generally low uptake of available economic evidence and dentified a number of barriers to its use. At the national level, the advent of the National Institute of Clinical Excellence (NICE) (DH, 1999) provides a vehicle by which clinical and cost-effectiveness evidence can be used in decisions about the use of health care interventions, either through technology appraisal or clinical guidelines development. However, at the local level, within the NHS, it is less clear how appropriate evidence (in particular economic evidence) can be brought to bear on NHS decisions. Under the existing structure, many of the decisions about the use of health care interventions will increasingly be taken by Primary Care Groups (PCGs) and rimary Care Trusts (PCTs). However, most of these will be too small to have a capacity to collect, assimilate and apply evidence. The health authorities’ main mechanism for coordinating health care provision, in partnership with PCGs/PCTs, NHS Trusts and other agencies is the Health Improvement Programme (HImP). Therefore, the objective of the research was to study HImPs in order to investigate the extent to which evidence, in particular economic evidence, had been used in their development.