Quality of Health Care in the UK and Saudi Arabia - Essay Example

Quality of diabetes health care in U.K. and Saudi Arabia; a comparative study Introduction Health care administration throughout the world is guided by the guidelines of the World Health Organisation (WHO). Hence it will be only appropriate to refer to what WHO has prescribed for quality of health care in any country. This paper will discuss the prevailing quality of health care in relation to Diabetes in the countries of U.K. and Saudi Arabia. U.K. being part of the European Union (EU) also has to balance the health care parameters of the WHO with EU though the latter may not prescribe to undermine WHO’s policy guidelines. The unique position of the E.U. is that it has to ensure that EU citizens obtain equal treatment in a host State. Thus while in case of U.K., one must both refer to the guidelines of WHO as well as E.U., Saudi Arabia needs to follow the guidelines of WHO only. In some countries health care for their respective citizens are regulated statutorily and some others it is only voluntary. Thus before going into the prevailing conditions in U.K. and Saudi Arabia, guidelines of the WHO and the E.U. must be examined. Standards of quality of general health care must be seen before going into the disease-specific health care quality standards. Definitions Some definitions relating to quality of health care need to be mentioned. They represent performance indicators or are used to describe performance measurement of health care industry. Rather than quality indicators, financial indicators have only played so far crucial role to describe performance. Financial indicators such as length of stay, average cost per discharge are no longer sufficient to understand quality of health care delivery of an organisation. In fact, Florence Nightingale set the tone for tracking healthcare outcomes. Later Earnest A. Codman, a surgeon from Boston, in early 1900s opined that physicians instead of just measuring what they did, should track results of their performance over a period. His thinking was ahead of his time and he called it the “end-result idea” saying that there should be some feedback system on what happened to the patients one year after receiving their treatment, though it was not welcomed by the profession and his colleagues at Massachusetts General Hospital criticised him for his outlandish idea.1 Donabedian In his two volume classic Explorations in Quality Assessment and Monitoring (1980,1982), Donabedian, another physician proposed three key issues in the health care delivery. They are Structures, Processes and Outcomes. Structures are the tools, resources and organisational components. Processes are activities that connect patients, physicians and staff. And outcomes are results. As his idea to capture the three dimensions of health care delivery, like Codman, was to ahead of the times, his contemporaries were not ready to embrace his model of measurement of health care quality by development of indicators representing structures, processes and outcomes.2 NLHI of JCAHO (1996) Later the three dimensions of Donabedian were expanded to nine dimensions by the JCAHO namely, Appropriateness, Availability, Continuity, Effectiveness, Efficacy, Efficacy, Efficiency, Respect and Caring, Safety and Time lines. 3 WHO WHO suggests the following definition incorporating quality and safety in health care. “A quality health service is one which organizes resources in the most effective way to meet the health needs of those most in need, for prevention and care, safety, without waste and within higher level requirements”4 This definition insisting on safe health care views quality in three dimensions of patient quality, professional quality and management quality. Patient quality, because it recognizes what patients want and experience. Professional quality as professionals need to understand what patients need and follow best practice. And management quality, in view of the need for efficiency and meeting regulatory requirements.5 IOM (2001) Institute of Medicine (IOM) in its report Crossing the Quality Chasm (2001) suggested improvement by giving six aims of Safety, Effectiveness, Patient-centeredness, Time Lines, Efficiency and Equity.6 World Health Organisation (WHO) WHO report of 2008 states that governments are accountable to their citizens for providing quality health care. It says, in several countries, quality of health care is suboptimal as the patients do not get timely and appropriate treatments due to poorly organised health care services. It documents large differences in health care standards between countries. However WHO does not advocate identical methods for all countries as conditions vary with countries and resources can be wasted on methods and approaches inappropriate for the country.7 The report adopting the definition under WHO above, advises several approaches to be chosen as may be found appropriate to improve quality given the local conditions. According to the report, safe health care is not a luxury for even low resources countries since these methods if effectively used can result in optimal use of resources. 8 The report points out while allocating more resources to health care, care should be had to ensure resources are not wasted for building more of the same facilities which can be dangerous and result in ineffective health care services. A strategy may require equipping specialists with resources, quality structures and training in methods to enhance quality of health care.9 Apart from the above common view of allocating more resources, the report states two other common views for improving quality in health care; They are large scale health reform and strengthening of management. The report cautions that large scale health care reform can divert time, attention and money from the local small scale improvement and dissipate energies of an otherwise sustained approach. Instead of blind large scale reorganisation and macro restructuring in the name of reforms, micro-reorganisation using specific quality methods may be necessary. The third view of strengthening management by training and recruiting professional and business managers is highly essential since without them, the large scale resources and reorganisation will not succeed.10 Specific quality and safety approaches advocated by the report under four categories are as follows. They are (1) Strengthening role of patients/consumers and citizens, (2) Regulating and assessment of health professionals and services, (3) Application of standards or guidelines locally and (4) Quality problem-solving teams. Strengthening of patients can be enhanced through regulations for consumer protection and patients’ rights besides providing for co-payments by patients to ensure their involvement. Regulation of health care services can be achieved by accreditation and licensing of service providers. The third category involves implementation standards and guidelines locally by setting up systems to supervise compliance. The fourth category of quality problem solving teams represents team work on specific problems such as a team in health centre monitoring prescription of antibiotics or improving medical records etc. 11 European Union (EU) It is necessary to have the EU’s guidelines in this regards as the U.K. is a member country of the E.U. and it is the prerogative of the EU to ensure that other EU State citizens are treated equally in U.K. besides ensuring the health care aspects of the U.K.’s own citizens. EU report of 2008 covers all the quality care definitions in the foregoing sections. It sates the following definitions on quality care in addition.12 Department of Health U.K. (1997) Quality of care is doing the right things to the right people at the right time and doing things right first time. 13 The EU report appreciates the definition of Donabedian as very relevant as quality of care depends upon the inputs available. It also recognises the definition of IOM which is the essence of over 100 definitions it reviewed keeping in view the presence or absence of 18 dimensions. 8 dimensions were considered and quality of care was ultimately defined as “ the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”14 The important dimensions are “effectiveness, efficiency, access, safety, equity, appropriateness, timeliness, acceptability, patient responsiveness/patient centredness, satisfaction, health improvement and continuity of care.”15 Delivery of Health care in U.K. in EU’s perspective Governmental actors The U.K. consists of four countries namely England, Scotland, Northern Ireland and Wales each having its own health systems. While there is an elected administration in the last three countries, there is none in England and it is the Government of U.K. that administers England. In U.K. Primary Care Trust that is responsible to purchase health care for residents of respective geographical locations co-terminous with local bodies. A provider trust is responsible for providing community health services. A Foundation Trust existing only in England is a health care provider having independent financial autonomy from the Department of Health. England is currently undergoing a rapid modernization process that any report becomes outdated by the time it printed. On the other hand, Scotland concentrates on incremental development. Similar is the case with Wales. In Northern Ireland, it was not clear at the time of release of EU report.16 The following aspects of quality of care only relates to England unless otherwise stated. Health care commission monitors quality of health care institutions by an updated assessment. It gives ratings to the institutions based on annual performance. The health care commission also inspects private and voluntary social care services which were earlier done by National Care Standards Commission. There is one National Patient Safety Agency (NPSA) which collects data on adverse incidents and “near miss” incidents. The NPSA is charged with the responsibility of ensuring safety in the hospital design, cleanliness in the hospitals, food safety in foods coming from NHS Estates, safe conduct of research etc. NPSA also deals with confidential enquiries relating to maternal, perinatal and post-operative deaths. The Medicines and Health Care Products Regulatory Agency (MHRA) is responsible for regulating pharmaceuticals, health care products and medical equipment. Its licensing arrangements are designed to evaluate quality, safety and efficacy of all new products. The above are the prerogatives of Governmental actors. Nongovernmental actors GMC which is the regulating body for medical profession for the entire NHS of the UK has been in operation since enactment of Medical Act 1858 mainly to safeguard patients against unlicensed and underperforming practitioners. While GMC is the apex body for medical education and training, Royal Colleges are left with the responsibility of providing specialist training and continuing professional development. They have significantly improved clinical standards and introduced clinical audit (earlier medical audit) since 1990s.17 While the above two Governmental and Non-Governmental are part of the structures of the definition of Donabedian, following are the processes part of it. Governmental In order to enhance organisational and clinical standards in primary care through what is called Quality and Outcomes Framework (QOF), practices are given payments only on the basis of achievement based on quality and outcome framework scoreboard. GP practices are assessed in four domains of clinical, organisational, patient experience and additional services. Clinical includes several diseases including diabetes. They are coronary heart disease, stroke or transient ischemic attacks, hypertension, diabetes, chronic obstructive airways disease, epilepsy, cancer, mental health, hyperthyroidism and asthma. Organisational standards are concerned with patients records maintenance, education and training, management of practice and medicines. Patient experience deals with obtaining of feedback through accredited questioners so as to improve upon deficiencies, usually through 10-minute appointments. There are additional services as part of the process such as cervical screening, child health surveillance, maternity and contraceptive services. The above quality and outcomes frame work has improved quality of care in general practices which were not there earlier. The process is criticised as being too mechanistic and giving more importance to easily measurable things rather than less tangible issues of patient communication etc rendering the whole process not being patient-specific or centred There are complaints that issues not being paid for, do not get attention. The Primary Care trust who is the purchaser also contracts with practices for delivery of services suitable for the local communities.18 Nongovernmental The nongovernmental part of the process includes EXPeRT19 , a project set up in 1998 with a view to exchange peer views within the EU. Shaw (2006) has categorised the peer-review systems in U.K. as those relating to organisation wide assessment such as hospital accreditation, those dealing with specialised functions such as accreditation and development of records and those dealing with specialities such as autism services accreditation.20 There are few more initiatives of the local individual clinicians aimed at developing quality of care such as maintenance of registers to monitor outcomes of patients subjected to special procedures, laboratory quality assurance programmes etc.21 EU’s assessment U.K. with special reference to England has witnessed emergence of an array of organisations entrusted with responsibility of maintenance of health care quality in addition to innumerable activities by the professional bodies and individual clinicians. However British Medical Association (BMA) has pointed out certain deficiencies still existing as detailed below. There is no claim of ownership of certain strategies by the health professional. In few cases, implementation is achieved by forcing of the staff by managers resulting in lowering of their morale. Clinical guidelines are not clear; “for example the shifting nature of evidence base”. Resources are inadequate for initiating pilot projects. There are shortages of workforce and beds especially in community care. However, the EU report is defensive in that these initiatives by the NHS made in 1998 have only undergone hardly a decade of implementation and that there is no indication to fear that rapid advancements in health care now afoot will diminish. In fact, Total Quality Management (TQM) has been achieved by the U.K. in a relatively short period. Yet there are critics who say that failure value its staff by the NHS is a continuing problem.22 Diabetes in U.K. U.K has 2.5 million people afflicted with Diabetes. 2 million of them have type 2 diabetes. In addition there is an estimated number of 500,000 undiagnosed patients with type 2 diabetes.23 By 2025, U.K. will have about four million people diagnosed with the disease.24 Already NHS is spending £ 9 million i.e ten percent of its budget on treatment of diabetes and its complications.25 Mortality in diabetes is much lower than in cancer or heart disease in spite of higher incidence and prevalence at the international level. It may be partially due to under reporting the cause of death highlighting only the secondary complications. In 2005, 26,300 excess deaths occurred (higher mortality rates than would expected in a non-diabetic population) among the population aged between 20 and 79 18years. In 2006, deaths due to diabetes were higher in males for Northern Ireland and females in Wales. Quality of care Blood pressure control measure has reduced the number of risk of deaths by 1/3rd as per a 2005 report.26 Control of serum cholesterol in diabetes patients below 5 mmol/l was achieved in 83.2 to 87.1 percent of patients across the U.K. countries.27 Blood Glucose (Glycemic) control aimed at reducing the risk of diabetic eye disease has reduced the risk by 25 percent and early kidney damage by one third.28 NICE guidelines for type 1 diabetes stipulate that HbA1c levels should be below 7.5 per cent. In all the four countries of the U.K., over 97 percent of diabetic patients have a record of testing for HbA1c. in the last 15 preceding months. 29 Retinal screening in 20 years for diabetic retinopathy caused by swelling of blood vessels in the retina which get blocked by leakage of fluid and haemorrhage, shows that nearly all type-1 diabetes patients and 60 percent of type 2 diabetes patients have been found to have some degree of retinopathy.30 Eye screening and treatment can achieve avoidance of severe visual loss in diabetic patients by less than a half.31 The report of Clark P.M. et al32 , apart from giving Quality and Outcomes Framework (QOF) indicators for diabetes as seen above, has given a positive picture of quality health care overall. In terms of effectiveness, over all mortality has significantly fallen in recent years in all the four countries of the U.K., England has registered the longest life expectancy rates both in males and females. Scotland has been having highest mortality rates and QOF data indicate that patients in all the four countries of the U.K. are receiving care consistent with evidence-based practice. And Scotland and Northern Ireland have achieved highest scores. In terms of capacity, from the historically low health spending, countries of the U.K. have shown increased spending in recent years. While Scotland has a per capita spending of £ 1,919, England has it at £1,676. In terms of safety, relative data is limited, though all the countries of the U.K. are experiencing health care problems due to MRSA and Clostridium difficile infections. In terms of patient centredness, patient ratings are high across U.K. with Scotland scoring the highest both based on the data for 2005 and 2006. However one fifth of the patients across the U.K. have not shown involvement in their decision making about their care. There is some scope for improving communication between clinicians and patients. In terms of equity, inequalities in life expectancy and mortality are found between the least and the most deprived populations. At the International perspective, patients of the U.K. have not hesitated in seeking medicare owing to cost of treatment problems. There is no evidence available to show existence of inequities in care based on age, gender and race.33 Saudi Arabia In accordance with WHO’s 1978 declaration, Saudi Arabia chose primary health care as the means to achieve health for all by 2000. Today the country has 1,787 primary health care centres each catering to an average 8,727 people. Just as in other countries including the U.K., Saudi Arabia has lot of challenges of growing demand for health care, increasing costs and public demand for better services. Quality of health care being a multidimensional concept, it is a combination of access, effectiveness generally. While access refers to the ability of individuals to access health care and the processes of care they require, effectiveness has two elements of clinical care and interpersonal care. Saudi Arabia established in 1993 guidelines for quality assurance. Since even after 10 years of establishment of the quality assurance, there was no data available on the quality of primary health care, study was undertaken in 2005 by Al-Ahmadi and Roland 34 through an extensive literature review on quality of primary care in Saudi Arabia in order to identify barriers to achievement of quality in primary care organisations.35 Study results showed there was a good access to health care in general. This could have been due to implementation appointment systems, registers and follow up systems. 36 Patient satisfaction indicated they were overall dissatisfied due to difficult access, waiting time, waiting place conditions and physical environment of the health care facilities.37 Although sixty percent of the patients informed that primary care facilities were their first choice for treatment of acute illness, 40 of the patients expressed dissatisfaction over opening hours, absence of speciality clinics and delays in getting care.38 As most of the professionals were non-Saudis and could not speak Arabic, 40 of the patients reported communication problems.39 As the study on primary care included Diabetes also, the general indicators should be applied to Diabetes also. As for effectiveness, some programmes have proved to be effective though not specifically for diabetes. It has been found effective in maternal health care and vaccination and endemic diseases. For example tuberculosis reduced from 97 to 54 between 1984 and 1989 and measles from 502 to 84.40 In respect of less effectiveness in chronic disease management, reasons cited are lack of professional skills and misdiagnosis and mismanagement of diseases such as diabetes 41 and others. In respect of Diabetic retinopathy, only 40 -68% percent of patients were referred to eye clinics due to poor diagnostic and referral practices despite high incidence of diabetic retinopathy.42 The study also says that only 80 percent on diabetes there was inadequate supply of diabetic drugs available. 43 Only 10 to 86 percent of the drugs and lab items were always available. 35 percent of the centers only had coordination with hospitals for diabetic care. While 74 per cent of the centres had mini clinic for diabetes, 90 percent had appointment systems in place for diabetes consultations. 8 percent alone had health educators. 43 percent had nurses trained to provide health education. Almost 90 percent had diabetic files, registers, follow up systems and protocols for diagnosis and treatment. It also revealed that only 20 percent of the doctors took training in diabetes. 44 Conclusion The above data relating to the U.K. and Saudi Arabia show that while U.K. as a developed country as having achieved high levels in health care in diabetes as in any other diseases, Saudi Arabia as a developing country does not compare well with U.K. its health care having been characterised by various barriers such as shortage of drugs and professionals, not unique Diabetes alone, needs to improve over a period of time. Though it has set in motion ambitious programmes, there can be no attribution to lack of will on the part of its rulers especially as a wealthy country. The inadequacies can only be attributed to the developing phase of the country, thanks to the WHO‘s health for all by 2000 which has stimulated growth of health care to the present levels. It is imperative on the part of the WHO to create another bench mark especially for developing countries. Read More