National Audit Office Research Articles

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Contributors

The National Audit Office Uses OR to Assess the Value for Money of Public Services

Supreme audit institutions (SAIs) have an important role in assessing value for money in the delivery of public services. Assessing value for money necessarily involves assessing counterfactuals: good value for money has been achieved if a policy could not reasonably have been delivered more efficiently, effectively, or economically. Operations research modelling has the potential to help in the assessment of these counterfactuals. However, is such modelling too arcane, complex, and technically burdensome for organisations that, like SAIs, operate in a time- and resource-constrained and politically charged environment? We report on three applications of modelling at the UK's SAI, the National Audit Office, in the context of studies on demand management in tax collection, end-of-life care, and health-care associated infections. In all cases, the models have featured in the audit reports and helped study teams come to a value-for-money judgment. We conclude that OR modelling is indeed a valuable addition to the value-for-money auditor's methodological tool box.

Improving the care of dying patients in hospitals

British Journal of Hospital MedicineVol. 72, No. 8 EditorialsImproving the care of dying patients in hospitalsJohn Ellershaw, Anita HayesJohn EllershawSearch for more papers by this author, Anita HayesSearch for more papers by this authorJohn Ellershaw; Anita HayesPublished Online:16 Aug 2013https://doi.org/10.12968/hmed.2011.72.8.426AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Care Quality Commission (2010) Guidance about Compliance: Essential standards of quality and safety. Care Quality Commission Google Scholar Department of Health (2008) End of Life Care Strategy – promoting high quality for all adults at the end of life. Department of Health, London Google Scholar Ellershaw J, Wilkinson S (2011) Care of the dying: a pathway to excellence. 2nd edn. Oxford University Press, Oxford Google Scholar General Medical Council (2010) Treatment and Care Towards the End of Life: Good Practice in Decision Making. General Medical Council, London Google Scholar Modernisation Initiative End of Life Care Programme (2009) AMBER (Assessment, Management, Best Practice, Engagement for patients whose Recovery is uncertain). www.gsttcharity.org.uk/projects/eolc.html (accessed 25 July 2011) Google Scholar National Audit Office (2008) End of Life Care Report 2008. The Stationery Office, London National Confidential Enquiry into Patient Google Scholar Outcome and Death (2009) Caring to the End? A review of the care of patients who died in hospital within four days of admission. National Confidential Enquiry into Patient Outcome and Death, London Google Scholar National End of Life Care Programme (2010) The Route to Success in end of life care – achieving quality in acute hospitals. National End of Life Care Programme, Leicester Google Scholar National Institute for Clinical Excellence (2004) Guidance on Cancer Services - Improving Supportive and Palliative Care for Adults with Cancer. The Manual. National Institute for Clinical Excellence, London. Google Scholar FiguresReferencesRelatedDetails 1 August 2011Volume 72Issue 8ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 16 August 2013 Published in print 1 August 2011 Information© MA Healthcare LimitedPDF download

Rheumatoid arthritis: bringing care closer to home

The move to offer more treatment in primary care started before the current round of NHS reforms and is generally well supported With the advent of GP and clinician led commissioning, and the move to shift the care of people with long term conditions out of the hospital setting, the focus on care in the community has never been stronger. Recent publications from organizations such as the King’s Fund (2011) argue for greater integration between primary and secondary care, improved medication management and self management. However, for some conditions the move has been slower and developing good community care requires funding and the parallel de-commissioning of hospital based services, something that patients themselves at times resist. Rheumatoid Arthritis is one example of this. It is a complex disease which is primarily currently treated in secondary care by a consultant led, specialist multi-disciplinary team, which also includes the GP and other primary care professionals as well as, of course, the patient themselves. Major government funding and training has enabled conditions such as asthma, diabetes and cardiovascular assessment and prevention strategies to be successfully delivered in primary care in recent years. Alongside this has been significant improvement in patient education and self management particularly in diabetes. No such funding or training has been allocated to the treatment of inflammatory arthritis (IA) and the majority of GPs lack the experience and skills necessary to safely diagnose or follow up patients with Inflammatory Arthritis. Treatment of IA has changed in a revolutionary way since the introduction of biological therapies over 10 years ago and such drugs can only be prescribed by a consultant rheumatologist, with the result that GPs are often unaware of the advances in treatment regimens for people with Rheumatoid Arthritis. The need for rapid referral for anyone with suspected inflammatory arthritis to a consultant rheumatologist to obtain a diagnosis at the earliest opportunity in order to maximize long term outcomes is paramount but delays persist. Whilst the issue of GP education was flagged in 2009 in the National Audit Office Report into Rheumatoid Arthritis services, it will take time for the Royal Colleges to address changes in the training of health professionals. However, there are aspects of the care of people with RA which are well placed to sit within primary care, such as cardiovascular risk assessment and advice. CV disease is increased in people with RA and similar to the risk in people with Type II Diabetes. The benefit of effective patient education and self management is also something which is well understood by GPs. The National Rheumatoid Arthritis Society has developed a self management programme for Rheumatoid Arthritis that is delivered by allied health professionals in rheumatology and people living with Rheumatoid Arthritis. Results of the pilot are encouraging and indicate positive changes in health-related behavior and an increase in the skills needed to manage the condition which in turn may help reduce the risk of developing cardio vascular disease especially where there are lifestyle issues present. Disease specific programmes such as the RA Self Management Programme could be commissioned and prescribed by GPs and community nurses who are providing support to people living with RA. This will benefit patients and potentially help improve medication adherence and increase health-related behaviours, which may offset some of the risk factors of cardiovascular disease. It may also help patients living with rheumatoid arthritis who are used being managed through secondary care begin to think about making more use of support that is closer to home. BJCN

Uncovering the Iceberg: Mandating the measurement of fraud in the United Kingdom

Having regard to the impact of the credit crunch on fraud, the 19% average cuts in public spending and the wide disparities in fraud loss data, this article will argue for the mandating of fraud measurement through the introduction of legislation in the United Kingdom. The proposed statute applies to both the public and private sectors and incorporates minimum standards of measurement accuracy and the publication of findings and subsequent reduction strategies. In support of this contention this paper offers empirical evidence provided by the United States (US) Improper Payments Information Act of 2002. Further options for change are also presented including developing the role of the National Audit Office and the creation of an infrastructure for knowledge management through the sharing of best practice.

Commentary: Performance Audit of PPPs - Getting the Basics Right

Performance auditing (PA) is an important vehicle for assessing Value for Money (VFM) of Public-Private Partnerships (PPPs), as well as providing assurance to the Parliament and to the public about the accountability for the supporting strategic and operational frameworks. Experience to date with PPPs in Australia has been limited and mixed in terms of results. Few projects have reached the mature stage, let alone been completed. It has been suggested that we can learn from the audit approaches and systems developed by the National Audit Office in the UK. Australian Audit Offices need to ensure that they have robust PA/VFM auditing systems, analytical methodologies and tools in place to undertake quality evaluations at various stages of a PPP, but experience to date at federal and state levels also indicates that there is still a lot to do to get the basis elements of PPPs “right”.

Location of community pharmacies: A rational approach using geographic information systems

Abstract The role played by community pharmacies in primary and community care and the extent to which they meet patient and customer needs has come under close scrutiny in Great Britain recently following publication of reports from the National Audit Office and House of Commons Public Accounts Committee.1,2 Spatial variations in the provision of pharmaceutical services and their physical accessibility to different sections of the community are issues at the forefront of the current debate. This paper reports on recent research, being undertaken in the North West region, to develop a systematic approach to the analysis of community pharmacy location drawing on the fields of geodemographics (ie, neighbourhood classifications) and geographical information systems (GIS). Comprehensive information is being assembled about individual pharmacies, the services they provide, the types of residential neighbourhood in which they are located, their advice-giving role, and their proximity to general practitioners, other health care outlets and residential homes. Data sources include the pharmaceutical register, the family health services authorities (FHSAs) and surveys of pharmacists and health care professionals. This is being augmented with digitised boundary information including the road network and small area statistics on demographic structure, social conditions and deprivation. These data are being utilised within a computerised system to identify how well the current distribution of pharmacies accords with expectations and alternative resource deployment scenarios. Particular attention is being paid to the identification of gaps in provision and areas of over-provision.

Safety programme reduces ICU mortality

One in 10 patients admitted to Scottish hospitals are unintentionally harmed and around 50% of these events could have been avoided if lessons from previous incidents had been learned. A National Audit Office report estimated that patient safety incidents cost the NHS an estimated £2 billion a year.

Reducing staff costs.

The National Audit Office (NAO) has published a framework for managing staff-cost reduction that sets out how organisations should deliver these savings in a way that minimises risk and maximises benefit to taxpayers. The framework also includes the NAO's expectations for effective ongoing management of staff costs.

An evaluation of the strengths and weaknesses of a register of newly diagnosed rheumatoid arthritis, 1986-2010

To evaluate the strengths and weaknesses of a register of management and outcomes of recently diagnosed RA, and allow comparisons between rheumatology centres on good clinical practice and guidelines. A register of newly diagnosed RA was initiated in 1986 in nine different regions of England, later expanded to UK-wide membership in 2002. Standardized data collection includes disease activity, function, radiological damage, therapy, hospitalizations, major comorbidity and mortality. A centralized database generates individual reports and comparative data for each centre yearly. Aims have been compared with actual achievements and any changes over 25 years. Thirty rheumatology centres have recruited 2866 patients. Study outputs have included peer-reviewed scientific publications and contributions to the recent National Audit Office report on RA. Referral times into secondary care have changed little over 25 years, but time to initiation of drug therapies has decreased. Delays between publication of clinical trial evidence and management guidelines and their implementation in normal clinical practice are illustrated by relatively infrequent use of combination therapies at diagnosis. Consecutive case recruitment, centre participation and follow-up were reportedly compromised by local funding issues. Centre participants report a benefit from feedback of actual clinical practice compared with recommended standards of care. Most of the original objectives have been achieved. Cohort studies based predominantly in District General Hospitals provide unique insights into the natural history and impact of RA, its management, the translation of research findings into clinical practice and provide participating centres with important clinical governance and professional development opportunities.

Entering a new paradigm: emergency nursing into the 21st Century

Two National Audit Office reports were published in February 2010. The first was highly critical of emergency healthcare delivery in England and highlighted the ways in which staffing and resource allocations could be areas that could have a negative impact on morbidity and mortality. The second report highlighted the significant positive impact that current military emergency care is making with focused training and development of all professionals contributing to the care delivery strategies. This article evaluates the two publications and emphasises on the contribution that appropriately educated, prepared and trained emergency nurses could make within the NHS context.

Managing emergent and complex change: the case of Dutch agencification

An analysis is made of agencification reform in the Netherlands from the viewpoint of the management of the complex change process. We will present a processual analysis of the complex change process of agencification reform by means of organization science insights on ‘emergent change’ and administrative science insights on ‘complex networks’. The analysis of the process of change events shows that it is not an example of centrally planned and controlled change. The reform is rather an example of ‘emergent and complex change’. The reform is a complex system of different intertwined change processes with many different decentralized actors, which is ‘managed’ by different central ‘change agents’. The ‘change managers’ themselves form a complex system as well.Points for practitionersOne of the important reform trends in Dutch central administration is the ‘agencification’ of executive government organizations, that is, the increase of managerial autonomy of executive parts of ministerial departments. In this article we analyse how this two-decades-long reform process was ‘managed’ by various central actors like Parliament, the National Audit Office, the Ministry of Finance, the Ministry of Home Affairs, various internal and external advisory committees and supervisory committees. It turned out that the reform can hardly be described as a centrally planned and controlled process. Initiatives for reform, in fact, popped up locally within the various ministries and agencies. The reform process was more a continuous accumulation of local initiatives for agencification. The various central actors tried to exercise some coordinating or supervisory influence, but that was rather indirect, reactive and limited.

GPs' attitudes, awareness, and practice regarding early diagnosis of dementia

In primary care, the diagnosis of dementia is often delayed and the 2007 National Audit Office Report concluded action was needed to improve patient care and value for money. To investigate the attitudes, awareness, and practice of GPs in England regarding early diagnosis and management of patients with dementia, and perceptions of local specialist services, to identify training or support needs. Secondary analysis of survey data that capture the above attitudes, awareness, and practice. Online survey, targeting GP members of medeConnect. Survey data were obtained using an anonymised online self-completion questionnaire, and then analysed using standard data-analysis software. A total of 1011 GPs across the eight English regions responded. Older GPs were more confident in diagnosing and giving advice about dementia, but less likely to feel that early diagnosis was beneficial, and more likely to feel that patients with dementia can be a drain on resources with little positive outcome. Younger GPs were more positive and felt that much could be done to improve quality of life. Attitudes had no correlation with sex. GPs in general felt they had not had sufficient basic and post-qualifying training in dementia, and overall knowledge about dementia was low. Much could be done to improve GPs' knowledge of dementia, and the confidence of older GPs could be an educational resource. However, greater experience may create scepticism about early diagnosis because of the perceived poor quality of specialist services.

Designs that enhance care.

One quarter of people accessing acute hospitals are likely to have dementia and the number with the condition is expected to double over the next 30 years ( National Audit Office 2010 ). The Alzheimer's Society ( 2009 ) highlighted the detrimental effect of hospital stays on the independence of this patient group. Yet relatively inexpensive aspects of the design and fabric of the care environment can have a positive effect on the wellbeing of people with dementia.

Care for end-of-life cancer patients should be 24/7

Up to 19 million people might not have access to 24/7 community nursing at the end of their life should they want it, because they do not live in an area where the primary care trust (PCT) provides this type of service to all patients, a new report by Macmillan Cancer Support has found. Simple changes, such as introducing 24/7 community nursing, would not only improve the quality of patients’ lives in their final weeks and months and enable them to die at home if they wish, but also make huge financial savings for the NHS. The National Audit Office (NAO) estimates that the average cost of keeping someone in hospital for their last year of life is £222 per day. In comparison the average cost of home/community care per day is £28; nearly eight times less (NAO, 2008).

Stroke awareness among British ethnic minorities

Stroke is the third common cause of death in the UK. It is also a leading cause of disability. The recent National Stroke Strategy (Department of Health, 2007) has provided major impetus behind changes in the ways in which stroke is prevented and treated (National Audit Office, 2010). Stroke awareness sits as a significant part of the Strategy, but there are some concerns that the Government's centrepiece campaign to increase public knowledge is not reaching some of the most vulnerable sections of our population, people from black and minority ethnic communities, despite clear evidence of increased risk among some ethnic communities. This paper describes some of the literature, mainly from the United States, which can help nurses working in community settings consider strategies for raising awareness about both stroke knowledge and risk. The paper points to three important themes: initial and prolonged engagement with local communities; self-management and cultural sensitivity.

PERFORMANCE AUDITING AND THE NARRATING OF A NEW AUDITEE IDENTITY

This paper analyzes how performance auditing affects the auditee in different and sometimes unexpected ways. On the basis of a detailed case study of the Danish Ministry of Transport's encounter with performance auditing we argue that performance audit is a practice that generates multiple effects and that some of these effects can be characterized as a reconfiguration of the organizational identity of the auditee. In this process, accountabilities are reformulated and reallocated which sometimes lead to ‘blame games’ and strong feelings of discomfort. We draw on actor‐network theory and a narrative approach to study how performance audit reports produce narratives that picture new possible identities that the auditee in question must take into consideration. We argue that auditee identities are partly shaped by relations to ‘significant others’, such as the National Audit Office, the politicians and the press who all give accounts of who the Ministry is and ought to be. Furthermore, we argue that accounting and management information systems are enrolled as important ‘nonhuman’ actors that enable the suggested identity positions.

Leading change in tissue viability best practice: an action learning programme for link nurse practitioners

This account of practice reports on an action learning initiative designed and implemented in partnership between a regional NHS Acute Trust and a UK Business School. The central initiative was the implementation of an action learning programme entitled ‘Leading change in tissue viability best practice: a development programme for Link Nurse Practitioners’. The purpose was primarily to foster ‘leadership’ in best practice, in frontline nursing staff who have a specific ward-based responsibility regarding ‘tissue viability’, that is the prevention and management of pressure ulcers and wounds. The approach engaged the active involvement of nurses to become problem identifiers and solvers and key influencers in improving practice. The initiative utilized action learning principles to draw out the real experience of nursing staff to identify and analyze the current situation regarding practices around tissue viability issues, to identify significant improvement areas and develop action and implementation plans to achieve improvements. The process of meeting, sharing experience and action planning took place several times over a five-month period from July to December 2009. The initiative is enveloped within a stand-alone University accredited module of the same title accruing 20 credits at level 4. This account provides a timely opportunity to reflect on and evaluate the outcomes of the initiative and the process of learning engaged in by the participants. The initiative was supported and funded by the regional NHS Strategic Health Authority as part of its commitment to improvements in ‘Patient safety’ (National Audit Office – 2005. London: The Stationery Office).

UK's NHS trauma systems: lessons from military experience

The pioneering and much anticipated London, UK, trauma system was launched on April 6, 2010, and represents the first coherent effort by the UK's National Health Service (NHS) to improve trauma care across a region.1 The UK's Defence Medical Services have substantial experience of delivering systematised care to major trauma patients in Iraq (2003–09) and Afghanistan (2006 to present). This military system was reviewed by the National Audit Office and judged to be highly effective,2 with one in four salvaged patients categorised as unexpected survivors—a strong indicator of good system-function.

Auditing the Australian Response to Trafficking

This article was written in response to the April 2009 publication of the Australian National Audit Office (ANAO) audit of the management of the Australian Government Action Plan to Eradicate Trafficking in Persons. It considers both the material presented to the audit office from a range of government agencies and the findings and recommendations arising from the audit. The article seeks to identify significant concerns regarding the operation of the existing policy response. It also identifies key implications of an audit report — a managerialist tool — being the most comprehensive official assessment of the policy response to date. While two other national reports were produced on the Australian response to human trafficking in the months following the tabling of the ANAO Report, it is argued that both reports primarily produced important, but limited, trend and implementation data. Drawing on research nationally and internationally in the area of human trafficking, migration and exploitation, this article argues that assessment of the effectiveness of policy implementation is not naturally or logically connected in any direct way to the eradication of human trafficking. It also argues that the absence of any commitment to evaluating the impact of, and alternatives to, the current response runs the risk of further entrenching the current counter-trafficking framework with limited regard to the broader impacts of this approach.