Essays in health economics: Volume-Outcome Effect, upcoding behaviour and the evaluation of a short-term intervention program

Evidence in the literature suggests a negative relationship between volume of medical procedures and mortality rates in the health care sector. In general, high-volume hospitals appear to achieve lower mortality rates, although considerable variation exists. However, most studies focus on US hospitals, which face different incentives than hospitals in a National Health Service (NHS). In order to add to the literature, this study aims to understand what happens in a NHS. Results reveal a statistically significant correlation between volume of procedures and better outcomes for the following medical procedures: cerebral infarction, respiratory infections, circulatory disorders with AMI, bowel procedures, cirrhosis, and hip and femur procedures. The effect is explained with the practice-makes-perfect hypothesis through static effects of scale with little evidence of learning-by-doing. The centralization of those medical procedures is recommended given that this policy would save a considerable number of lives (reduction of 12% in deaths for cerebral infarction).

Practice variations in the production of health

This study investigates three questions related to medical practice variation. First, it tests whether average length of stay across Portuguese National Health Service hospitals varies when controlling for differences in patients’ characteristics. Second, it looks at hospital-level characteristics in order to find out whether these are able to explain differences in average length of stay across hospitals. Finally, it proposes a best practice average length of stay for each of the six episodes of care analyzed. To perform the analysis, administrative data from the Diagnosis-Related groups’ data set for the year of 2012 was used. A replication of a hierarchical two-stage model with hospital fixed effects was carried out. The results show that after taking patients’ characteristics into account, variation in average length of stay across hospitals exists. This variation cannot be explained by hospital-level characteristics.

Implementation of WHO Quality Rights assessment in Kabul Mental Health Hospital

RESUMO: Objetivo Avaliar a qualidade dos serviços de saúde mental e a situação dos direitos humanos no Hospital de Saúde Mental de Kabul (KMHH) e fornecer recomendações para o desenvolvimento de um plano de melhoria, actualização e revisão da Política, Estratégia e Plano Nacionais de Saúde Mental,. Métodos A avaliação foi realizada em Janeiro de 2015 no KMHH e na Burn Ward do Hospital Terciário de Isteqlal por uma equipa multidisciplinar usando Qualidade Direitos Tool Kit da OMS. Antes da avaliação, o protocolo foi aprovado pelo Institutional Review Board e obtido o consentimento informado de cada entrevistado. Realizaram-se entrevistas com 16 utentes do serviço, 17 funcionários do hospital e 7 familiares, além da revisão de documentos e da observação das unidades de internamento do KMHH e das interações interpessoais entre funcionários do hospital e utentes do serviço. A comissão de avaliação reviu também a documentação e observou a Unidade de Queimados do Hospital Terciário de Isteqlal, a fim de avaliar e comparar a paridade entre as duas instalações. Após a avaliação, todos os membros da comissão se reuniram e puseram em conjunto todas as conclusões num relatório final. Resultados Encontrámos algumas lacunas graves no nível de prestação de serviços e no respeito pelos direitos humanos dos utentes dos serviços e dos seus familiares. Uma série de políticas, diretrizes e procedimentos relacionados com os direitos humanos dos pacientes estavam ausentes. O ambiente terapêutico e o padrão de vida eram inadequados, existia má qualidade do atendimento e dos serviços prestados, os utilizadores enfrentavam violações do direito ao exercício da capacidade legal e da liberdade pessoal, eram quimica e fisicamente (uso de correntes) contidos e expostos a abusos verbais, físicos e emocionais, e havia grande ênfase no tratamento institucional. Todos estes aspectos foram considerados como extensa violação dos direitos humanos dos utentes de serviço do KMHH. Conclusão Os serviços disponíveis para utentes dos serviços de saúde mental apresentam alguns problemas devido à desconfiança e falta de consciencialização sobre os direitos das pessoas com doença mental e precisam ser alterados de forma positiva. A Lei de Saúde Mental existente difere muito das recomendações da Convenção sobre os Direitos das Pessoas com Incapacidades (CRPD) e requer revisão e adaptação de acordo com esta Convenção. -------------------------------- ABSTRACT: Objective To assess the quality of mental health services and human rights condition in the Kabul Mental Health Hospital (KMHH) and provide recommendations for development of an improvement plan and to update and revise the National Mental Health Policy, Strategy and Plan. Methods The assessment was conducted in January 2015 in the KMHH and the Burn Ward of Isteqlal Tertiary Hospital by a multidisciplinary team using WHO Quality Rights Tool Kit. Before the assessment, Institutional Review Board approval and informed consent from each interviewee were obtained. Interviews were conducted with 16 service users, 17 hospital staffs and 7 family members in addition to documents review and observation of inpatient units of KMHH plus interpersonal interactions between hospital staff and service users. The assessment committee reviewed the documentation and observed the Burn Ward of Isteqlal Tertiary hospital in order to measure and compare parity between the two facilities. After the assessment, all committee members gathered and synchronized all findings into a final report. Results There were some serious gaps on service provision level and respecting human rights of service users and their family members. A series of policies, guidelines and procedures related to patients’ human rights were absent. Inadequate treatment environment and standard of living, poor quality of care and services, violations of the right to exercise legal capacity and personal liberty, being chemically and physically (e.g. chain) restrained, being exposed to verbal, physical and emotional abuse, and emphasis on institutional treatment were all extensive human rights violation that service users were experiencing in KMHH. Conclusion The available services for mental health service users are questionable due to mistrust and lack of awareness about rights of people with disabilities and need to be positively changed. Existing Mental Health Act has a large number of disparities with the CRPD and requires revision and adaptation in accordance to CRPD.

Decentralization and privatization in Portuguese health reforms

ABSTRACT - The Portuguese National Health Service (SNS), a universal, centralized and public owned health care system, exhibits an extraordinary record of equalization in the access to health care and health gains in the late thirty years. However, the most recent history of the Portuguese health reform is pervaded by the influence of decentralization and privatization. Decentralization has been present in the system design since the 1976 Constitution, at least in theory. Private ownership of health care suppliers and out-ofpocket expenditures, on the financing side, both have a long tradition of relevance in the NHS mix of services. The initial aim of this study was to demonstrate expected parallelism between health reforms and public administration reforms, where a common pattern of joint decentralization and privatization was observed in many countries. Observers would be tempted to consider these two movements as common signs of new public management (NPM) developments. They have common objectives, are established around the core concepts of gains in effectiveness, efficiency, equity and quality of public services, through improved accountability. However, in practice, in Portugal, each movement was developed in a totally separated way. Besides those rooted in the NPM theory, there are few visible signs of association between decentralization and privatization. Decentralization, in the Portuguese SNS, was never intended to be followed by a privatization movement; it was seen merely as a public administration tool. Private management of health services, as stated in the most recent SNS legislation, was never intended to have decentralization as a condition or as a consequence. Paradoxically, in the Portuguese context, it has led invariably to centralized control. While presented as separate instruments for a common purpose, the association between decentralization and privatization still lacks a convincing demonstration. Many common health care management stereotypes remain to be checked out if we want to look for eventual associations between these two organizational tools.

IPH response to NI Health and Social Care Board 'Tranforming Your Care' consultation

The 'Transforming Your Care (TYC)' consultation relates to proposals for changes in the delivery of Health and Social Care in Northern Ireland in the context of the TYC report published in December 2011. TYC is about making changes to ensure safe, high quality and sustainable services for patients, service users and staff. TYC sets out proposals in respect of how health and social services will need to adapt and be organised to best meet the needs associated with population ageing, increasing long-term conditions and other challenges. Key points from IPH response include: IPH welcomes the HSC commitment to transform health and social care services to meet Northern Ireland’s changing population health needs Inequalities are a dominant feature of health service utilisation patterns in Northern Ireland – for example hospital admission rates for self-harm and alcohol-related admissions in the most deprived areas are double the regional figure. IPH recommends that

IPH response to the Joint Committee on Health and Children and members of the Northern Ireland Assembly on “Cross-border cooperation on healthcare”

The Institute of Public Health in Ireland were asked to submit a paper on 'Cross-border cooperation on healthcare' for a joint meeting between the Oireachtas Joint Committee on Health and Children and the Northern Ireland Assembly Health Committee which took place in Leinster House on 1 March 2012. Key points from the submission included: o    The Institute of Public Health in Ireland (IPH) is an all-island organisation which promotes cooperation between the Republic of Ireland and Northern Ireland with the aim of improving population health on the island and tackling health inequalities. IPH work is focused on addressing the causes of ill health rather than the design and delivery of treatment services. o    North/South cooperation on health was mandated under the Belfast Agreement in 1998 in five domains, including health promotion. IPH has supported the North South Ministerial Council (NSMC) in respect of the health promotion strand since inception. o    The Department of Health and Department of Health, Social Services and Public Safety North-South Feasibility Study (December 2011) states that mutual benefits are most evident from cooperation in the areas of (i) anticipating trends and illnesses in a collective manner (ii) public health issues (iii) specialised services where the population or activity required to sustain the service cannot be met by either jurisdiction alone and (iv) in relation to those areas adjacent to the border. o    The European Directive on Cross-Border Healthcare will be implemented in the next few years which will have implications in relation to patients travelling for healthcare across the Republic of Ireland/Northern Ireland border. o    IPH is supporting the development of new public health strategies in the Republic of Ireland and Northern Ireland which are both due for publication this year. o    There are tangible benefits from cross-border cooperation in the health sector, both in public health and in health service planning and delivery and there are many examples of successful initiatives. However, developments are not occurring in the context of an agreed plan or overall strategic context and tend to be project-based and concentrated in border counties. o    Successful cross-border cooperation requires high level support and integration into departmental policy cycles. The provision of data on an all-island basis supports cross-border cooperation as does the operation of sustainable all-island organisations which can support research, evaluations and programmes. o    In the future, cross-border cooperation in health will be more effective if developed with a strategic planning process intrinsically linked to Departmental priorities. o    North-South cooperation in the areas of alcohol, obesity, tobacco health surveys and rare diseases will be particularly beneficial.

Sexual Health Promotion Strategy and Action Plan

A five year sexual health strategy including addendum 2008-2013

Health Building Note 00-10 (PDF 1MB)

Part D: Windows and associated hardware

Health Technical Memorandum 04-01: Addendum & Pseudomonas Aeruginosa & Advice for augmented care units

Water Systems HTM 04-01

Investing for Health Update 2005

Investing for Health Update 2005