Author Archives: jokemp

Payment by results – a route to social policy innovation in nervous, cash-strapped times


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Be pragmatic: ask not ‘whether’ but ‘how’ to adopt public sector performance-related pay

By Simon Burgess

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Alternatives to the chemical cosh

By Bob Erens

There is wide concern about anti-psychotic drugs being prescribed far too readily for patients with dementia, particularly in care homes. The so-called ‘chemical cosh’ has been blamed by government-commissioned research for the premature deaths of 1,800 people a year.

And the side-effects on an estimated 180,000 UK dementia sufferers can be profound, including social withdrawal, accelerated cognitive decline as well as dizziness and unsteadiness that can lead to falls.

That’s why the Care Services Minister, Paul Burstow, wants a dramatic two-thirds reduction in prescription levels. But what can be offered instead for patients with dementia who may wander or become agitated or aggressive?

The Department of Health has asked PIRU to look at alternatives to these antipsychotic drugs. There are lots of potential options including massage, music therapy, light therapy, physical activity and exercise interventions, cognitive training interventions, better behaviour management therapy as well as specific training and education for care givers.

The big question is what works, in what circumstances and for which patients? We hope to come up with some answers and also identify the research gaps so that these drugs are used only as the last resort.

PIRU is bringing speed and expertise to reviewing a vast swathe of existing research (there are already over 30 literature reviews of more than 400 research papers). We should be able to nail down what is known and what requires further study. We have excellent partners at the EPPI-Centre, Institute of Education and at Collaborations for Leadership in Applied Health Research and Care: Cambridgeshire and Peterborough (CLAHRC CP).

The PIRU investment will be money well-spent if, at the end of our project, we can make a real difference to vulnerable people’s lives and help turn Paul Burstow’s laudable policy ambition into a practical reality. Our work could give doctors, nursing staff and carers the confidence to employ better treatments that enhance dignity and well-being during the twilight years of life.

Bob Erens is Deputy Director of PIRU

How PIRU aims to make a difference

By Nick Mays

Governments these days are less interested in simply supplying services and much more concerned to guarantee results, regardless of how services are provided. That’s true particularly for healthcare. After all, what is healthcare policy meant to achieve? Fundamentally, it is designed to make people healthier within a reasonable budget. So, just as pharmaceuticals and devices require scientific proof of effectiveness, PIRU is now helping to apply more of that rigour to healthcare policy-making.

We are, for example, involved in developing the Government’s programme to improve the rehabilitation of drug users. In the past, agencies might typically have been funded simply to provide a service. They would have reported what they had done, but with no financial link to their real achievement.

In contrast, today, Ministers increasingly want to pay for performance, for the measurable impact that rehabilitation services have, for example, on drug users’ behaviour. That sounds good in theory. But to make this approach work, you need to know clearly what you want to achieve, what progress you can reasonably expect, which indicators you want to use to measure achievement, how much it is worth to you and what you can afford.

This is where PIRU comes in. We are experts in evaluation and in establishing, for example, what is likely to work according to available evidence. So, in terms of the rehabilitation programme, we are helping eight pilot sites right from the start, to develop a realistic payment for performance regime based on our knowledge and experience of what works and for whom.

For example, we are bringing to bear the recent evidence from the Quality and Outcomes scheme in the UK that pays general practices for their performance and applying it to the development of the drug rehabilitation pilots.

Our early involvement also means that, when the outcomes of this programme are finally evaluated, we’ll have more than anecdotes that contribute to a ‘feel good story’. We will really know whether important goals were achieved and we should have some idea of the cost of achieving these important outcomes. That will inform long-term policy choices such as whether to roll-out the programme and also whether to apply it to other services such as for alcohol dependency.

We have not always been involved, like this, at the start of a programme. However, we are a relatively new research unit and we hope policy-makers will increasingly appreciate the extra value gained by using our speed of response and expertise in evidence analysis during the earliest stages of policy development.

We’ve been funded primarily to advise policy-makers at the Department of Health. But we are not cheerleaders for Government. We are independent academics. They have asked us to help find out what works and what does not work, so they can build on success.

Nick Mays is Director of PIRU