HMS: Identifying and Measuring Spillover Effects of Changes to Healthcare Organisation and Delivery

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Changes to the way in which healthcare services are organised and delivered have wider consequences beyond the patients or the services targeted. These types of wider changes are called spillovers. They may have positive effects, because more patients benefit than was originally intended, and/or they may have negative effects, because more attention is paid to some patients and activities at the expense of others. A limited amount of research has shown that these spillover effects can be substantial. They may be substantial enough to affect whether a proposed change in service organisation is good value-for-money. There is therefore a need for a systematic method of identifying and measuring spillover effects.Our aim is to develop structured guidance for incorporating spillovers in the evaluation of changes to health care organisation and delivery. Our proposal contains three work packages. The first work package will review the published literature to identify and summarise how spillovers have been considered and measured in previous studies. The second work package will use the example of three case studies to develop the methods. The first case study will focus on a new system introduced for General Practitioners (GPs) under which they received financial bonuses for improving a wide range of quality measures. The second case study will focus on a change to the way hospitals were paid to encourage them to discharge patients on the same day rather than keep them in hospital overnight. We have previously shown that both of these initiatives changed activity as intended and improved the outcomes for the patients that were targeted. However, the wider consequences for other activities and other patients have not been considered. The third case study will focus on the initiative to provide the population with access to GPs seven-days a week. This is expected to increase the use of general practice services and improve convenience for patients. It is also hoped that it will improve the health of the population and lead to a reduction in visits to Accident and Emergency departments for relatively minor complaints that would be better dealt with by GPs. However, the overall impact of these changes will depend on whether availability at the weekend leads to reduced access to GPs during the week, the size of the reduction in demand on A&E, the benefits to the patients with more severe conditions who continue to visit A&E and the costs of compensating GPs for opening out-of-hours. We will estimate these wider consequences using our spillovers framework and provide an overall assessment of extending access to GP services. We will re-visit each of these policy changes and examine whether they had spillover effects. We will consider how these spillover effects influence the overall costs and benefits of these policy changes.In the third and final work package, we will generate structured methodological guidance to evaluate diverse changes to health services. We will work with a project advisory group including decision-makers, health care professionals and academic experts to identify the potential for spillovers, develop the methods and ensure the guidance is comprehensive, authoritative and user-friendly. The work will provide a consistent way of assessing the wider effects on all patients of changing the way that health and social care services are organised for some patients. We will demonstrate these methods on three important policy changes and examine how considerations of spillovers affect the design of service changes and the way these are evaluated. We will work with decision-makers, professionals and evaluators throughout the project to create guidance that will ensure that the potential for spillover effects is widely recognised and that they are included in the evaluation of changes to the way care services are organised and delivered.