Health economic skills for advancing health policy: capturing effects of prevention and intervention beyond traditional health services

世界各地的卫生系统都落后于患者的需求。规模更大、年龄更大的人口和越来越多的长期疾病正在增加对卫生服务的需求。直到最近，医疗服务机构一直试图将资源集中在那些紧急护理风险最高的人身上。然而，这种方法并不奏效。最近，服务机构将重点放在预防上，将其作为减少需求的潜在手段。NHS长期计划提倡预防，超越传统的卫生服务(例如社会工作和社会处方)，并使用政策杠杆，如新的筹资和组织服务的方式。我们需要研究为这些新方法提供证据，特别是对于目前经历最糟糕结果的多发病患者。我将：1)检查NHS/地方当局公共支出对预防和优先结果的相对影响；据建议，只有大约10%的健康结果依赖于获得传统医疗服务。在紧缩期间，NHS的预算得到了相对保护，但一些地方当局大幅削减了预算。在同事和其他人工作的基础上，我将使用公共支出的公开数据，并计算出医疗保健系统支出以及其他可能影响健康的服务支出的相对好处。这将有助于决定将公共资金花在哪里。2)使用我发布的框架绘制Vanguard新的护理模式，并检查哪些干预措施的组合可以影响特定的结果；从2015年开始，NHS England资助了50个Vanguard新的护理模式。所有人都有大致相同的目标，但方法有所不同。我将使用我之前的多病框架来绘制先锋队的干预地图。然后，我将看看先锋的不同类型的干预是否会导致特定的结果。这将建立在UOM通过先锋国家方案评估开展的工作的基础上。此外，尽管整个英格兰都制定了可持续发展和转型计划(STP)(2016)，但只有14/44的STP(2018年)采取了额外的步骤，形成了综合医疗体系(也称为责任医疗组织，ACO)。这些组织将拥有更大的财务和运营自由。我将研究在STP形成的基础上，这种额外的组织整合对健康、体验和成本结果的影响。我将使用住院事件统计(HES)的个人水平结果来衡量活动和成本，还将使用记录患者生活质量和患者体验的全科医生患者调查(GPPS)。结果将帮助委员们决定提供何种干预组合，以获得明确的结果。3)建立一个模型来检查和模拟新政策变化的系统内影响，索尔福德是英格兰首批试验ACO方法的卫生系统之一，也是英格兰综合保健政策的相对领导者。我将使用索尔福德综合医疗记录的本地关联数据(保存在UOM)，开始建立一个微观模拟模型，以检查地理系统内对未来政策决策影响的影响，并开发该模型作为向政策制定者提供信息的工具。最近由MRC方法学研究方案咨询小组委托进行的一次小插曲强调，这种类型的模型应用于卫生服务提供的使用不足，主要是由于缺乏利益攸关方的参与。它还将重点放在“为卫生和社会保健领域内的组织和部门之间的流动和互动建模”，将其作为开发方法潜力的一个领域。我将致力于解决这些差距。结果将为当地政策方向和推广提供信息。整个项目的研究访问和年度利益相关者参与会议将保持项目政策和临床相关性，增加传播和影响。

Health systems around the world are lagging behind the needs of their patients. Larger, older populations with increasing numbers of long-term conditions are increasing demand on health services. Until recently, services have tried to target resources on those at highest risk of emergency care. However, this approach has not worked well. More recently, services have focused on prevention as a potential means of reducing demand. The NHS Long Term Plan advocates prevention, working beyond traditional health services (e.g. social work and social prescribing) and using policy levers such as new ways of financing and organising services. We need research to provide evidence for these new approaches, particularly for patients with multimorbidity who currently experience the worst outcomes.I will:1) Examine the relative effects of NHS/Local Authority public spending on prevention and priority outcomes; It has been proposed that only around 10% of health outcomes depend on access to traditional medical services. During austerity, the NHS budget has been relatively protected, but there have been substantial cuts in some Local Authorities. Building on work by colleagues and others, I will use publically available data on public spending and work out the relative benefits of spending in the health care system, and spending on other services that can affect health. This will help decisions about where to spend public money.2) Map Vanguard new care models using my published framework and examine what combination of interventions works to affect specific outcomes; From 2015, 50 Vanguard new care models were funded by NHS England. All had roughly the same aims, but with some variation in approach. I will use my previous multimorbidity framework to map interventions in Vanguards. I will then see if different types of interventions in a Vanguard lead to particular outcomes. This will build on work at UoM through the Vanguard National Programme Evaluation. Furthermore, while the whole of England has developed Sustainability and Transformation Plans (STPs) (2016), only 14/44 STPs have taken the additional step (in 2018) of forming an integrated care system (a.k.a accountable care organisation, ACO). These organisations will have greater financial and operational freedoms. I will examine the effects on health, experience and cost outcomes of this extra organisational integration over and above STP formation. I will use individual-level outcomes from hospital episode statistics (HES) to measure activity and costs, but also the GP Patient Survey (GPPS) which records patient quality of life and patient experience. The results will help commissioners decide what mix of interventions to provide to get defined outcomes. 3) Build a model to examine and simulate within-system effects of new policy changes Salford has been one of the first health systems in England to trial the ACO approach, and is a relative leader in integrated care policy in England. I will work with local linked data (held at UoM), the Salford integrated care record, to begin to build a microsimulation model to examine within-geographical system effects on the impact of future policy decisions, and develop the model as a tool to inform policymakers. A recent vignette commissioned by the MRC Methodology Research Programme Advisory Group highlighted the underuse of this type of modelling applied to health service delivery, primarily due to lack of stakeholder engagement. It also focused on "modelling flows and interactions between organisations and sectors within health and social care" as an area where development of methods has potential. I will aim to address these gaps. Results will inform local policy direction and roll-out. Research visits throughout the project and yearly stakeholder engagement meetings will keep the project policy and clinically relevant increasing dissemination and impact.