A review of the application of health economics to health and safety in healthcare
Introduction
In the UK National Health Service (NHS), managers, and executive teams routinely face challenging resource allocation decisions to control identified significant risks in order to comply with health and safety law. It can be argued that, because of competing priorities, the approach adopted has concentrated on the minimum required to comply with the law rather than to tackle risk control from a positive business management perspective, which would also, ironically, produce legal compliance. For example, a survey identified that most finance directors in the NHS in Scotland were unaware of the cost to their organisations of back injuries among nurses [1]. The same authors also identified a bias toward the provision of manual handling training rather that the provision of appropriate mechanical aids [2]. This is despite it being widely accepted that training alone does not reduce the risk of musculoskeletal injury and that the law requires hazardous manual handling activities to be avoided or automated/mechanised where this is not practicable [3].
The positive economic value of health and safety management has not been widely accepted by NHS directors and managers. It has been argued that lack of top management commitment, failure to integrate medical staff into health and safety management arrangements, and lack of ownership of health and safety by line mangers, can all conspire to foster a culture where health and safety interventions are seen to be expensive luxuries, implemented at the expense of those more obviously related to patient care [4].
A literature review was, therefore, undertaken to identify likely causes for this by evaluating applications of health economic techniques to health and safety within healthcare. The aim of this article is to describe the results of this review.
The review was conducted after the method of Crombie and Davies [5]. A range of online or compact disc (CD-ROM) computer databases was searched to identify relevant professional and scientific literature. These encompassed literature relating to medicine, healthcare, health and safety, economics and health economics. The search was limited to literature published in English since 1970. A standard search string was devised comprising a combination of either medical subject heading (MeSH) terms or range of textwords.
Publications were identified by their abstracts or, where these were unavailable, their titles and authors. Each item was evaluated to determine its relevance and apparent importance to the review after the guidance of Crombie [6] and Drummond et al. [7].
Copies were retrieved for more detailed evaluation. These articles, books or monographs were read and appraised and where possible, coded after the manner of Warner et al. and Greenhalgh [8], [9]. This entailed evaluation of the following aspects.
- 1
Disciplinary base and findings.
- 2
Methodological rigor (where appropriate, including consideration of external and internal validity, statistical validity and data quality).
- 3
Outcomes sought by the intervention; the problem or research question addressed (i.e. why was the study done?).
- 4
Subjective judgements about the quality and contribution of the publication (including comprehensibility).
- 5
Type of study (descriptive, empirical, conceptual, review or other).
- 6
Whether the contribution of the publication was additive (i.e. building upon prior theoretical or empirical work).
In practice it was found that most of the publications were not based on sound empirical analysis or reasoning so this objective coding could not be applied, in which case reliance had to be placed on subjective judgement.
Section snippets
Findings
Good quality research into the costs and benefits of occupational health and safety care has been identified as the highest priority in developing a coherent programme of topics for occupational health research [10]. This theme has been reinforced with the launch of the HSE's long term occupational health strategy for the UK, ‘Securing Health Together’ [11].
However, the most significant finding has been that there are still significant methodological limitations underpinning most attempts at
Problems with methodological rigor
Drucker has suggested that the guiding principle for occupational health and safety programmes should be that additional money should continue to be invested so long as the benefits exceed the costs (i.e. providing an appropriate economic rate of return (ERR)). However, the author acknowledged the practical difficulties of measuring this [23].
Indeed, the published literature on the application of economic evaluation to health and safety in healthcare has been found to be woefully inadequate in
Conclusions
A relative minority of work has been successful in demonstrating cost-effectiveness of health and safety interventions [71], [72], [73], [74]. It is worth considering why these are successful while others have failed to meet their potential. One reason may be related to the subject area. They have concentrated on the control of hepatitis B and HIV, both issues, which are culturally regarded as important and, therefore, receiving more investment and the assistance of scientists skilled in the
Acknowledgements
The author wishes to thank the Scottish Office Department of Health Chief Scientist Office for funding this literature review. Also, Dr John Cherrie and Dr John Cairns at Aberdeen University's Department of Environmental and Environmental Medicine and Health Economic Research Unit, respectively, for invaluable support and guidance
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