Improving health outcomes--a review of case studies from English health authorities.

We review a series of case studies from English health authorities that have tackled the assessment and improvement of health outcomes. We reflect their concerns and difficulties and the lessons they learnt. We identified case studies from a telephone survey of 91 representatives of the 100 English health authorities (61 were directors of public health). We edited 26 structured case studies which described how they had used population health outcome assessments or indicators. The health outcome assessments included service reviews, needs assessment projects, case-control studies, small area variations analyses, action research, and the use of focus groups. Many case studies highlighted inequalities in health service delivery. Health authorities chose some topics because they were outliers on national indicators, others had found unacceptable inequalities within their district, and others had been concerned that clinicians were not using the most effective interventions. Public health departments played a major role in these population-based health outcome assessments. The case studies highlighted the strengths and weakness of national population-based health outcome indicators, the difficulties of using information on effectiveness, the role of evidence-based process proxies for outcome, the need to extend information sources, the involvement of patients and carers, and the difficulty of changing clinical behaviour. We make recommendations as to how the Department of Health and NHS Executive could help health authorities improve the health outcomes of the populations they serve.