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Henderson DAG, Donaghy E, Dozier M, Guthrie B, Huang H, Pickersgill M, Stewart E, Thompson A, Wang HHX, Mercer SW. Understanding primary care transformation and implications for ageing populations and health inequalities: a systematic scoping review of new models of primary health care in OECD countries and China. BMC Med 2023; 21:319. [PMID: 37620865 PMCID: PMC10463288 DOI: 10.1186/s12916-023-03033-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/15/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Many countries have introduced reforms with the aim of primary care transformation (PCT). Common objectives include meeting service delivery challenges associated with ageing populations and health inequalities. To date, there has been little research comparing PCT internationally. Our aim was to examine PCT and new models of primary care by conducting a systematic scoping review of international literature in order to describe major policy changes including key 'components', impacts of new models of care, and barriers and facilitators to PCT implementation. METHODS We undertook a systematic scoping review of international literature on PCT in OECD countries and China (published protocol: https://osf.io/2afym ). Ovid [MEDLINE/Embase/Global Health], CINAHL Plus, and Global Index Medicus were searched (01/01/10 to 28/08/21). Two reviewers independently screened the titles and abstracts with data extraction by a single reviewer. A narrative synthesis of findings followed. RESULTS A total of 107 studies from 15 countries were included. The most frequently employed component of PCT was the expansion of multidisciplinary teams (MDT) (46% of studies). The most frequently measured outcome was GP views (27%), with < 20% measuring patient views or satisfaction. Only three studies evaluated the effects of PCT on ageing populations and 34 (32%) on health inequalities with ambiguous results. For the latter, PCT involving increased primary care access showed positive impacts whilst no benefits were reported for other components. Analysis of 41 studies citing barriers or facilitators to PCT implementation identified leadership, change, resources, and targets as key themes. CONCLUSIONS Countries identified in this review have used a range of approaches to PCT with marked heterogeneity in methods of evaluation and mixed findings on impacts. Only a minority of studies described the impacts of PCT on ageing populations, health inequalities, or from the patient perspective. The facilitators and barriers identified may be useful in planning and evaluating future developments in PCT.
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Affiliation(s)
- D A G Henderson
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - E Donaghy
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - M Dozier
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - B Guthrie
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - H Huang
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - M Pickersgill
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - E Stewart
- School of Social Work and Social Policy, University of Strathclyde, Glasgow, UK
| | - A Thompson
- School of Social and Political Sciences, University of Edinburgh, Edinburgh, UK
| | - H H X Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - S W Mercer
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK.
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Regmi K, Mudyarabikwa O. A systematic review of the factors - barriers and enablers - affecting the implementation of clinical commissioning policy to reduce health inequalities in the National Health Service (NHS), UK. Public Health 2020; 186:271-282. [PMID: 32871449 DOI: 10.1016/j.puhe.2020.07.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/15/2020] [Accepted: 07/19/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of the present study is two-fold. First, it attempts to identify the barriers and enablers of implementing clinical commissioning policy. Second, it synthesises how these barriers and enablers affect the success of National Health Service (NHS) efforts to reduce health inequalities in the UK. METHODS A systematic review was conducted. We searched large biomedical bibliographic databases, namely MEDLINE, EMBASE, CINAHL, Allied & Complementary Medicine, DH-DATA, Global Health and CINAHL for primary studies, conducted in the UK, that assessed the factors - barriers and enablers related to health inequalities, published from 2010 onwards and in English, and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We used Joanna Briggs Institute (JBI) Critical Appraisal and Mixed Methods Appraisal tools to assess the methodological qualities, and synthesised by performing thematic analysis. Two reviewers independently screened the articles and extracted data. RESULTS We included six primary studies (including a total of 1155 participants) in the final review. The studies reported two broad categories, under four separate themes: (1) the agenda of health inequalities has not been given priority; (2) there was very little evidence for reducing health inequalities through the clinical commissioning (CC) process; (3) CC was positively associated with the restructuring of NHS; and (4) CC brings better collaboration and engagement, which led to some improvements in health services access, utilisation and delivery at the local level. CONCLUSION This study provides useful factors - barriers and enablers - to implement and deliver clinical commissioning policy in improving health and well-being. These factors could be assessed in future to develop objective measures and interventions to establish the link between commissioning and health inequalities.
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Affiliation(s)
- K Regmi
- Institute for Health Research, Faculty of Health and Social Sciences, University of Bedfordshire, University Square, Luton, Bedfordshire, LU1 3JU, United Kingdom; Centre for Medical Education, School of Medicine, University of Dundee, Dundee, DD2 4BF, United Kingdom.
| | - O Mudyarabikwa
- Faculty of Health and Life Sciences, Coventry University, Richard Crossman Building, Room RC145, Priory Street, Coventry, CV1 5FB, United Kingdom.
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Robinson L, Poole M, McLellan E, Lee R, Amador S, Bhattarai N, Bryant A, Coe D, Corbett A, Exley C, Goodman C, Gotts Z, Harrison-Dening K, Hill S, Howel D, Hrisos S, Hughes J, Kernohan A, Macdonald A, Mason H, Massey C, Neves S, Paes P, Rennie K, Rice S, Robinson T, Sampson E, Tucker S, Tzelis D, Vale L, Bamford C. Supporting good quality, community-based end-of-life care for people living with dementia: the SEED research programme including feasibility RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2020. [DOI: 10.3310/pgfar08080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
In the UK, most people with dementia die in the community and they often receive poorer end-of-life care than people with cancer.
Objective
The overall aim of this programme was to support professionals to deliver good-quality, community-based care towards, and at, the end of life for people living with dementia and their families.
Design
The Supporting Excellence in End-of-life care in Dementia (SEED) programme comprised six interlinked workstreams. Workstream 1 examined existing guidance and outcome measures using systematic reviews, identified good practice through a national e-survey and explored outcomes of end-of-life care valued by people with dementia and family carers (n = 57) using a Q-sort study. Workstream 2 explored good-quality end-of-life care in dementia from the perspectives of a range of stakeholders using qualitative methods (119 interviews, 12 focus groups and 256 observation hours). Using data from workstreams 1 and 2, workstream 3 used co-design methods with key stakeholders to develop the SEED intervention. Worksteam 4 was a pilot study of the SEED intervention with an embedded process evaluation. Using a cluster design, we assessed the feasibility and acceptability of recruitment and retention, outcome measures and our intervention. Four general practices were recruited in North East England: two were allocated to the intervention and two provided usual care. Patient recruitment was via general practitioner dementia registers. Outcome data were collected at baseline, 4, 8 and 12 months. Workstream 5 involved economic modelling studies that assessed the potential value of the SEED intervention using a contingent valuation survey of the general public (n = 1002). These data informed an economic decision model to explore how the SEED intervention might influence care. Results of the model were presented in terms of the costs and consequences (e.g. hospitalisations) and, using the contingent valuation data, a cost–benefit analysis. Workstream 6 examined commissioning of end-of-life care in dementia through a narrative review of policy and practice literature, combined with indepth interviews with a national sample of service commissioners (n = 20).
Setting
The workstream 1 survey and workstream 2 included services throughout England. The workstream 1 Q-sort study and workstream 4 pilot trial took place in North East England. For workstream 4, four general practices were recruited; two received the intervention and two provided usual care.
Results
Currently, dementia care and end-of-life care are commissioned separately, with commissioners receiving little formal guidance and training. Examples of good practice rely on non-recurrent funding and leadership from an interested clinician. Seven key components are required for good end-of-life care in dementia: timely planning discussions, recognising end of life and providing supportive care, co-ordinating care, effective working with primary care, managing hospitalisation, continuing care after death, and valuing staff and ongoing learning. Using co-design methods and the theory of change, the seven components were operationalised as a primary care-based, dementia nurse specialist intervention, with a care resource kit to help the dementia nurse specialist improve the knowledge of family and professional carers. The SEED intervention proved feasible and acceptable to all stakeholders, and being located in the general practice was considered beneficial. None of the outcome measures was suitable as the primary outcome for a future trial. The contingent valuation showed that the SEED intervention was valued, with a wider package of care valued more than selected features in isolation. The SEED intervention is unlikely to reduce costs, but this may be offset by the value placed on the SEED intervention by the general public.
Limitations
The biggest challenge to the successful delivery and completion of this research programme was translating the ‘theoretical’ complex intervention into practice in an ever-changing policy and service landscape at national and local levels. A major limitation for a future trial is the lack of a valid and relevant primary outcome measure to evaluate the effectiveness of a complex intervention that influences outcomes for both individuals and systems.
Conclusions
Although the dementia nurse specialist intervention was acceptable, feasible and integrated well with existing care, it is unlikely to reduce costs of care; however, it was highly valued by all stakeholders (professionals, people with dementia and their families) and has the potential to influence outcomes at both an individual and a systems level.
Future work
There is no plan to progress to a full randomised controlled trial of the SEED intervention in its current form. In view of new National Institute for Health and Care Excellence dementia guidance, which now recommends a care co-ordinator for all people with dementia, the feasibility of providing the SEED intervention throughout the illness trajectory should be explored. Appropriate outcome measures to evaluate the effectiveness of such a complex intervention are needed urgently.
Trial registration
Current Controlled Trials ISRCTN21390601.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research, Vol. 8, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Louise Robinson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Marie Poole
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Emma McLellan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Richard Lee
- Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Sarah Amador
- Division of Psychiatry, University College London, London, UK
| | - Nawaraj Bhattarai
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Bryant
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Dorothy Coe
- North East and North Cumbria Local Clinical Research Network, Newcastle upon Tyne, UK
| | - Anne Corbett
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Claire Goodman
- School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Zoe Gotts
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Sarah Hill
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Denise Howel
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Susan Hrisos
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Ashleigh Kernohan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Helen Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Christopher Massey
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Paul Paes
- Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Katherine Rennie
- Faculty of Medical Sciences, Professional Services, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen Rice
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tomos Robinson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Elizabeth Sampson
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | | | - Dimitrios Tzelis
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Claire Bamford
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Riner B, Bussy A, Hélène-Pelage J, Moueza N, Lamy S, Carrère P. "No generics, Doctor!" The perspective of general practitioners in two French regions. BMC Health Serv Res 2017; 17:707. [PMID: 29121918 PMCID: PMC5680768 DOI: 10.1186/s12913-017-2682-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 11/03/2017] [Indexed: 12/13/2022] Open
Abstract
Background Generic medicines are essential to controlling health expenditures. Their market share is still small in France. The discourse and practices of prescribers may play a major role in their use. The purpose of this study was to explore the knowledge, attitudes and practices of general practitioners (GPs) toward generic medicines in two French regions with the lowest penetration rate of these products. Methods An observational study was carried out from October 2015 to February 2016 in Guadeloupe and Martinique. The first qualitative phase involved a diversified sample of 14 GPs who underwent semi-structured interviews. The second phase involved a random sample of 316 GPs (response rate = 74%) who were administered a structured questionnaire developed from the results of the first phase. Results Seventy-eight percent of the participants defined a generic drug as a drug containing an active substance identical to a brand-name drug, but only 11% considered generic drugs to be equivalent to brand-name drugs, and the same proportion believed that the generic drugs were of doubtful quality. The primary recognized advantage of generic medicines was their lower cost (82%). The main drawbacks cited were the variability of their presentation (44%), the confusion that they caused for some patients (47%), frequent allegations of adverse side effects (37%) and a lack of efficacy (24%), and frequent refusal by patients (26%). Seventy-four percent of the participants stated that they adapted their prescribing practices to the situation, and of this group, 47% prescribed the originator product simply on demand. Conclusion Most surveyed GPs were not hostile towards generic medicines. They were caught between the requirements of health insurance regimes and the opposition of numerous users and suggested that the patient information provided by health authorities should be improved and that drug composition and packaging should be made uniform.
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Affiliation(s)
- Béatrice Riner
- Department of General Practice, University of the French West Indies, Pointe-à-Pitre, France
| | - Adèle Bussy
- Department of General Practice, University of the French West Indies, Pointe-à-Pitre, France
| | - Jeannie Hélène-Pelage
- Department of General Practice, University of the French West Indies, Pointe-à-Pitre, France
| | - Nycrees Moueza
- Department of General Practice, University of the French West Indies, Pointe-à-Pitre, France
| | - Sébastien Lamy
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France.,Laboratory of Epidemiology and Analysis in Public Health, UMR1027 INSERM, University of Toulouse III Paul Sabatier, Toulouse, France
| | - Philippe Carrère
- Department of General Practice, University of the French West Indies, Pointe-à-Pitre, France. .,Laboratory of Epidemiology and Analysis in Public Health, UMR1027 INSERM, University of Toulouse III Paul Sabatier, Toulouse, France. .,Département de Médecine Générale, Faculté de Médecine Hyacinthe Bastaraud, Campus Universitaire de Fouillole, Université des Antilles, 97157 Pointe-à-Pitre Cedex, Guadeloupe, BP 250, France.
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