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Martin S, Claxton K, Lomas J, Longo F. The impact of different types of NHS expenditure on health: Marginal cost per QALY estimates for England for 2016/17. Health Policy 2023; 132:104800. [PMID: 37004415 DOI: 10.1016/j.healthpol.2023.104800] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Abstract
English data from 2003 to 2012 suggests that it costs the NHS £10,000 to generate an additional quality-adjusted life year (QALY). This estimate relates to all NHS expenditure and no attempt was made to explore possible heterogeneity within this total. Different types of expenditure - such as secondary care, primary care and specialized commissioning - may have different productivities and estimates of these may help policymakers decide where additional investment is most beneficial. We use the two-stage least squares estimator and data for 2016 to explore the mortality response to three types of healthcare expenditure. Three specifications are estimated for each type of expenditure: backward selection and regularized regression are used to identify parsimonious specifications, and a full specification with all covariates is also estimated. The regression results are combined with information about survival and morbidity disease burden to calculate the marginal cost per QALY for each type of expenditure: the most conservative results suggest that this is about £8,000 for locally (CCG) commissioned services, while estimates for specialized commissioning and primary care are more uncertain. When this heterogeneity is taken into account, the estimated marginal cost per QALY for all NHS expenditure increases slightly, from about £6,000 to £7,000. Our results suggest that additional investment is likely to be most productive in primary care and in locally commissioned services.
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McHugh S, Riordan F, Shelton RC. Breaking the quality-equity cycle when implementing prevention programmes. BMJ Qual Saf 2022; 32:247-250. [PMID: 36598002 DOI: 10.1136/bmjqs-2022-015558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Sheena McHugh
- School of Public Health, University College Cork, Cork, Ireland
| | - Fiona Riordan
- School of Public Health, University College Cork, Cork, Ireland
| | - Rachel C Shelton
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
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Dieckelmann M, Schütze D, Gerber M, Siebenhofer A, Engler J. Preventive and health-promoting activities in general practices in Germany: A scoping review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:2025-2036. [PMID: 35373409 DOI: 10.1111/hsc.13801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 02/28/2022] [Accepted: 03/12/2022] [Indexed: 06/14/2023]
Abstract
General practices are rooted in the local community and considered to be particularly well-positioned for engaging in preventive and health-promoting activities. The overall aim of the scoping review is to identify priorities and gaps in research published in the past 20 years on preventive and health-promoting activities provided by general practitioners or their teams in general practices in Germany. MEDLINE and Embase databases were systematically searched in November 2020. Papers were selected in dual-review mode and extracted in single-review mode. Data analysis was finished by May 2021. In total, 530 papers were included in the synthesis. Little research has been carried out into collaboration opportunities both within the general practice team and in communities as a whole, with specialists (18%), hospitals (9%), and health insurance companies (6%) being the most frequent cooperation partners of GPs. 15%-20% of papers each dealt with 'early detection', 'information provision' and 'cardiovascular prevention'. Secondary (53%) and tertiary prevention (43%) was more often the subject of research than primary (39%) and quaternary prevention (15%). Healthy subjects (26%) were less often studied than people with pre-existing conditions (42%) and risk factors (48%). Little information was available on preventive activities in terms of gender, young people, migration background, housing conditions or educational background. Personal counselling (15%) was the most frequently described approach to health promotion in general practices, along with printed information materials (10%). This scoping review provides information on which to base targeted interventions and future research that can contribute towards transforming general practices into promoters of health within the community.
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Affiliation(s)
- Mirjam Dieckelmann
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Dania Schütze
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Meike Gerber
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Andrea Siebenhofer
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
- Institute of General Practice and Evidence-based Health Services Research, Medical University Graz, Graz, Austria
| | - Jennifer Engler
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
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Edwards J, Coward M, Carey N. Barriers and facilitators to implementation of non-medical independent prescribing in primary care in the UK: a qualitative systematic review. BMJ Open 2022; 12:e052227. [PMID: 35676011 PMCID: PMC9185484 DOI: 10.1136/bmjopen-2021-052227] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To support workforce deficits and rising demand for medicines, independent prescribing (IP) by nurses, pharmacists and allied health professionals is a key component of workforce transformation in UK healthcare. This systematic review of qualitative research studies used a thematic synthesis approach to explore stakeholders' views on IP in primary care and identify barriers and facilitators influencing implementation. SETTING UK primary/community care. PARTICIPANTS Inclusion criteria were UK qualitative studies of any design, published in the English language. Six electronic databases were searched between January 2010 and September 2021, supplemented by reference list searching. Papers were screened, selected and quality-appraised using the Quality Assessment Tool for Studies with Diverse Designs. Study data were extracted to a bespoke table and two reviewers used NVivo software to code study findings. An inductive thematic synthesis was undertaken to identify descriptive themes and interpret these into higher order analytical themes. The Diffusion of Innovations and Consolidated Framework for Implementation Research were guiding theoretical anchors. PRIMARY AND SECONDARY OUTCOME MEASURES N/A. RESULTS Twenty-three articles addressing nurse, pharmacist and physiotherapist IP were included. Synthesis identified barriers and facilitators in four key stages of implementation: (1) 'Preparation', (2) 'Training', (3) 'Transition' and 4) 'Sustainment'. Enhancement, substitution and role-specific implementation models reflected three main ways that the IP role was used in primary care. CONCLUSIONS In order to address global deficits, there is increasing need to optimise use of IP capability. Although the number of independent prescribers continues to grow, numerous barriers to implementation persist. A more coordinated and targeted approach is key to overcoming barriers identified in the four stages of implementation and would help ensure that IP is recognised as an effective approach to help alleviate workforce shortfalls in the UK, and around the world. PROSPERO REGISTRATION NUMBER CRD42019124400.
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Affiliation(s)
- Judith Edwards
- School of Health Sciences, University of Surrey Faculty of Health and Medical Sciences, Guildford, UK
| | - Melaine Coward
- School of Health Sciences, University of Surrey Faculty of Health and Medical Sciences, Guildford, UK
| | - Nicola Carey
- Department of Nursing and Midwifery, University of the Highlands and Islands, Inverness, UK
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Ren L, Ren J, Liu C, He M, Qiu X. Policy Goals of Contract Arrangements in Primary Care in Jeopardy: A Cross-Sectional Consumer Satisfaction Survey of Community Residents in Hangzhou, China. Front Public Health 2022; 10:800612. [PMID: 35586005 PMCID: PMC9108144 DOI: 10.3389/fpubh.2022.800612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 04/12/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveChina is attempting to establish a voluntary contracting system in primary care. This study aimed to determine the degree of consumer satisfaction with the entitlements of contract arrangements and its associated factors.MethodsA stratified cluster sampling strategy was adopted to recruit study participants from three administrative districts of Hangzhou municipality, each containing six residential communities. In each community, 50 households were recruited. A questionnaire was administered through face-to-face interviews with members of the households who signed a contract with community health centers, to collect data regarding their sociodemographic characteristics, health conditions, and knowledge of and attitudes toward the contract entitlements. Consumer satisfaction was measured using six items rated on a five-point Likert scale ranging from “1=very dissatisfied” to “5=very satisfied” and a summed score was calculated. A mixed linear regression model was established to identify individual predictors of consumer satisfaction after adjustment of the random (intercept) effect of household clusters.ResultsOverall, the respondents reported low levels of awareness and understanding of the contract entitlements, with an average knowledge score of 8.21 (SD = 3.74) out of a maximum possible of 19. The respondents had relatively lower levels of satisfaction (satisfied or very satisfied) with their prioritized entitlements (51.5%) and hospitals at home and telemedicine services (31.3%), compared with the contract and insurance policies (85.5%) and medical services provided (87.0%). Female gender, older age, chronic conditions, and perceived better health were associated with higher levels of satisfaction, while poor awareness and knowledge were associated with lower levels of satisfaction.ConclusionThe study participants perceived limited benefits from the contract arrangements in primary care, which may jeopardize the policy purpose of the arrangements to encourage patients to use primary care as the first contact point in accessing health care services. It is evident that consumer satisfaction with the contract entitlements varies by healthcare needs. Lower levels of satisfaction are associated with poor awareness and knowledge of the entitlements.
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Affiliation(s)
- Lixian Ren
- Department of Health Management, School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Jianping Ren
- Department of Health Management, School of Public Health, Hangzhou Normal University, Hangzhou, China
- *Correspondence: Jianping Ren
| | - Chaojie Liu
- Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
- Chaojie Liu
| | - Mengyan He
- Department of Health Management, School of Public Health, Hangzhou Normal University, Hangzhou, China
| | - Xiantao Qiu
- Department of Health Management, School of Public Health, Hangzhou Normal University, Hangzhou, China
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Identifying how GPs spend their time and the obstacles they face: a mixed-methods study. Br J Gen Pract 2021; 72:e148-e160. [PMID: 34844920 PMCID: PMC8813099 DOI: 10.3399/bjgp.2021.0357] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/14/2021] [Indexed: 11/25/2022] Open
Abstract
Background Although problems that impair task completion — known as operational failures — are an important focus of concern in primary care, they have remained little studied. Aim To quantify the time GPs spend on different activities during clinical sessions; to identify the number of operational failures they encounter; and to characterise the nature of operational failures and their impact for GPs. Design and setting Mixed-method triangulation study with 61 GPs in 28 NHS general practices in England from December 2018 to December 2019. Method Time–motion methods, ethnographic observations, and interviews were used. Results Time–motion data on 7679 GP tasks during 238 hours of practice in 61 clinical sessions suggested that operational failures were responsible for around 5.0% (95% confidence interval [CI] = 4.5% to 5.4%) of all tasks undertaken by GPs and accounted for 3.9% (95% CI = 3.2% to 4.5%) of clinical time. However, qualitative data showed that time–motion methods, which depend on pre-programmed categories, substantially underestimated operational failures. Qualitative data also enabled further characterisation of operational failures, extending beyond those measured directly in the time–motion data (for example, interruptions, deficits in equipment/supplies, and technology) to include problems linked to GPs’ coordination role and weaknesses in work systems and processes. The impacts of operational failures were highly consequential for GPs’ experiences of work. Conclusion GPs experience frequent operational failures, disrupting patient care, impairing experiences of work, and imposing burden in an already pressurised system. This better understanding of the nature and impact of operational failures allows for identification of targets for improvement and indicates the need for coordinated action to support GPs.
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Anderson M, Pitchforth E, Asaria M, Brayne C, Casadei B, Charlesworth A, Coulter A, Franklin BD, Donaldson C, Drummond M, Dunnell K, Foster M, Hussey R, Johnson P, Johnston-Webber C, Knapp M, Lavery G, Longley M, Clark JM, Majeed A, McKee M, Newton JN, O'Neill C, Raine R, Richards M, Sheikh A, Smith P, Street A, Taylor D, Watt RG, Whyte M, Woods M, McGuire A, Mossialos E. LSE-Lancet Commission on the future of the NHS: re-laying the foundations for an equitable and efficient health and care service after COVID-19. Lancet 2021; 397:1915-1978. [PMID: 33965070 DOI: 10.1016/s0140-6736(21)00232-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 12/10/2020] [Accepted: 01/07/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Michael Anderson
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Emma Pitchforth
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Miqdad Asaria
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Carol Brayne
- Cambridge Public Health, University of Cambridge, Cambridge, UK
| | - Barbara Casadei
- Radcliffe Department of Medicine, BHF Centre of Research Excellence, NIHR Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Anita Charlesworth
- The Health Foundation, London, UK; College of Social Sciences, Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Angela Coulter
- Green Templeton College, University of Oxford, Oxford, UK; Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Bryony Dean Franklin
- UCL School of Pharmacy, University College London, London, UK; NIHR Imperial Patient Safety Translational Research Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Cam Donaldson
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | | | | | - Margaret Foster
- National Health Service Wales Shared Services Partnership, Cardiff, UK
| | | | | | | | - Martin Knapp
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Gavin Lavery
- Belfast Health and Social Care Trust, Belfast, UK
| | - Marcus Longley
- Welsh Institute for Health and Social Care, University of South Wales, Pontypridd, UK
| | | | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Ciaran O'Neill
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Rosalind Raine
- Department of Applied Health Research, University College London, London, UK
| | - Mike Richards
- Department of Health Policy, London School of Economics and Political Science, London, UK; The Health Foundation, London, UK
| | - Aziz Sheikh
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Peter Smith
- Centre for Health Economics, University of York, York, UK; Centre for Health Economics and Policy Innovation, Imperial College London, London, UK
| | - Andrew Street
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - David Taylor
- UCL School of Pharmacy, University College London, London, UK
| | - Richard G Watt
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Moira Whyte
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Michael Woods
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Alistair McGuire
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Elias Mossialos
- Department of Health Policy, London School of Economics and Political Science, London, UK; Institute of Global Health Innovation, Imperial College London, London, UK.
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Knittle K, Charman SJ, O'Connell S, Avery L, Catt M, Sniehotta FF, Trenell MI. Movement as medicine for cardiovascular disease prevention: A pilot feasibility study of a physical activity promotion intervention for at-risk patients in primary care (Preprint). JMIR Cardio 2021; 6:e29035. [PMID: 35767316 PMCID: PMC9280491 DOI: 10.2196/29035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 12/08/2021] [Accepted: 12/27/2021] [Indexed: 11/13/2022] Open
Abstract
Background Objective Methods Results Conclusions Trial Registration
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Affiliation(s)
- Keegan Knittle
- Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Sarah J Charman
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
- Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Sophie O'Connell
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
| | - Leah Avery
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
- School of Health & Life Sciences, Teesside University, Middlesbrough, United Kingdom
| | - Michael Catt
- National Innovation Centre for Ageing, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Falko F Sniehotta
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Michael I Trenell
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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Pate A, Emsley R, Ashcroft DM, Brown B, van Staa T. The uncertainty with using risk prediction models for individual decision making: an exemplar cohort study examining the prediction of cardiovascular disease in English primary care. BMC Med 2019; 17:134. [PMID: 31311543 PMCID: PMC6636064 DOI: 10.1186/s12916-019-1368-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/14/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Risk prediction models are commonly used in practice to inform decisions on patients' treatment. Uncertainty around risk scores beyond the confidence interval is rarely explored. We conducted an uncertainty analysis of the QRISK prediction tool to evaluate the robustness of individual risk predictions with varying modelling decisions. METHODS We derived a cohort of patients eligible for cardiovascular risk prediction from the Clinical Practice Research Datalink (CPRD) with linked hospitalisation and mortality records (N = 3,792,474). Risk prediction models were developed using the methods reported for QRISK2 and 3, before adjusting for additional risk factors, a secular trend, geographical variation in risk and the method for imputing missing data when generating a risk score (model A-model F). Ten-year risk scores were compared across the different models alongside model performance metrics. RESULTS We found substantial variation in risk on the individual level across the models. The 95 percentile range of risks in model F for patients with risks between 9 and 10% according to model A was 4.4-16.3% and 4.6-15.8% for females and males respectively. Despite this, the models were difficult to distinguish using common performance metrics (Harrell's C ranged from 0.86 to 0.87). The largest contributing factor to variation in risk was adjusting for a secular trend (HR per calendar year, 0.96 [0.95-0.96] and 0.96 [0.96-0.96]). When extrapolating to the UK population, we found that 3.8 million patients may be reclassified as eligible for statin prescription depending on the model used. A key limitation of this study was that we could not assess the variation in risk that may be caused by risk factors missing from the database (such as diet or physical activity). CONCLUSIONS Risk prediction models that use routinely collected data provide estimates strongly dependent on modelling decisions. Despite this large variability in patient risk, the models appear to perform similarly according to standard performance metrics. Decision-making should be supplemented with clinical judgement and evidence of additional risk factors. The largest source of variability, a secular trend in CVD incidence, can be accounted for and should be explored in more detail.
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Affiliation(s)
- Alexander Pate
- Centre of Health eResearch, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK.
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crispigny Park, London, SE5 8AF, UK
| | - Darren M Ashcroft
- NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population of Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK
| | - Benjamin Brown
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population of Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK
- Public Health England North West, 3 Piccadilly Place, London Road, Manchester, M1 3BN, UK
| | - Tjeerd van Staa
- Centre of Health eResearch, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
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Hammond J, Mason T, Sutton M, Hall A, Mays N, Coleman A, Allen P, Warwick-Giles L, Checkland K. Exploring the impacts of the 2012 Health and Social Care Act reforms to commissioning on clinical activity in the English NHS: a mixed methods study of cervical screening. BMJ Open 2019; 9:e024156. [PMID: 30987985 PMCID: PMC6500278 DOI: 10.1136/bmjopen-2018-024156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Explore the impact of changes to commissioning introduced in England by the Health and Social Care Act 2012 (HSCA) on cervical screening activity in areas identified empirically as particularly affected organisationally by the reforms. METHODS Qualitative followed by quantitative methods. Qualitative: semi-structured interviews (with NHS commissioners, managers, clinicians, senior administrative staff from Clinical Commissioning Groups (CCGs), local authorities, service providers), observations of commissioning meetings in two metropolitan areas of England. Quantitative: triple-difference analysis of national administrative data. Variability in the expected effects of HSCA on commissioning was measured by comparing CCGs working with one local authority with CCGs working with multiple local authorities. To control for unmeasured confounders, differential changes over time in cervical screening rates (among women, 25-64 years) between CCGs more and less likely to have been affected by HSCA commissioning organisational change were compared with another outcome-unassisted birth rates-largely unaffected by HSCA changes. RESULTS Interviewees identified that cervical screening commissioning and provision was more complex and 'fragmented', with responsibilities less certain, following the HSCA. Interviewees predicted this would reduce cervical screening rates in some areas more than others. Quantitative findings supported these predictions. Areas where CCGs dealt with multiple local authorities experienced a larger decline in cervical screening rates (1.4%) than those dealing with one local authority (1.0%). Over the same period, unassisted deliveries decreased by 1.6% and 2.0%, respectively, in the two groups. CONCLUSIONS Arrangements for commissioning and delivering cervical screening were disrupted and made more complex by the HSCA. Areas most affected saw a greater decline in screening rates than others. The fact that this was identified qualitatively and then confirmed quantitatively strengthens this finding. The study suggests large-scale health system reforms may have unintended consequences, and that complex commissioning arrangements may be problematic.
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Affiliation(s)
- Jonathan Hammond
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Thomas Mason
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - Matt Sutton
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Alex Hall
- School of Health Sciences, University of Manchester, Manchester, UK
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Nicholas Mays
- Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Anna Coleman
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | - Lynsey Warwick-Giles
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Kath Checkland
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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11
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Crocker-Buque T, Edelstein M, Mounier-Jack S. A process evaluation of how the routine vaccination programme is implemented at GP practices in England. Implement Sci 2018; 13:132. [PMID: 30348182 PMCID: PMC6198492 DOI: 10.1186/s13012-018-0824-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 10/09/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND In recent years, the incidence of several pathogens of public health importance (measles, mumps, pertussis and rubella) has increased in Europe, leading to outbreaks. This has included England, where GP practices implement the vaccination programme based on government guidance. However, there has been no study of how implementation takes place, which makes it difficult to identify organisational variation and thus limits the ability to recommend interventions to improve coverage. The aim of this study is to undertake a comparative process evaluation of the implementation of the routine vaccination programme at GP practices in England. METHODS We recruited a sample of geographically and demographically diverse GP practices through a national research network and collected quantitative and qualitative data as part of a Time-Driven Activity-Based Costing analysis between May 2017 and February 2018. We conducted semi-structured interviews with practice staff involved in vaccination, who then completed an activity log for 2 weeks. Interviews were transcribed and coded using a framework method. RESULTS Nine practices completed data collection from diverse geographic and socio-economic contexts, and 52 clinical and non-clinical staff participated in 26 interviews. Information relating to 372 vaccination appointments (233 childhood and 139 adult appointments) was captured using activity logs. We have defined a 14-stage care delivery value chain and detailed process map for vaccination. Areas of greatest variation include the method of reminder and recall activities, structure of vaccination appointments and task allocation between staff groups. For childhood vaccination, mean appointment length was 15.9 min (range 9.0-22.0 min) and 10.9 min for adults (range 6.8-14.1 min). Non-clinical administrative activities comprised 59.7% total activity (range 48.4-67.0%). Appointment length and total time were not related to coverage, whereas capacity in terms of appointments per eligible patient may improve coverage. Administrative tasks had lower fidelity of implementation. CONCLUSIONS There is variation in how GP practices in England implement the delivery of the routine vaccination programme. Further work is required to evaluate capacity factors in a wider range of practices, alongside other contextual factors, including the working culture within practices.
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Affiliation(s)
- Tim Crocker-Buque
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Michael Edelstein
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
- Department of Immunisation, Hepatitis and Blood Safety, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, UK
| | - Sandra Mounier-Jack
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
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Street-level diplomacy? Communicative and adaptive work at the front line of implementing public health policies in primary care. Soc Sci Med 2017; 177:9-18. [PMID: 28152422 DOI: 10.1016/j.socscimed.2017.01.046] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 11/15/2016] [Accepted: 01/22/2017] [Indexed: 01/25/2023]
Abstract
Public services are increasingly operating through network governance, requiring those at all levels of the system to build collaborations and adapt their practice. Agent-focused implementation theories, such as 'street-level bureaucracy', tend to focus on decision-making and the potential of actors to subvert national policy at a local level. While it is acknowledged that network leaders need to be adaptable and to build trust, much less consideration has been given to the requirement for skills of 'diplomacy' needed by those at the front line of delivering public services. In this article, drawing on theoretical insights from international relations about the principles of 'multi-track diplomacy', we propose the concept of street level diplomacy, offer illustrative empirical evidence to support it in the context of the implementation of public health (preventative) policies within primary care (a traditionally responsive and curative service) in the English NHS and discuss the contribution and potential limitations of the new concept. The article draws on qualitative data from interviews conducted with those implementing case finding programmes for cardiovascular disease in the West Midlands. The importance of communication and adaptation in the everyday work of professionals, health workers and service managers emerged from the data. Using abductive reasoning, the theory of multi-track diplomacy was used to aid interpretation of the 'street-level' work that was being accomplished.
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