Clinical Commissioning Research Articles

HbA1c and hypoglycaemia in intensively treated type 2 diabetes: a retrospective cohort study in primary care.

ObjectiveTo establish whether low HbA1c is associated with clinical hypoglycaemia among people with type 2 diabetes prescribed insulins or sulphonylureas.DesignRetrospective cohort study using routine electronic GP health records collected between January 2013 and December 2015.SettingThree east London Clinical Commissioning Groups.ParticipantsTwo cohorts of adults with type 2 diabetes prescribed either (i) insulins with or without other oral antidiabetic medication (n = 6788, 36.4%) or (ii) sulphonylureas with or without other oral antidiabetic medications excluding insulins (n = 11,840, 63.6%).Main outcome measuresFirst clinically recorded hypoglycaemia and all-cause mortality. Hazard ratios (HR) adjusting for age, ethnicity, renal function and comorbidities were calculated using Cox regression models.ResultsCompared with an HbA1c of 53–63 mmol/mol, the adjusted HR of hypoglycaemia in those with a low HbA1c, below 53 mmol/mol, in the insulin and sulphonylurea cohorts were 1.26 (95% CI, 0.97 to 1.62) and 1.54 (95% CI, 1.27 to 1.87), respectively. Adjusted HRs of all-cause mortality from low HbA1c in the insulin and sulphonylurea cohorts were 1.54 (95% CI, 1.15 to 2.07) and 1.42 (95% CI, 1.11 to 1.81), respectively. Increasing age and renal impairment were also associated with increased hypoglycaemic risk in both cohorts.ConclusionsHbA1c below 53 mmol/mol was associated with episodes of clinical hypoglycaemia among people with type 2 diabetes prescribed sulphonylureas, and all-cause mortality in those prescribed insulins and sulphonylureas. These findings support the need for reviewing glycaemic targets and the intensities of treatment in those with low HbA1c prescribed insulins or sulphonylureas to reduce the risk of hypoglycaemia.

Specialist services in early diagnosis and support for older people with dementia in England: Staff roles and service mix.

This study investigated staff roles and tasks in Community Mental Health Teams (CMHT) and memory clinics, which are provided within a framework determined by local Clinical Commissioning Groups. A cross-sectional survey design was used to collect data in England in 2015. Teams were identified by mental health providers (n=68) and invited to complete a questionnaire. Fifty-one NHS Trusts responded to the request. The response rate varied. Data were obtained for all Clinical Commissioning Groups areas in 3 of the 9 regions in England, but only half in one of them. CMHTs were significantly more likely to have larger staff groups. Compared with memory clinics they were also more likely to have staff that were not professionally qualified. The occupational therapist role showed a strong association with the provision of all services in CMHTs. Both CMHTs and memory clinics provided information and advice about dementia. CMHTs provided more services associated with the support of a person with dementia at home. Variations in the staff mix in CMHTs and memory clinics reflected their different functions. There was limited evidence in both of profession specific interventions relating to the provision of support, information, therapy and education, associated with either diagnosis or long-term support. The potential for a single service to undertake both diagnostic and long-term support and the associated costs and benefits are areas for future research.

Identifying Patterns in Signs and Symptoms Preceding the Clinical Diagnosis of Alzheimer's Disease: Retrospective Medical Record Review Study and a Nested Case-control Design.

Evidence suggests that individuals with Alzheimer's disease (AD) are often diagnosed in the later stages of their disease with a poor prognosis. This study is aimed to identify patterns in signs and symptoms preceding the clinical diagnosis of AD to suggest a predictive model for earlier diagnosis of the disease in the primary care. A retrospective medical record review; nested case control design. Participants included one hundred and nine patients from three general practice (GP) surgeries in Milton Keynes and Luton Clinical Commissioning Groups (CCG) (37 cases with AD and 72 controls without AD). A retrospective analysis using the logistic regression of the presence of signs and symptoms before the diagnosis of AD was attained. Identification of the timing and sequence of appearance of these presentations as first reported before the clinical diagnosis was measured. Episodic memory with an odds ratio of 1.85 was the most frequent presentation, documented in 1.38% of the controls and 75.6% in cases. Auditory disturbance with an odds ratio of 3.03, which has not previously been noted except in the form of auditory hallucination, could have a diagnostic value. Auditory disturbance, which occurred mostly in the Caucasian females, could discriminate individuals with AD from those without the disease. The symptom, which presented up to 14.5 (mean time) years prior to clinical diagnosis, was identified in Caucasians and mixed race individuals only. The study demonstrates that auditory disturbance could allow an earlier diagnosis of AD in Caucasian females. Episodic memory was confirmed as being frequently noted in AD patients prior to a clinical diagnosis as per previous publications. This study supports the development of a scoring system for the earlier diagnosis of AD. The data used was free from the confounding effects of misinformation, as this was written at the point of collection, thereby benefitting from the use of GP data that is diversified, reliable and valid. Limited sample size that will not allow for generalization of less frequent observations due to their low prevalence in case notes. Randomisation was not achieved; however, the best available nonrandomisation which is consecutive sampling was used. Patterns identified were in LOAD, the baseline could vary with other geographical areas.

Local implementation of AMS initiatives: a mixed-methods study

BackgroundThe NHS English Quality Premium recommends that inappropriate antibiotic prescribing is reduced; there are a range of national antimicrobial stewardship (AMS) initiatives to support this.AimThe aim of this study is to assess AMS activities in primary care across England. The findings will be used to inform how the RCGP, PHE and NHS can help optimise stewardship activities.MethodQualitative interviews: with AMS leads within Clinical Commissioning Groups’ (CCGs) and Commissioning Support Units’ (CSUs) medicines management teams. Questionnaire: informed by the qualitative data, sent to all 209 CCGs in England in 2017.ResultsIn total, 89% (187/209) of CCGs returned a questionnaire; 82% of AMS leads reported spending only 0.1 whole-time equivalent on AMS activities, as it was only one role within a wider remit, so dedicating time is challenging. 99% (167/169) of CCGs had delivered AMS education in the last 2 years: 140 face-to-face; 121 via e-learning. 99% (184/186) actively promoted the TARGET Antibiotics Toolkit; 94% (175/187) actively promoted TARGET patient leaflets: 92% The Treating Your Infection (TYI) leaflet. 90% (166/185) used the PHE managing common infections guidance: 81% (149/185) modify or localise; 41/185 (22%) signpost directly to it. Eighty-six CCGs reported using CCG audit tools and 82 CCGs reported using TARGET’s audit tools. 85% (142/168) fed back antimicrobial prescribing data to the CCG/CSU board; 100% (169/169) to general practices and 33% (56/169) to out-of-hours providers.ConclusionAlthough CCGs reported promoting these AMS activities, there was little evaluation of uptake by primary care practitioners. Future work should focus on measuring AMS uptake; having staff dedicated solely to AMS could facilitate this.

Primary care improvement for patients with complex long-term conditions

BackgroundPatients with five or more long-term conditions have been shown in Barking, Havering and Redbridge Clinical Commissioning Groups to be the heaviest users of health and social care. An innovative new model of primary care, ‘Health 1000’ was thus established. Comprising a fully integrated multidisciplinary team (including third sector, a social worker and dual skilled ‘keyworkers’) this practice aligned the care of complex patients and endeavoured to avoid unnecessary hospital admissions.AimTo test the hypothesis that Health 1000 (a multidisciplinary GP practice with consultant geriatrician support) would align and improve quality of care and health/social outcomes for complex patients with five-plus long-term conditions.MethodUsing anonymised disease registers, an eligible cohort was identified and invited by their existing practices to re-register with Health 1000. Each patient received comprehensive initial consultation at registration, encompassing reviews of pill burden and social need. Biweekly multidisciplinary discussion ensured their care was aligned and met to a high quality. Independent qualitative evaluation was undertaken by the Nuffield Trust using face to face/telephone interviews with staff/patients.Results408 patients (from an eligible cohort of approximately 2000) were registered. Most patients were extremely satisfied with the new service highlighting friendly welcoming atmosphere, speed of service, key workers’ responsiveness, availability of phone consultations with GPs, longer appointment slots and home visits.ConclusionQualitative outcomes were very positive and suggest that there is benefit for patients with multiple long-term conditions from embedding a multidisciplinary team in primary care with specialist expertise.

Mental health in Sexual Assault Referral Centres: A survey of forensic physicians

A national survey of Forensic Physicians (FPs) working in Sexual Assault Referral Centres was undertaken. The survey was advertised in the weekly bulletin sent out by the Faculty of Forensic and Legal Medicine. Response was relatively low (n = 45). It is estimated that this figures represents about 12% of the workforce. The aim of the survey was to investigate FPs experience of accessing mental health pathways out of a SARC for complainants of all ages. The results concurred with a previous survey of SARC clinical managers with mental health services proving unresponsive. Informed co-commissioning between NHS England and Clinical Commissioning groups can only improve if aspects of complainant's mental health are routinely assessed within SARCs using structured outcome measures. Structured outcomes should be integrated into NHS England's Sexual Assault Referral Centres Indicators of Performance (SARCIP).

Socially engaged photography and wellbeing: reflections on a case study in the northwest of England.

This paper describes a 9-month project commissioned by Halton Clinical Commissioning Group (CCG) and Liverpool photography organisation, Open Eye Gallery. Socially engaged photographers worked with local residents from the Windmill Hill estate in Runcorn to describe healthy and unhealthy aspects of the area. Six women were trained to use cameras to document everyday things that mattered to them. Through focus groups they discussed what these photographs revealed about the health and ill-health of the area. The resulting exhibition, As and When, told their story. Despite being a deprived area with more than average incidence of illness, they identified many positive things that enhanced their sense of wellbeing and resilience. The benefits of the project included increased social engagement and participation, an improved sense of vitality and rejuvenation, emotional benefits, a feeling of greater political agency and increased visual literacy. This paper outlines the model of practice developed with the support of CCG and in collaboration with local stakeholders. It makes a case for the value and the ways in which clusters of general practices could develop links and work with health assets in their local communities.

Management of children and young people (CYP) with asthma: a clinical audit report

An asthma attack or exacerbation signals treatment failure. Most attacks are preventable and failure to recognize risk of asthma attacks are well recognized as risk factors for future attacks and even death. Of the 19 recommendations made by the United Kingdom National Review of Asthma Deaths (NRAD) (1) only one has been partially implemented—a National Asthma Audit; however, this hasn’t reported yet. The Harrow Clinical Commissioning Group (CCG) in London implemented a clinical asthma audit on 291 children and young people aged under 19 years (CYP) who had been treated for asthma attacks in 2016. This was funded as a Local Incentive Scheme (LIS) aimed at improving quality health care delivery. Two years after the publication of the NRAD report it is surprising that risks for future attacks were not recognized, that few patients were assessed objectively during attacks and only 10% of attacks were followed up within 2 days. However, it is encouraging that CYP hospital admissions following the audit were reduced by 16%, with clear benefit for patients, their families and the local health economy. This audit has provided an example of how clinicians can focus learning on patients who have had asthma attacks and utilize these events as a catalyst for active reflection in particular on modifiable risk factors. Through identification of these risks and active optimization of management, preventable asthma attacks could become ‘never events’.

Parity of access to memory services in London for the BAME population: a cross-sectional study

ABSTRACTObjective: To investigate whether referrals to memory services in London reflect the ethnic diversity of the population.Methods: Memory service data including referral rates of BAME was collected from London Clinical Commissioning Groups (CCGs).Results: The expected percentage of BAME referrals using census data was compared against White British population percentages using the chi squared test. We found that within 13,166 referrals to memory services across London, the percentage of people from BAME groups was higher than would be expected (20.3 versus 19.4%; χ2 = 39.203, d.f. = 1, p < 0.0001) indicating that generally people from BAME groups are accessing memory services. Seventy-nine percent of memory services had more referrals than expected or no significant difference for all BAME groups. When there were fewer referrals then expected, the largest difference in percentage for an individual ethnic group was 3.3%.Conclusions: Results are encouraging and may indicate a significant improvement in awareness of dementia and help seeking behaviour among BAME populations. Prevalence of dementia in some ethnic groups may be higher so these numbers could still indicate under-referral. Due to the data available we were unable to compare disease severity or diagnosis type.

The role of joint working between primary and secondary care in supporting people with type 1 diabetes

The role of joint working between primary and secondary care in supporting people with type 1 diabetes

Application of Bayes' to the prediction of referral decisions made by specialist optometrists in relation to chronic open angle glaucoma.

To determine the accuracy of a Bayesian learning scheme (Bayes') applied to the prediction of clinical decisions made by specialist optometrists in relation to the referral refinement of chronic open angle glaucoma. This cross-sectional observational study involved collection of data from the worst affected or right eyes of a consecutive sample of cases (n = 1,006) referred into the West Kent Clinical Commissioning Group Community Ophthalmology Team (COT) by high street optometrists. Multilevel classification of each case was based on race, sex, age, family history of chronic open angle glaucoma, reason for referral, Goldmann Applanation Tonometry (intraocular pressure and interocular asymmetry), optic nerve head assessment (vertical size, cup disc ratio and interocular asymmetry), central corneal thickness and visual field analysis (Hodapp-Parrish-Anderson classification). Randomised stratified tenfold cross-validation was applied to determine the accuracy of Bayes' by comparing its output to the clinical decisions of three COT specialist optometrists; namely, the decision to discharge, follow-up or refer each case. Outcomes of cross-validation, expressed as means and standard deviations, showed that the accuracy of Bayes' was high (95%, 2.0%) but that it falsely discharged (3.4%, 1.6%) or referred (3.1%, 1.5%) some cases. The results indicate that Bayes' has the potential to augment the decisions of specialist optometrists.

Moving anticoagulation initiation and monitoring services into the community: evaluation of the Brighton and hove community pharmacy service

BackgroundAs part of the NHS desire to move services closer to where people live, and provide greater accessibility and convenience to patients, Brighton and Hove Clinical Commissioning Group (CCG) underwent a review of their anticoagulation services during 2008. The outcome was to shift the initiation and monitoring service in secondary care for non-complex patients, including domiciliary patients, into the community. This was achieved via a procurement process in 2008 resulting in the Community Pharmacy Anticoagulation Management Service (CPAMs) managed by Boots UK (a large chain of community pharmacies across the United Kingdom).MethodsThis evaluation aims to review the outcomes (International Normalised Ratio [INR] readings) and experiences of those patients attending the anticoagulation monitoring service provided by community pharmacists in Brighton and Hove. All patients on warfarin are given a target INR range they need to achieve; dosing of and frequency of appointment are dependent on the INR result. Outcome measures for patients on the CPAM service included percentage INR readings that were within target range and the percentage time the patient was within therapeutic range. Data collected from 2009 to 2016 were analysed and results compared to the service targets. Patient experience of the service was evaluated via a locally developed questionnaire that was issued to patients annually in the pharmacy.ResultsThe evaluation shows that community pharmacy managed anticoagulation services can achieve outcomes at a level consistently exceeding national and local targets for both percentage INR readings in therapeutic target range (65.4%) compared to the recommended minimum therapeutic target range of 60.0% and percentage time in therapeutic range (72.5%, CI 71.9–73.1%) compared to the national target of 70.0%. Patients also indicated they were satisfied with the service, with over 98.6% patients rating the service as good, very good or excellent.ConclusionThe Brighton and Hove CPAM service achieved above average national target management of INR and positive patient feedback, demonstrating that community pharmacy is ideally placed to provide this service safely and deliver enhanced clinical outcomes and positive patient experience.

Recruitment and retention in general practice nursing: What about pay?

As the employees of independent contractors, most nurses working in general practice are not subject to Agenda for Change. This article looks at a pay framework that has been developed for nurses and healthcare assistants in Lambeth, South London When Agenda for Change was introduced in 2004, many nurses saw an increase in pay, alongside the potential for annual incremental pay rises and the ability to progress through pay bands with appropriate study and the undertaking of additional responsibilities. As practice nurses are the employees of independent contractors, most were not enrolled in Agenda for Change. They now have no nationally recognised payscale and have to negotiate pay, terms and conditions on an individual basis. The lead nurses in Lambeth, South London decided to develop a pay framework that mapped to the general practice nurse career framework. This was fully endorsed by Lambeth Clinical Commissioning Group and Community Education Providers Network and was launched in June 2017. In January 2018, a pay framework was also launched for healthcare assistants in Lambeth. The framework aims to allow general practice to compete with all healthcare sectors and to make general practice an attractive and viable career option.

Feasibility, acceptability and effectiveness of an online alternative to face-to-face consultation in general practice: a mixed-methods study of webGP in six Devon practices

ObjectivesTo evaluate the feasibility, acceptability and effectiveness of webGP as piloted by six general practices.MethodsMixed-methods evaluation, including data extraction from practice databases, general practitioner (GP) completion of case reports, patient...

Clinical leadership in service redesign using Clinical Commissioning Groups: a mixed-methods study

BackgroundA core component of the Health and Social Care Act 2012 (Great Britain.Health and Social Care Act 2012. London: HMSO; 2012) was the idea of devolving to general practitioners (GPs) a health service leadership role for service redesign. For this purpose, new Clinical Commissioning Groups (CCGs) were formed in the English NHS.ObjectivesThis research examined the extent to which, and the methods by which, clinicians stepped forward to take up a leadership role in service redesign using CCGs as a platform.DesignThe project proceeded in five phases: (1) a scoping study across 15 CCGs, (2) the design and administration of a national survey of all members of CCG governing bodies in 2014, (3) six main in-depth case studies, (4) a second national survey of governing body members in 2016, which allowed longitudinal comparisons, and (5) international comparisons.ParticipantsIn addition to GPs serving in clinical lead roles for CCGs, the research included insights from accountable officers and other managers and perspectives from secondary care and other provider organisations (local authority councillors and staff, patients and the public, and other relevant bodies).ResultsInstances of the exercise of clinical leadership utilising the mechanism of the CCGs were strikingly varied. Some CCG teams had made little of the opportunity. However, we found other examples of clinicians stepping forward to bring about meaningful improvements in services. The most notable cases involved the design of integrated care for frail elderly patients and others with long-term conditions. The leadership of these service redesigns required cross-boundary working with primary care, secondary care, community care and social work. The processes enabling such breakthroughs required interlocking processes of leadership across three arenas: (1) strategy-level work at CCG board level, (2) mid-range operational planning and negotiation at programme board level and (3) the arena of practical implementation leadership at the point of delivery. The arena of the CCG board provided the legitimacy for strategic change; the programme boards worked through the competing logics of markets, hierarchy and networks; and the practice arena allowed the exercise of clinical leadership in practical problem-solving, detailed learning and routinisation of new ways of working at a common-sense everyday level.LimitationsAlthough the research was conducted over a 3-year period, it could be argued that a much longer period is required for CCGs to mature and realise their potential.ConclusionsDespite the variation in practice, we found significant examples of clinical leaders forging new modes of service design and delivery. A great deal of the service redesign effort was directed at compensating for the fragmented nature of the NHS – part of which had been created by the 2012 reforms. This is the first study to reveal details of such work in a systematic way.Future workFurther focus is needed on the emergent sustainability and transformation plans and the locality/hubs/primary care homes that integrate care across population groups.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Clinical pharmacists in general practice: an initial evaluation of activity in one English primary care organisation.

This aim of this research was to characterise the breadth and volume of activity conducted by clinical pharmacists in general practice in Dudley Clinical Commissioning Group (CCG), and to provide quantitative estimates of both the savings in general practitioner (GP) time and the financial savings attributable to such activity. This descriptive observational study retrospectively analysed quantitative data collected by Dudley CCG concerning the activity of clinical pharmacists in GP practices during 2015. Over the 9-month period for which data were available, the 5.4 whole time equivalent clinical pharmacists operating in GP practices within Dudley CCG identified 23172 interventions. Ninety-five per cent of the interventions identified were completed within the study period saving the CCG in excess of £1000000. During the 4months for which resource allocation data were available, the clinical pharmacists saved 628 GP appointments plus an additional 647h that GPs currently devote to medication review and the management of repeat prescribing. This research suggests that clinical pharmacists in general practice in Dudley CCG are able to deliver clinical interventions efficiently and in high volume. In doing so, clinical pharmacists were able to generate considerable financial returns on investment. Further work is recommended to examine the effectiveness and cost-effectiveness of clinical pharmacists in general practice in improving outcomes for patients.

Enacting localist health policy in the English NHS: the 'governing assemblage' of Clinical Commissioning Groups.

Objectives The Health and Social Care Act 2012 introduced Clinical Commissioning Groups to take responsibility for commissioning (i.e. planning and purchasing) the majority of services for local populations in the English NHS. Constituted as 'membership organizations', with membership compulsory for all GP practices, Clinical Commissioning Groups are overseen by, and are accountable to, a new arm's-length body, NHS England. This paper critically engages with the content and policy narrative of the 2012 Act and explores this in relation to the reality of local policy enactment. Methods Set against a careful review of the 2012 Act, a case study of a nascent Clinical Commissioning Groups was conducted. The research included observations of Clinical Commissioning Group meetings and events (87 h), and in-depth interviews (16) with clinical commissioners, GPs, and managers. Results The 2012 Act was presented as part of a broader government agenda of decentralization and localism. Clinical Commissioning Group membership organizations were framed as a means of better meeting the needs and preferences of local patients and realizing a desirable increase in localism. The policy delineated the 'governing body' and 'the membership', with the former elected from/by the latter to oversee the organization. 'The membership' was duty bound to be 'good', engaged members and to represent their patients' interests. Fieldwork with Notchcroft Clinical Commissioning Group revealed that Clinical Commissioning Groups' statutory duty to NHS England to 'ensure the continuous improvement' of GP practice members involved performance scrutiny of GP practices. These governance processes were carried out by a varied cast of individuals, many of whom did not fit into the binary categorization of membership and governing body constructed in the policy. A concept, the governing assemblage, was developed to describe the dynamic cast of people involved in shaping the work and direction of the Clinical Commissioning Group, many of whom were unelected and of uncertain status. This was of particular significance in Notchcroft Clinical Commissioning Group because the organization explicitly pursued a governance system based on developing positions of consensus. The governing assemblage concept is valuable in articulating the actual practices of Clinical Commissioning Group governance, how these relate to the normative content of the 2012 Act, and the tensions that emerge. Conclusions The governing assemblage concept provided clarity in discussion of the dynamics of organizational governance in Notchcroft Clinical Commissioning Group, which did not follow the simple template articulated in the 2012 Act. The concept merits application in the study of other Clinical Commissioning Groups and may prove valuable in illuminating governance processes within a range of other health care organizations in different contexts. The governing assemblage holds promise for the analysis of ongoing changes to NHS organization, as well as international health care organizations such as accountable care organizations in the US.

Growth in NHS admissions and length of stay: A policy-based evidence fiasco

Growth in NHS admissions and length of stay: A policy-based evidence fiasco

Commissioning of the world's first compact pencil-beam scanning proton therapy system.

This paper summarizes clinical commissioning of the world's first commercial, clinically utilized installation of a compact, image‐guided, pencil‐beam scanning, intensity‐modulated proton therapy system, the IBA Proteus® ONE, at the Willis‐Knighton Cancer Center (WKCC) in Shreveport, LA. The Proteus® ONE is a single‐room, compact‐gantry system employing a cyclotron‐generated proton beam with image guidance via cone‐beam CT as well as stereoscopic orthogonal and oblique planar kV imaging. Coupling 220° of gantry rotation with a 6D robotic couch capable of in plane patient rotations of over 180° degrees allows for 360° of treatment access. Along with general machine characterization, system commissioning required: (a) characterization and calibration of the proton beam, (b) treatment planning system commissioning including CT‐to‐density curve determination, (c) image guidance system commissioning, and (d) safety verification (interlocks and radiation survey). System readiness for patient treatment was validated by irradiating calibration TLDs as well as prostate, head, and lung phantoms from the Imaging and Radiation Oncology Core (IROC), Houston. These results confirmed safe and accurate machine functionality suitable for patient treatment. WKCC also successfully completed an on‐site dosimetry review by an independent team of IROC physicists that corroborated accurate Proteus® ONE dosimetry.

Leading support for those with mental health issues and learning disabilities

Alistair Quaile provides the highlights of the NHS Health and Care Innovation Expo 2017 session entitled Leading support for those with mental health issues and learning disabilities. It was a panel discussion with Professor Jane Cummings, Chief Nursing Officer, NHS England; Claire Murdoch, National Director for Mental Health, NHS England, and Chief Executive Officer, Central and North West London NHS; Vicky Stobbart, Executive Director of Nursing and Quality, Guildford and Waverley Clinical Commissioning Group; Julia Hunt, Director of Nursing at James Paget University Hospitals NHS Foundation Trust; Sue Hartley, Executive Director of Nursing, Birmingham and Solihull Mental Health Foundation Trust; Carl Shaw, Learning Disability Advisor; and Katy Chachou, peer support worker.