Local Health Care Co-operatives Research Articles

Using prescribing health and population data to describe the health of a locality: the development and evaluation of a locality health profile

Abstract Objective To develop and evaluate a pharmaco-epidemiological and public health profile that will aid in the determination and evaluation of the health and pharmaceutical needs of a local population with the National Health Service (NHS). Method Two local health areas (known as local health care co-operatives (LHCCs)) in NHS Lothian with diverse population characteristics had health profiles formally developed using prescribing, hospitalisation and other public health data. The integrated report was able to highlight morbidity issues in each LHCC that could be acted on by either LHCC management or local pharmacy groups. A steering committee and focus groups were used in the design and evaluation process. An evaluation survey of participants including LHCC management, community and LHCC pharmacists and other healthcare professionals was conducted with the main outcome measure being the relative utility of the health profile. Key findings Participants evaluating the health profiles found them informative and useful in decision making and planning for the locality. Participants anticipated using prescribing data to fill information gaps in other datasets and/or provide a primary care perspective to health in the locality. Conclusions Health profiles were developed from prescribing health and population data that were shown to be meaningful and useful to local health authority management and other healthcare professionals. The health profiles contained information that could be used to inform decisions or identify areas where further investigation may be required to find out why a particular anomaly is occurring. In Scotland, the focus of a new community pharmacy contract is on the dual elements of chronic disease management and public health contributions, through prevention of disease and/or limitation of disease impact. There is an urgent need to develop tools that help to inform professional interventions involving pharmacists, and thereby improvements to multidisciplinary co-operation. This study suggests a means of describing the population characteristics for informing a network of community pharmacists about public health priorities within their LHCC.

What impact did the creation of Local Health Care Co-operatives have on indicators of practice resources and activity?

BackgroundThe creation of Local Health Care Cooperatives (LHCCs) in Scotland in 1999 was typical of attempts to encourage voluntary integration and co-operation between health care providers. One of the three stated objectives of their introduction was to tackle inequalities and improve access to care.MethodsWe used administrative data on all general practices in 1999 and 2003 to examine whether LHCCs had any measurable impact on six indicators of practice resources and activity. We compare three groups (participant, non-participant, and ineligible practices) through regression analysis of changes over time in group means and within-group inequality (measured using Gini coefficients). In addition, for participants we measure changes in the variation between and within LHCCs.ResultsDespite having similar registered populations to participants, non-participants had lower levels of resources at the start of the period and this differential widened over time. The changes over time in the activity indicators were similar across the three groups. There was little evidence that inequality between LHCC practices narrowed more than in the other two groups. Practices within LHCCs appear to be become more homogenous while variation increased between LHCCs.ConclusionThe mixed messages from our examination of resources and activity indicators demonstrates that there are likely to be important lessons to be learned from the brief experiment with LHCCs. Clear objectives that are evaluated using a battery of simple performance indicators may help to ensure demonstrable change in future initiatives to foster integration and co-operation.

Scottish survey of diabetes services for minority ethnic groups

BackgroundIn the UK, all ethnic minority groups have higher rates of diabetes than the general population. Although there have been a number of projects to assess diabetic care amongst minority ethnic groups in the United Kingdom, little is known about the extent to which the needs of ethnic minority groups are actually met by the National Health Service (NHS) Scotland. Therefore we conducted this study to understand of the current situation for diabetes care available to minority ethnic groups in Scotland.MethodsWe conducted this cross-sectional study in all health boards in Scotland. A questionnaire was designed based on expert comments. It was completed by Local Health Care Cooperatives (LHCC) managers, chairs, diabetes specialist nurses and public health practitioners.Results57 of questionnaires were returned (response rate = 69.5%). Of these LHCCs, 71% responded that diabetes was part of their LHCC plan. However 69% answered that ethnic group was not recorded by community services and GPs, and 80% of LHCCs did not monitor trends of complications of diabetes by ethnic group.ConclusionImprovement is needed in quality, completeness, and availability of minority ethnic group data for diabetes at a national level, particularly if NHS Primary Care Organisations are to be responsible for providing diabetes care as laid out in the Scottish Diabetes Framework.

Document delivery service at a Scottish primary care hospital library: Maria Henderson Library, Glasgow

Document delivery service at a Scottish primary care hospital library: Maria Henderson Library, Glasgow

Voluntary or compulsory health care reform?: The case of primary care organisations in Scotland

Previous studies have suggested that voluntary reform of the delivery of primary care services is more likely to occur in affluent areas. Health system reforms that include voluntary participation of GPs may therefore lead to a two-tier service in terms of access to and utilisation of medical services. New primary care organisations in Scotland (local health care co-operatives) were introduced in 1999. These are groups of general practices and membership was voluntary. The aim of this study is to examine whether the voluntary nature of membership was likely to exacerbate or reduce inequalities in the provision of primary care services. Logistic regression analysis was used to identify differences in population, practice, and GP characteristics between general practices that have joined a co-operative and those that have not. The results indicated that practices located in deprived areas and covering populations with high levels of morbidity were more likely to join a co-operative. High workload decreased the probability of membership. General practices that found it difficult to obtain access to local authority residential care homes were more likely to join a co-operative. The number of fee claims for minor surgery sessions per whole-time equivalent GP increased the probability of membership. There is therefore some evidence indicating that general practices located in areas of high need are more likely to join a co-operative. This suggests that voluntary participation in these new primary care organisations may reduce rather than exacerbate inequalities in the provision of primary care.

Epidemiology of multiple sclerosis in Glasgow.

The objectives of the study were to establish the prevalence and incidence of multiple sclerosis in Glasgow and to assess the epidemiological importance of deprivation and ethnicity. The study was a descriptive cross-sectional study. Multiple sources of ascertainment were used to identify cases. The study was carried out in the population of three Local Health Care Cooperatives (LHCCs) in the area of Greater Glasgow NHS Board. The total population was approximately 169,000. In total, 245 patients with multiple sclerosis were identified. The mean age of patients was 49.8 years, the female to male ratio was 3.2:1, and the mean duration of disease was 16 years. The overall prevalence was 14.5 per 10,000, and the overall incidence 5.7 per 100,000 per year. Both the prevalence and incidence of multiple sclerosis were higher in the more affluent population. The crude prevalence in the Asian population was 6.3 per 20,000. The epidemiology of multiple sclerosis in Glasgow was similar, in most respects, to the epidemiology described in other parts of the U.K. There was evidence for the importance of deprivation as a determinant of both incidence and prevalence of disease. The reasons for the higher incidence and prevalence of multiple sclerosis in less deprived populations are not clear.

Attitudes and knowledge of primary care professionals towards evidence-based practice: a postal survey.

To describe the attitudes, awareness and use of evidence across key professional groups working in primary care. A postal questionnaire was sent to all lead/chairs, general managers, clinical governance leads, lead nurses, lead pharmacists and public health practitioners working in local health care cooperatives in Scotland. 289 (66.1%) health care professionals responded, ranging from 51% of general managers to 80% of lead nurses. All professional groups supported evidence-based practice. General practitioners (GPs) were less likely to agree that they had the skills to carry out literature reviews or appraise evidence compared to nurses and public health facilitators (36% vs. 75% vs. 80%; 51% vs. 64% vs. 70%). Access to the internet and bibliographic databases was good for all groups but GPs used a narrower spectrum of evidence-based journals, relying mainly on medical literature. Only nurses and public health practitioners appeared to have any understanding of qualitative research terms. Public health practitioners were also least likely to view guidelines or protocols developed by others as the best source of evidence for primary care. The major perceived barrier to practising evidence-based practice was time. Consequently the most important facilitator was protected time, but increased resources (financial and staff) and training were also cited. Professional groups other than GPs perceived inter-professional boundaries as a barrier and suggested multi-professional teamworking and learning as potential supports for evidence-based practice. While all professional groups welcome and support evidence-based practice, there are clear differences in the starting point and perspectives across the groups. These need to recognized and addressed to ensure that learning the skills of evidence-based practice and implementing evidence are effective. This will also enhance the ability of primary care organizations to develop robust mechanisms for supporting key aspects of clinical governance.

Patients in waiting: a qualitative study of type 2 diabetes patients' perceptions of diagnosis.

Our aim was to examine how diagnosis is perceived by a sample of newly diagnosed type 2 diabetes patients. A qualitative study was carried out in the Lothian region of Scotland using in-depth interviews of 40 newly diagnosed type 2 diabetes patients recruited from 16 general practices in four Local Health Care Co-operatives and three hospital clinics. Purposive selection ensured that the sample's demographic characteristics were broadly representative of newly diagnosed type 2 diabetes patients in Lothian/Scotland. Clarity, timing and authority of the diagnosis delivery were highly salient for patients. Many patients perceived their GP as unwilling to deliver/confirm the diagnosis. Patients who were not referred to hospital were unclear why a referral had not taken place. Those referred perceived confirmation of diagnosis by the consultant as a central reason. Waiting for a hospital appointment could be problematic for patients. Most wanted the diagnosis confirmed before they felt confident making lifestyle changes. Input from health services during the period prior to the hospital visit was highly valued. Waiting was taken by some asymptomatic patients to indicate that they did not have the condition. Others used a lengthy period of waiting to confirm their view that they had a 'milder' or 'less serious' form of diabetes than other patients. Adequate input from practitioners is needed to ensure that diagnosis is fully exploited as a crucial period in which patients learn to adapt to their condition. Being explicit about the diagnosis at first contact may avoid the problem of patients feeling 'in limbo' or uncertain whether they have type 2 diabetes. Practitioners should convey to patients that post-diagnosis/initial care is a process, stages of this process should be clarified to avoid misunderstanding and services should be integrated during this interim period to best effect.

Partnerships in primary care: What we can learn from the experience of Scottish local health care co-operatives

A number of countries are introducing partnerships in primary care that promote collaboration within the primary health care sector in order to provide seamless and high-quality care to patients, whilst containing costs. This paper reports on a nationwide survey of Scottish local health care co-operatives to illustrate how partnerships in primary care manage the process of organisational change and start tackling their core functions. During their first year of operation, local health care co-operatives have put an organisational structure in place to start developing primary care services in collaboration with other health care providers. Strong management has been fundamental to the success of local health care co-operatives in stimulating collaboration between health care providers and in developing services. However, a lack of time of general practitioners to participate in the activities of the co-operative, inadequate representation of stakeholders in management bodies, constraints on management budgets, and reluctance by general practitioners to embrace clinical governance may inhibit the further development of local health care co-operatives. Although local health care co-operatives have made considerable progress, they still need to demonstrate whether they are able to deliver tangible benefits to patients.

Women's knowledge of and attitudes towards hormone replacement therapy.

Hormone replacement therapy (HRT) could benefit women who have reached the natural menopause, have had a hysterectomy or have a family history of osteoporosis. Our aim was to monitor changes in women's knowledge of, and attitudes towards, HRT since 1991. The study was a repeat of a postal survey conducted in 1991 in the Grampian region in the North East of Scotland. Six hundred women, aged 20-69 years, were selected randomly from the eight Local Health Care Co-operatives in Grampian, Scotland. The main outcome measures were women's knowledge of HRT, their attitudes towards it and the percentage of users, past users and never users within the sample. A 79% response rate was achieved. Overall, 17% of post-menopausal women were current takers (increased from 9% in 1991), 22% were previous takers (increased from 7%) and 61% were never takers (decreased from 84%). This increase in ever use of HRT was more pronounced in the less educated women (increase of 24% since 1991) compared with the more educated (increase of 13%). Almost half (48%) of post-menopausal women had considered taking HRT (25% increase). However, of never users, the majority (86%) had never considered HRT and had not discussed it with a doctor. Attitudes towards the menopause remained positive, although knowledge of the effects of HRT and of risk factors for osteoporosis had decreased. Forty-two per cent of never users would be persuaded to take HRT if they knew it would not cause any problems, and 52% would be persuaded to take HRT on the recommendation of a doctor. Since 1991, HRT use increased overall; this increase was greater in the less educated women. However, the majority of post-menopausal women remain never users, and many were unaware of HRT. Conflicting research evidence since 1991 on the risks and benefits of HRT may account for the decrease in the women's knowledge of the effects of HRT.

How are Scottish integrated primary care organisations managed?

In the absence of central guidance on the development of integrated primary care organisations, a diversity of models is emerging. This paper examines the management arrangements of Scottish local health care co-operatives (LHCCs). A postal questionnaire survey of all 79 LHCCs was conducted. The response rate was 35 per cent. LHCCs set up management bodies and created workgroups. Stakeholder representation was not socially inclusive: attempts to engage patients and local communities were limited and need to be stepped up to increase responsiveness and accountability to local health care users. LHCCs were also vehicles for local ownership and control of health care provision. To facilitate co-operation among participating practices, LHCCs need to focus on issues of leadership, organisation, and involvement in decision making. Finally, management expenditure per capita was comparable with that of other types of integrated primary care organisations.

Progress in the development of integrated mental health care in Scotland

The development of integrated care through the promotion of 'partnership working' is a key policy objective of the Scottish Executive, the administration responsible for health services in Scotland. This paper considers the extent to which this goal is being achieved in mental health services, particularly those for people with severe and enduring mental illness. Distinguishing between the horizontal and vertical integration of services, exploratory research was conducted to assess progress towards this objective by examining how far a range of functional activities in Primary Care Trusts (PCTs) and their constituent Local Health Care Co-operatives (LHCCs) were themselves becoming increasingly integrated. All PCTs in Scotland were surveyed by postal questionnaire, and followed up by detailed telephone interviews. Six LHCC areas were selected for detailed case study analysis. A Reference Group was used to discuss and review emerging themes from the fieldwork. The report suggests that faster progress is being made in the horizontal integration of services between health and social care organisations than is the case for vertical integration between primary health care and specialist mental health care services; and that there are significant gaps in the extent to which functional activities within Trusts are changing to support the development of integrated care. A number of models are briefly considered, including the idea of 'intermediate care' that might speed the process of integration.

Can primary care be both patient-centred and community-led?

Examines the relationships between the macro-, meso-, and micro-levels in the NHS at the end of the fundholding period and considers their contemporary implications for primary care groups (PCGs) and local health care co-operatives (LHCCs). Fundholding achieved some success in challenging the way in which services were provided at the micro-level (the practice), but had a less marked effect in terms of changing service provision at the health authority (meso-) level or in developing collaborative working with trusts and health authorities in strategic decision making. The health authorities prioritized alternative models of devolved commissioning. Trusts regarded fundholders as a distraction who exerted influence and commanded trust management time disproportionate to their "market share". PCGs and LHCCs represent a shift back to the meso-level in service planning and purchasing. As such there is a risk that the micro-level benefits of fundholding and other forms of devolved commissioning will be lost, while uncertainties remain regarding the capacity of PCGs and LHCCs to incorporate GPs into a collaborative approach to strategic decision making.

Localization and Partnership in the ‘New National Health Service': England and Scotland Compared

This article examines some important and interesting differences in the designs of the ‘New NHS’ in England and Scotland in respect of two common guiding imperatives – localization and partnership. In examining the view of key local stakeholders faced with introducing the changes, we contrast the generally more flexible and less prescriptive approach in Scotland. In England there was, initially, a raft of guidance from the centre: in Scotland, by contrast, there was virtually none. In England the prime bases for localization will be PCGs and PCTs: in Scotland they will be Local Health Care Co‐operatives (LHCCs). The latter, like the English PCGs, are to be GP‐led; but unlike PCGs, membership is voluntary. Underlying such redesign of the organizational architecture are some important changes in cultures and modes of governance. In particular, we note the rhetoric of a shift, at macro‐level, from hierarchies and quasi‐markets to networks and the perceived reality of a micro‐level shift from individualism to collegiality amongst GPs.

The development of integrated health care models in Scotland

Integrated health care is a key policy aim of Scotland's newly devolved government. 'Partnership working' is the mechanism that has been selected to achieve this goal. Three illustrative examples of health care integration models developed in Scotland are considered; system organisation and structure; Local Health Care Co-operatives (LHCCs); and Managed Clinical Networks. Using these examples the paper explores the nature of 'partnership' and asks if it can deliver integrated care.

New Zealand's independent practitioner associations: a working model of clinical governance in primary care?

Clinical governance has achieved “band wagon” status in recent months in the United Kingdom.1–3 Yet there remains considerable confusion and uncertainty about its scope and purpose. Since 1991-2, the NHS...

Local health care cooperatives

In Scotland, 1999 may be remembered as the year of devolution. For those working in primary health care, it will be remembered as the year of evolution. Heralded by the White Paper, Designed to Care (Scottish Office Department of Health (SODoH), 1997), April marked the start of the move into locally-led health care. The rationalizing of trusts has been an exercise in expediency, whereas the launch of the local health care cooperative (LHCC) will see the evolution of locally-led health services.

Towards primary care groups The development of local healthcare cooperatives in Scotland

This is the third of four articles showing how primary care groups have been set up in various areas in Britain The plan for the NHS in Scotland mapped out...

Update on the new NHS

In 1998, primary health care staff in the UK made preparations for an overhaul of the health service. The changes were spelled out in The New NHS (England), Putting PatientsFirst (Wales) and Designed To Care(Scotland). Now, in 1999, the proposed changes are about to happen. The shadow primary care groups (PCCs) in England and local health groups in Wales are now in place, while in Scotland the local health care cooperatives (LHCCs) are due to kick off on April 1.

General Practice

# Meeting the information and budgetary requirements of primary care groups {#article-title-2} Primary care is experiencing another wholesale reorganisation as the government's “new NHS” is implemented. The intention is to...