London Primary Care Trusts Research Articles

Hospital data may be more accurate than census data in estimating the ethnic composition of general practice populations

Equity of service provision by age, ethnicity and sex is a key aim of Government policy in the UK. The prevalence, natural history and management of common chronic conditions, such as diabetes and hypertension, vary between ethnic groups. Developing and monitoring responsive local services requires accurate measures of ethnicity and language needs. Hence establishing the ethnic composition of GP populations is important. To compare three methods of estimating the ethnic composition of GP registered populations in three east London primary care trusts (PCTs). Self-reported ethnicity, routinely collected at practice level (and considered the 'gold standard'), was compared with two indirect methods of attributing ethnicity. The indirect method currently used in the UK assigns ethnicity to GP populations based on geographical postcode attribution from the national census. A proposed alternative indirect method uses the ethnic breakdown of hospital admission data from practice lists to attribute ethnicity to the whole practice population. Comparisons were made between practice self-report recording and these two indirect methods. Bland-Altman plots were used to assess the agreement between methods of measurement. Data from 103 practices, covering 70% of the GP registered population, was used. The hospital admission method showed better agreement with practice self-report data than the census attributed method. For white populations Bland-Altman plots showed a mean difference of 1.4% (95% CI-14.9 to 17.7) between hospital admission and practice data, and a mean difference of 12.5% (95% CI-6.2 to 31.1) between census attributed and practice data. Differences were also found for south Asian and black populations. Practice ethnicity measured using hospital attendance data is in closer agreement with practice recording of self-reported ethnicity than the census attribution method. Census attribution may provide misleading information on the ethnic composition of practice populations. We recommend that healthcare commissioners change to this method of measurement when practice self-report data is not available.

Data mining of tuberculosis patient data using multiple correspondence analysis

The aim of this study was to demonstrate the epidemiological use of multiple correspondence analysis (MCA), as applied to tuberculosis (TB) data from North East London. Data for TB notifications in North East London primary care trusts (PCTs) between the years 2002 and 2007 were used. TB notification data were entered for MCA allowing display of graphical data output (n=4947); MCA analyses were performed on the whole dataset, by PCT, and by year of notification. Graphical MCA output displayed variance of data categories; clustering of variable categories in MCA output signified association. Clustering patterns in MCA output demonstrated different associations by year of notification, within PCTs and between PCTs. MCA is a useful technique for displaying association of variable categories used in TB epidemiology. Results suggest that MCA could be a useful tool in informing commissioning of TB services.

Diabetes intermediate care services in Hounslow.

Practice based commissioning (PBC), payment by results and financial deficits have all placed a financial imperative on primary care trusts (PCT) to deliver savings by reducing referrals to secondary care. In many London PCTs, referrals to secondary care diabetes services have been a priority and this has led to intermediate PCT led services springing up all over London. Hounslow Diabetes Intermediate Care Service is one of them and at a time when many PBC groups are trying to develop intermediate services I sent Lauren Baines to meet the Hounslow team and tell us about their journey to becoming a well established service.

A cluster-randomised controlled trial of a brief training session to facilitate general practitioner referral to smoking cessation treatment

Objectives: General practitioners (GPs) are the main source of referrals to specialist smoking cessation services (SSCS), but the referral rates are low. We evaluated effects of a brief GP training...

Nursing the dying within a generalist caseload: A focus group study of district nurses

Background Community nurses (members of UK District Nursing teams) have a key role in the provision of palliative care in the community in the UK. However, their views about delivering palliative care within their generalist workload have not been assessed. Objectives To explore community nurses’ perceptions of their palliative care role, and their provision of such care within the context of their wider generalist workload. Design Focus group study. Setting Four Primary Care Trusts in London, UK. Participants A purposive sample of 51 community nurses. Methods Nine focus groups (four to seven participants in each) were conducted between 2003 and 2004. Data were analysed using the framework approach. Results We identified five broad themes. Community nurses felt they had a central role in the provision of palliative care to patients at home. Many felt this role was not recognised by other health care professionals and managers. Palliative care was identified as unpredictable and time-consuming within a pressurized context characterised by staff shortages and consequent lack of time. Whilst rewarding, palliative care took its toll on nurses’ emotions, compounded by a perceived lack of formal support. Finally, undertaking palliative within a generalist workload created additional pressures for community nurses. Conclusions The integration of palliative care into routine generalist caseloads generated workload stresses in time and emotion. Community nurses felt their palliative care role and its impact on workload was not adequately acknowledged. Palliative care specific support mechanisms and ways of working may be necessary to meet patients’ and professionals’ expectations of effective, compassionate care at the end of life.

The management of type 2 diabetes care: the challenge within primary care

AbstractManaging type 2 diabetes in primary care poses many challenges for health professionals in preventing and managing complications. These challenges are greatly amplified in those environments with high levels of deprivation and ethnic diversity.A retrospective structured audit of patient electronic medical records, with systematic extraction of clinical data, was undertaken in three general practices in an ethnically diverse outer London primary care trust. The records of 646 patients were analysed.Patients from minority ethnic groups were significantly more likely to have poor glycaemic control (p<0.05), and a higher proportion of patients with poor control were aged under 60 (p<0.05). Asian patients showed much higher levels of overall body mass index (BMI) risk, with all Asian patients (100%, n=85) having a sub‐optimal BMI compared to other patient groups (p<0.001). Younger age (50 years and under) was associated with less frequent contact (p<0.05). Patients managed solely in general practice had significantly better glycaemic control than those in shared care schemes (p<0.01). Feedback from practices found that diabetes support services were limited and, as such, influenced health professionals' ability to provide some on‐going care in terms of dietary advice and insulin initiation.The audit findings suggest that there are some significant relationships between diabetes outcomes, patient characteristics and the care process. It may be possible to develop interventions suitable for metropolitan primary care and which reflect the diversity of population needs. Copyright © 2008 John Wiley & Sons.

Ethnic inequalities in the treatment and outcome of diabetes in three English Primary Care Trusts

BackgroundAlthough the prevalence of diabetes is three to five times higher in UK South Asians than Whites, there are no reports of the extent of ethnicity recording in routine general practice, and few population-based published studies of the association between ethnicity and quality of diabetes care and outcomes. We aimed to determine the association between ethnicity and healthcare factors in an English population.MethodsData was obtained in 2002 on all 21,343 diabetic patients registered in 99% of all computerised general practitioner (GP) practices in three NW London Primary Care Trusts (PCTs), covering a total registered population of 720,000. Previously practices had been provided with training, data entry support and feedback. Treatment and outcome measures included drug treatment and blood pressure (BP), total cholesterol and haemoglobin A1c (HbA1c) levels.ResultsSeventy per cent of diabetic patients had a valid ethnicity code. In the relatively older White population, we expected a smaller proportion with a normal BP, but BP differences between the groups were small and suggested poorer control in non-White ethnic groups. There were also significant differences between ethnic groups in the proportions of insulin-treated patients, with a smaller proportion of South Asians – 4.7% compared to 7.1% of Whites – receiving insulin, although the proportion with a satisfactory HbA1c was smaller- 25.6% compared to 37.9%.ConclusionRecording the ethnicity of existing primary care patients is feasible, beginning with patients with established diseases such as diabetes. We have shown that the lower proportion of South Asian patients with good diabetes control, and who are receiving insulin, is at least partly due to poorer standards of care in South Asians, although biological and cultural factors could also contribute. This study highlights the need to capture ethnicity data in clinical trials and in routine care, to specifically investigate the reasons for these ethnic differences, and to consider more intensive management of diabetes and education about the disease in South Asian patients.

Improving the care of people with multiple sclerosis through implementing NICE guidance

People with multiple sclerosis (MS) need services that are specialized and responsive to their needs. They require thorough and sensitive assessment of problems and need to be able to access services when required. This report is an evaluation of how effectively an MS nursing team working across three south London primary care trusts is implementing the priorities outlined in the NICE guidelines for the management of MS. This evaluation shows that four of the six key priorities of the NICE guidelines are being implemented. It is argued that national initiatives can be embraced by nurses in a practical way to improve services for people living with long-term conditions such as MS.

Is primary care ready to embrace e-health? A qualitative study of staff in a London primary care trust

e-Health refers to the organisation and delivery of health services and information using the internet and related technologies. We investigated the perceptions of primary care staff towards e-health initiatives in the NHS Connecting for Health programme and whether front-line staff are ready to implement such changes. Twenty participants from different professional groups were purposively selected for interview, based on their current computer usage. The same practice staff were subsequently observed in order to gain an insight into how they use computers. Practice staff (doctors, nurses, practice managers and receptionists) who will be expected to use new information technology and primary care trust (PCT) staff who are involved in its implementation were selected to participate in this study. A north London PCT with 62 general practices. Four practices were selected for the study. Analysis of the interviews and the observational data yielded six recurrent themes that have a bearing on readiness to use information and communication systems to support clinical care: perceptions of technology and NHS Connecting for Health; issues relating to resources; patient choice; matters relating to confidentiality and security; political pressures; and how information technology is currently used within primary care. At the time of the study the systems that form part of NHS Connecting for Health, apart from the Quality Management and Analysis System (QMAS), were not implemented across the PCT. All the practices in the study acknowledged the benefits new technology would bring to the workplace, but there were also some common concerns, which suggest that staff working in primary care practices are not ready for e-health. Successful implementation of the NHS Connecting for Health programme rests on identifying, acknowledging and overcoming these concerns. A different approach might be required for those practices that have made very little progress in using email or moving towards an electronic patient record. This study suggests that a mistrust of technology and fears as to the heavy initial workload involved in becoming fully computerised have dissuaded some practices from embracing e-health. If NHS Connecting for Health is to be a success, implementation teams might need to focus initially on practices that have been reluctant to use technology to support both clinical care and the day-to-day work of the practice.

Association of Population and Practice Factors with pOtentially Avoidable Admission Rates for Chronic Diseases in London: Cross Sectional Analysis

To examine the association between underlying ill health, material deprivation and primary care supply factors and hospital admission rates for potentially avoidable admissions in primary care trusts in London. Cross sectional analysis at primary care trusts level using routine data from multiple sources. All 31 primary care trusts in London with a total resident population of 7 million patients. Age-standardized hospital admission rates for asthma, diabetes, heart failure, hypertension and chronic obstructive pulmonary disease. Admission rates varied widely for the conditions examined across the 31 primary care trusts. In 2001, age adjusted admission rates for asthma varied from 76 to 189 per 100,000 and for diabetes from 38 to 183 per 100,000. There was a significant association between higher admission rates and measures of underlying ill health and material deprivation but not quantitative measures of primary care service provision. Provision of specialist chronic disease services in primary care for diabetes but not for asthma were significantly associated with reduced admission rates. There was no association of prescribing levels in primary care trusts with admission rates for any of the conditions examined. Although hospital admission for some chronic diseases is potentially avoidable and rates of hospital admission for these conditions are possible indicators of the quality of care, they should be interpreted in conjunction with measures of population composition and deprivation. Failure to do this may result in primary care trusts and general practitioners being criticized for aspects of health care utilization that are not under their direct control.

Association of population and practice factors with potentially avoidable admission rates for chronic diseases in London: cross sectional analysis

To examine the association between underlying ill health, material deprivation and primary care supply factors and hospital admission rates for potentially avoidable admissions in primary care trusts in London. Cross sectional analysis at primary care trusts level using routine data from multiple sources. All 31 primary care trusts in London with a total resident population of 7 million patients. Age-standardized hospital admission rates for asthma, diabetes, heart failure, hypertension and chronic obstructive pulmonary disease. Admission rates varied widely for the conditions examined across the 31 primary care trusts. In 2001, age adjusted admission rates for asthma varied from 76 to 189 per 100,000 and for diabetes from 38 to 183 per 100,000. There was a significant association between higher admission rates and measures of underlying ill health and material deprivation but not quantitative measures of primary care service provision. Provision of specialist chronic disease services in primary care for diabetes but not for asthma were significantly associated with reduced admission rates. There was no association of prescribing levels in primary care trusts with admission rates for any of the conditions examined. Although hospital admission for some chronic diseases is potentially avoidable and rates of hospital admission for these conditions are possible indicators of the quality of care, they should be interpreted in conjunction with measures of population composition and deprivation. Failure to do this may result in primary care trusts and general practitioners being criticized for aspects of health care utilization that are not under their direct control.

Let's be PALS: User‐Driven Organizational Change in Healthcare*

This paper explores user‐driven organizational change in the National Health Service (NHS). The NHS Plan (Department of Health, 2000) created Patient Advice and Liaison Services (PALS) to provide information, solve problems and drive user‐led change. Evidence is drawn from a study of PALS in London acute, primary care, mental health and specialist trusts, drawing on discussion forums, interviews with PALS officers and documentation. From context and role profiles, two conclusions are evident. First, organizational instability, boundary disputes, variable management support, resource limitations, financial insecurity and multi‐site working characterize the context in which PALS operate, and the officer role is characterized by problem diversity, overlap with complaints systems, monitoring problems, relationship building and ‘serial users’. Second, these context and role attributes restrict PALS to ‘repair and maintenance’, ensuring that established systems work correctly. While PALS sit on the bottom rung of a ‘participation ladder’, their contribution is more than tokenistic. However, a processual perspective demonstrates how a fluid, networked, and diversified context isolates PALS structures from management decision‐making, constraining their power base, and inhibiting the promotion of substantive change agendas.

Evaluation of an occupational health service for general practitioners and their staff in a primary care trust

An occupational health service was set up in 2002 for general practitioners (GPs) and their staff in a London primary care trust (PCT). The service was based on a needs assessment undertaken in the locality in 1998. To evaluate awareness, usage and perceived helpfulness of the service amongst GPs and practice managers, and to ascertain current perceived priorities for what to include in the service. Questionnaire survey sent postally and electronically to 199 named GPs and 69 practice managers in 78 practices in the PCT. Overall 119/268 (44%) responses were received from 54/78 practices (69%). Awareness of the existence of the service was high (76%), and although uptake had been poor, this was not related to a perception that the service was unlikely to be helpful. Almost all those who had used the service had found it helpful. Nineteen (16%) respondents asked for more information about the service. Advice on health and safety law and fitness for work assessments were the highest priorities and hepatitis B immunization lowest, as in the 1998 needs assessment. However, a discrepancy between GPs and practice managers with regard to the perceived relative importance of pre-employment health screening and counselling/stress management emerged. The service is valued by users but could be developed by exploring new ways to disseminate information about the service and deliver it.

Evaluating the impact of Information Skills Training within primary care

Evaluating the impact of Information Skills Training within primary care

Explaining variation in antidepressant prescribing rates in east London: a cross sectional study

Rates of depression and anxiety in south Asian populations are lower than expected. It remains uncertain whether this reflects a real difference in prevalence or differences in case recognition and management. To examine whether concordance of culture or ethnicity between doctors and patients affects the prescribing rates for antidepressant and anxiolytic medications in general practice populations, taking into account demography, practice size and organization. A cross-sectional general practice study, using practice and demographic data from primary care trusts, doctors' place of qualification from the General Medical Council, combined with practice level prescribing data from the prescription pricing authority (PACT) for the period 2000-2002. Set in 139 practices in the east London primary care trusts (PCTs) of Tower Hamlets, Hackney and Newham, multiethnic areas with large populations of south Asian residents and doctors. The main outcome measure was the annual prescribing rates for each group of drugs, calculated as the mean of two years average daily quantities (ADQs) for each medication, divided by the practice population. In east London the median prescribing rate (ADQs) for all antidepressants was 7.97 (inter-quartile range 4.91-10.76), for all anxiolytics and hypnotics 2.27 (interquartile range 1.11-3.96). There were significant differences in prescribing rates between practices with UK trained GPs and practices with south Asian trained GPs, with the highest rates of antidepressant prescribing in practices with UK trained GPs and low proportions of south Asian patients. No differences were found in anxiolytic and hypnotic prescribing rates between these practices. 57% of the variation in prescribing between practices could be explained by a model including the place of GP qualification, the proportion of registered women, older (>65) patients, and the list size per full time GP. Compared with previous studies prescribing rates for antidepressants have almost doubled over five years, the greatest increase being for selective serotonin re-uptake inhibitors (SSRIs). There is a modest fall in prescribing rates for anxiolytics and hypnotics. Concordance between south Asian practice populations and doctors from similar south Asian cultures is not associated with an increase in antidepressant prescribing. Lower rates of prescribing in practices with south Asian trained doctors occur regardless of the ethnic composition of the practice population. Reasons for these differences are uncertain, but may include differences in explanatory models for presenting symptoms, and management strategies which rely less on a biomedical paradigm.

Exploring the effects of population mobility on cervical screening coverage

London has the lowest cervical screening coverage in England and in 1998/1999 accounted for 11 of the 13 health authorities that fell below the national 80% coverage target. There are several factors which may contribute to the difference in coverage between the capital and the rest of the country. London's population is much more diverse, there is greater deprivation and there are well-established structural differences in primary care. London has high levels of population mobility which will also affect the ability of GPs to achieve high population coverage. This paper explores the possible size of the effect that population mobility is likely to have on coverage of the cervical screening programme in London. The analysis estimates the size of ‘missing populations’ that may not receive an invitation for a smear test, or artificially inflate the list size of registered patients. A simple model suggests that in some London Health Authorities up to 14% of residents, and 11% of patients on GP lists, may miss out on invitations for screening as a result of population mobility. Moreover the large differences between list and resident populations in some areas mean that the current government target of 80% coverage of the registered population will be largely unattainable for many London Health Authorities and Primary Care Trusts. Moving towards a resident-based system, whereby the numbers screened are related to the number of residents, avoids some of the problems associated with list inflation and gives a fairer picture of coverage of the eligible population. Public Health (2002) 116, 353–360.

Exploring the effects of population mobility on cervical screening coverage

London has the lowest cervical screening coverage in England and in 1998/1999 accounted for 11 of the 13 health authorities that fell below the national 80% coverage target. There are several factors which may contribute to the difference in coverage between the capital and the rest of the country. London's population is much more diverse, there is greater deprivation and there are well-established structural differences in primary care. London has high levels of population mobility which will also affect the ability of GPs to achieve high population coverage. This paper explores the possible size of the effect that population mobility is likely to have on coverage of the cervical screening programme in London. The analysis estimates the size of ‘missing populations’ that may not receive an invitation for a smear test, or artificially inflate the list size of registered patients. A simple model suggests that in some London Health Authorities up to 14% of residents, and 11% of patients on GP lists, may miss out on invitations for screening as a result of population mobility. Moreover the large differences between list and resident populations in some areas mean that the current government target of 80% coverage of the registered population will be largely unattainable for many London Health Authorities and Primary Care Trusts. Moving towards a resident-based system, whereby the numbers screened are related to the number of residents, avoids some of the problems associated with list inflation and gives a fairer picture of coverage of the eligible population. Public Health (2002) 116, 353–360.