Primary Care Commissioners Research Articles

The usage of data in NHS primary care commissioning: a realist evaluation

BackgroundTo improve health outcomes and address mounting costs pressures, policy-makers have encouraged primary care commissioners in the British National Health Service (NHS) to increase the usage of data in decision-making. However, there exists limited research on this topic. In this study, we aimed to understand how and why primary care commissioners use data (i.e. quantitative, statistical information) to inform commissioning, and what outcomes this leads to.MethodsA realist evaluation was completed to create context-mechanism-outcome configurations (CMOs) relating to the contexts influencing the usage of data in primary care commissioning. Using a realist logic of analysis and drawing on substantive theories, we analysed qualitative content from 30 interviews and 51 meetings (51 recordings and 19 accompanying meeting minutes) to develop CMOs. Purposive sampling was used to recruit interviewees from diverse backgrounds.ResultsThirty-five CMOs were formed, resulting in an overarching realist programme theory. Thirteen CMOs were identical and 3 were truncated versions of those formed in an existing realist synthesis on the same topic. Seven entirely new CMOs, and 12 refined and enhanced CMOs vis-à-vis the synthesis were created. The findings included CMOs containing contexts which facilitated the usage of data, including the presence of a data champion and commissioners’ perceptions that external providers offered new skillsets and types of data. Other CMOs included contexts presenting barriers to using data, such as data not being presented in an interoperable way with consistent definitions, or financial pressures inhibiting commissioners’ abilities to make evidence-based decisions.ConclusionsCommissioners are enthusiastic about using data as a source of information, a tool to stimulate improvements, and a warrant for decision-making. However, they also face considerable challenges when using them. There are replicable contexts available to facilitate commissioners’ usage of data, which we used to inform policy recommendations. The findings of this study and our recommendations are pertinent in light of governments’ increasing commitment to data-driven commissioning and health policy-making.

The usage of data in NHS primary care commissioning: a realist review

BackgroundPrimary care has been described as the ‘bedrock’ of the National Health Service (NHS) accounting for approximately 90% of patient contacts but is facing significant challenges. Against a backdrop of a rapidly ageing population with increasingly complex health challenges, policy-makers have encouraged primary care commissioners to increase the usage of data when making commissioning decisions. Purported benefits include cost savings and improved population health. However, research on evidence-based commissioning has concluded that commissioners work in complex environments and that closer attention should be paid to the interplay of contextual factors and evidence use. The aim of this review was to understand how and why primary care commissioners use data to inform their decision making, what outcomes this leads to, and understand what factors or contexts promote and inhibit their usage of data.MethodsWe developed initial programme theory by identifying barriers and facilitators to using data to inform primary care commissioning based on the findings of an exploratory literature search and discussions with programme implementers. We then located a range of diverse studies by searching seven databases as well as grey literature. Using a realist approach, which has an explanatory rather than a judgemental focus, we identified recurrent patterns of outcomes and their associated contexts and mechanisms related to data usage in primary care commissioning to form context-mechanism-outcome (CMO) configurations. We then developed a revised and refined programme theory.ResultsNinety-two studies met the inclusion criteria, informing the development of 30 CMOs. Primary care commissioners work in complex and demanding environments, and the usage of data are promoted and inhibited by a wide range of contexts including specific commissioning activities, commissioners’ perceptions and skillsets, their relationships with external providers of data (analysis), and the characteristics of data themselves. Data are used by commissioners not only as a source of evidence but also as a tool for stimulating commissioning improvements and as a warrant for convincing others about decisions commissioners wish to make. Despite being well-intentioned users of data, commissioners face considerable challenges when trying to use them, and have developed a range of strategies to deal with ‘imperfect’ data.ConclusionsThere are still considerable barriers to using data in certain contexts. Understanding and addressing these will be key in light of the government’s ongoing commitments to using data to inform policy-making, as well as increasing integrated commissioning.

Emergency Admission Risk Prediction (EARP) tools in primary care to reduce emergency admissions to hospital: clash of evidence and practice.

Policy initiatives have incentivised use of EARP tools in primary care to reduce emergency admissions. A recently published trial in South Wales found that EARP increased emergency admissions and emergency department attendances without clear benefits. This cost the NHS an additional £76 per patient per year. But the use of EARP in primary care across the UK was unknown. To assess implementation and facilitators use of EARP tools in primary care across the UK. Structured email survey of 235 UK primary care commissioners across the UK. There were 148 (87%) of 171 responders (73%) who reported that EARP tools were available in their areas. We identified 39 different EARP tools in use. Access to EARP tools varied widely by country: Northern Ireland (100%), Scotland (91%), England (76%) and Wales (14%). Promotion by NHS commissioners, and engagement of clinical leaders and practice managers were identified as the most important factors in encouraging use of EARP tools. Research evidence was seen as less important. Nearly 40% of areas using EARP reported that they had revised services as a result, but few reported use of EARP for service evaluation. Though EARP tools are widely available in primary care, new evidence shows that they are counter-productive. We estimate that by delaying the dissemination of EARP for evaluation NHS Wales saved >£200 million per year. We encourage further research and discussion about next steps in use of EARP tools in emergency admission prevention in the UK.

OC-056 Evaluation of a novel nurse-led one-stop clinic for patients referred for investigation of suspected non-alcoholic fatty liver disease

Introduction Non-alcoholic fatty liver disease (NAFLD) affects approximately 1 in 4 adults in the UK.1In our hospital catchment area there are an estimated 150000 individuals with NAFLD, approximately 12000 of who are likely to have advanced liver fibrosis. Our aim was to evaluate the utility of a weekly nurse-led NAFLD clinic including transient elastography (Fibroscan; TE) to screen for advanced fibrosis in the management of rising numbers of referrals to our secondary care Hepatology clinics. Method A designated referral pathway was devised in conjunction with local primary care commissioners where patients with suspected NAFLD and with a NAFLD-fibrosis score2in the indeterminate or high risk range (>–1.455) were assessed in a one-stop clinic by a clinical nurse specialist using a specific clerking template. TE was performed on all patients with NAFLD and discharge to primary care with lifestyle advice considered in those with TE values below the threshold for advanced liver fibrosis/cirrhosis (7.9 kPa).3Prospective demographic and clinical data were collected on all patients seen in the clinic from May 1st–Dec 31st2014. Results A total of 112 patients were seen during the evaluation period; Male:Female 3:2, median age 59 years (range 20–91). Thirteen (12%) consumed alcohol at levels above those consistent with a diagnosis of NAFLD (females >14 units/week; males >21 units/week), 2 (1.8%) had autoimmune hepatitis and 2 (1.8%) had chronic hepatitis C. The remaining 95 (85%) were diagnosed with NAFLD. Amongst this NAFLD population, TE values <7.9 kPa were present in 56 patients (59%), 43 of whom were discharged to primary care. This represented 45% of the NAFLD patients and 38% of all referrals made. Thirteen NAFLD patients had TE readings <7.9 kPa but were followed up in consultant clinics for other clinical reasons. Thirty-three patients (35%) had TE readings ≥7.9 kPa, all of whom were followed-up in consultant clinics, as well as 6 patients (6%) in whom TE was unreliable. Conclusion A one-stop nurse-led clinic for patients with suspected NAFLD and an indeterminate or high NAFLD fibrosis score allowed early discharge of approximately 40% of the patients referred. Such clinics may be a useful way of stratifying patient risk and utilising resources effectively in the face of increasing demand on secondary care Hepatology services. Disclosure of interest None Declared.

Frailty in Primary Care.

This chapter considers the pragmatic integration of frailty in primary care. While some patients present to primary care practitioners with relatively well-defined problems that can be managed by a single intervention and/or organ-specific specialist referral, others present with nonacute, poorly defined problems that are complex and rooted in multiple factors. The latter are often in need of a comprehensive geriatric assessment (CGA). CGA can have important positive impacts on the health of older people, but it is labor-intensive and costly. Therefore, patients at higher risk of adverse outcomes should have higher priority to publicly funded CGA services. Frailty is an age-independent marker of risk that fits the biopsychosocial model of primary care, and its use (as opposed to age alone) may promote equity of access to CGA services. A number of frailty assessment tools have been recommended for use in primary care. Some randomized controlled trials have shown that frailty screening in primary care, with subsequent CGA and intervention, can prevent adverse outcomes. However, this result has not been obtained with every screening tool, and comparative trials are ongoing. Meanwhile, primary care commissioners in the UK are establishing new frailty care pathways and developing frailty registers in primary care.

Defining GP practice areas based on true service utilisation

Where patients who are registered with a general practice actually live (the service utilisation area) often differ from what GPs consider their practice boundaries or catchment area to be, as well as from administrative boundaries. A key aim of primary care commissioners is to allocate resources efficiently and to locate services in such a way that access is convenient for patients. To achieve this robust understanding of practice service utilisation areas and the overlap between practices and administrative areas are essential. We used kernel analysis of the postcodes of over 400,000 registered patients to define GP service utilisation areas. We estimated service utilisation for each of 64 practices for a period of five years (2002–2006) exploring the areas in which 99%, 98%, and 95% of registered patients were expected to live. These service utilisation areas were not coterminous with other practices or with administrative boundaries. We present a simple analytical method to define GP catchment areas that captures the true service utilisation area and identifies the extent of overlap. This is a practical tool that can assist health care commissioning.

Widening Access to Treatment for Alcohol Misuse: Description and Formative Evaluation of an Innovative Web-Based Service in One Primary Care Trust

To describe the development and evaluation of an innovative web-based service for hazardous or harmful drinkers. Patients were identified in General Practice and referred to the new service. Mixed methods were used for evaluation. The service was feasible and acceptable to patients, primary care professionals and commissioners. Users appeared to reduce their alcohol consumption. This model may be of interest to other primary care commissioners looking to increase access to alcohol treatments at low cost.

Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials

Objectives To determine whether trials of physical activity promotion based in primary care show sustained effects on physical activity or fitness in sedentary adults, and whether exercise referral interventions are...