Primary Care Organisations In England Research Articles

Cluster randomized trials utilizing primary care electronic health records: methodological issues in design, conduct, and analysis (eCRT Study).

BackgroundThere is growing interest in conducting clinical and cluster randomized trials through electronic health records. This paper reports on the methodological issues identified during the implementation of two cluster randomized trials using the electronic health records of the Clinical Practice Research Datalink (CPRD).MethodsTwo trials were completed in primary care: one aimed to reduce inappropriate antibiotic prescribing for acute respiratory infection; the other aimed to increase physician adherence with secondary prevention interventions after first stroke. The paper draws on documentary records and trial datasets to report on the methodological experience with respect to research ethics and research governance approval, general practice recruitment and allocation, sample size calculation and power, intervention implementation, and trial analysis.ResultsWe obtained research governance approvals from more than 150 primary care organizations in England, Wales, and Scotland. There were 104 CPRD general practices recruited to the antibiotic trial and 106 to the stroke trial, with the target number of practices being recruited within six months. Interventions were installed into practice information systems remotely over the internet. The mean number of participants per practice was 5,588 in the antibiotic trial and 110 in the stroke trial, with the coefficient of variation of practice sizes being 0.53 and 0.56 respectively. Outcome measures showed substantial correlations between the 12 months before, and after intervention, with coefficients ranging from 0.42 for diastolic blood pressure to 0.91 for proportion of consultations with antibiotics prescribed, defining practice and participant eligibility for analysis requires careful consideration.ConclusionsCluster randomized trials may be performed efficiently in large samples from UK general practices using the electronic health records of a primary care database. The geographical dispersal of trial sites presents a difficulty for research governance approval and intervention implementation. Pretrial data analyses should inform trial design and analysis plans.Trial registrationCurrent Controlled Trials ISRCTN 47558792 and ISRCTN 35701810 (both registered on 17 March 2010).

Constructing the gendered body? A critical discourse analysis of gender equality schemes in the health sector in England

This article examines gender discourses embedded in gender equality policies in the health sector. Gender mainstreaming was first adopted by a number of international and intergovernmental, regional and national actors some time ago, yet there is limited evidence of progress in addressing gender justice in health. Failures in gender equality policies have often been attributed to the lack of gender-disaggregated data, combined with a lack of resources, training and skills. In addition, studies have identified problems originating in the shift from participatory approaches to technocratic solutions, and the persistence of underlying gender relations of power. However, gender equality policies may also contribute to gender discourse in ways which reinforce and perpetuate inequalities between men and women. This article draws on Bacchi’s ‘what is the problem represented to be’ (WPR) approach to policy analysis, to explore responses of primary care organisations in England to legislation requiring public sector organisations to tackle gender discrimination and promote equality of opportunity between men and women. The article adopts a critical discourse approach to gender equality documents and suggests that such texts construct women and men as essentially different, reinforcing specific forms of masculinity and male performance and notions of male disadvantage in health systems.

Cash for student placements will help promote primary care jobs

Primary care organisations in England could be given cash for providing practice placements to nursing students as part of plans to boost nurse numbers in community settings. Health Education England is exploring the idea of standardised payments to primary care organisations that offer placements. Its director of nursing Lisa Bayliss-Pratt said that if more trainee nurses completed community placements they might seek jobs in primary care after qualifying, instead of taking the traditional route into secondary care. Traditionally, acute trusts have received payments but there have been wide regional variations, resulting in an uneven distribution of students and a lack of opportunities for nurses to gain experience of the community sector, said Dr Bayliss-Pratt. She made the comments at a Queen’s Nursing Institute (QNI) conference in London last week on providing health care in patients’ homes. The comments followed a question from the audience asking what was being done to attract more nurses into community settings. The audience member told Dr Bayliss-Pratt that some university courses for community

Demand for hospital beds in primary care organisations

This paper demonstrates that the ratio of bed days per death reflects the contribution from factors which increase demand for hospital admission and bed use. Data covering primary care organisations was extracted from a variety of sources and the relationships affecting higher bed days per death were explored. The capitation formula used to fund primary care organisations in England shows no correlation with bed days per death and may be inadvertently creating financial pressures. Healthcare policy needs to foster greater integration in healthcare. Bed days per death is introduced as a new performance measure which can be used to track the success of a variety of admission avoidance and other schemes for care in the community and to support international comparisons of bed utilisation.

P1-21 Cluster randomised trials in a healthcare database: utilising electronic patient records for intervention research

IntroductionCluster randomised trials (CRTs) may have limited power because of the correlation of individual responses within clusters and the allocation of only small numbers of clusters. This ongoing study evaluates...

Medicines Use Review: adoption and spread of a service innovation

Abstract Background Research has shown that implementation of community pharmacy Medicines Use Review and Prescription Intervention (MUR) in the first year of the service in England and Wales was less extensive than anticipated. Several barriers to MUR becoming accepted and embedded in the National Health Service (NHS) were identified. Objective To evaluate progress in the provision of the MUR service in England and Wales in its second year (April 1, 2006-March 31, 2007) compared with the first year; and to analyse trends from available national data from the third year of provision in 2007–2008. Methods The analysis drew on the following data sources: routine data on provision of MURs for community pharmacies in a stratified random sample of 31 primary care organisations in England and Wales, and national datasets on MUR provision from the Pharmaceutical Services Negotiating Committee and NHS Information Centre. Outcome measures The percentage of community pharmacies providing the MUR service, the numbers of MURs provided in 2006–2007 at pharmacy and primary care organisation level, and the extent of, and variation in, provision. Key findings The percentage of community pharmacies providing the MUR service increased from 38 to 67.2%. Overall, 62 559 MURs were provided (a more than four-fold increase on the previous year), representing 13.8% of the possible maximum. The mean number of MURs provided (per provider) increased from 36 to 85. For existing providers the mean number increased from 36 to 111 (median 78, range 0–423). For new providers the mean number was 52 (median 17, range 1–401). More than half (52%) of the pharmacies in the sample claimed for fewer than 50 MURs. Overall, 82% of MURs were provided by multiples and this percentage was lower among new providers (62%) than existing providers (89%). Thirty-three (8.1%) existing MUR providers had no recorded MURs in the second year: almost two-thirds of these (64%) were independents. Eleven pharmacies (1.5%) provided the maximum number of 400 MURs per year: all but one were branches of multiples. Of the pharmacies not yet providing MURs, 78% were independent. Conclusions Both numbers of MURs and numbers of providers of MUR services increased markedly during the service's second year. Those newly providing the service in the second year claimed for more than twice as many MURs as did those who had been ‘new providers' the previous year. Overall just over half of all providing pharmacies claimed for the equivalent of one MUR a week or fewer. Therefore the extent of ‘successful adoption’ of MURs is debatable. Differences in the level of provision continued between independent and multiple pharmacies in terms of both adoption of the service and the number of reviews conducted. As in the previous year, independent pharmacies were less likely to provide the MUR service and when they did the numbers conducted were lower than those provided by multiples.

Is multidisciplinary teamwork the key? A qualitative study of the development of respiratory services in the UK

Using frameworks, such as the long-term conditions pyramid of healthcare, primary care organizations (PCOs) in England and Wales are exploring ways of developing services for people with long-term respiratory disease. We aimed to explore the current and planned respiratory services and the roles of people responsible for change. A purposive sample of 30 PCOs in England and Wales. Semi-structured telephone interviews with the person responsible for driving the reconfiguration of respiratory services. Recorded interviews were transcribed and coded, and themes identified. The association of the composition of the team driving change with the breadth of services provided was explored using a matrix. All but two of the PCOs described clinical services developed to address the needs of people with respiratory conditions, usually with a focus on preventing admissions for chronic obstructive pulmonary disease (COPD). Although the majority identified the need to develop a strategic approach to service development and to meet educational needs of primary care professionals, relatively few described clearly developed plans for addressing these issues. Involvement of clinicians from both primary and secondary care was associated with a broad multifaceted approach to service development. Teamwork was often challenging, but could prove rewarding for participants and could result in a fruitful alignment of objectives. The imminent merger of PCOs and overriding financial constraints resulted in a 'fluid' context which challenged successful implementation of plans. While the majority of PCOs are developing clinical services for people with complex needs (principally in order to reduce admissions), relatively few are addressing the broader strategic issues and providing for local educational needs. The presence of multidisciplinary teams, which integrated primary and secondary care clinicians with PCO management, was associated with more comprehensive service provision addressing the needs of all respiratory patients. Future research needs to provide insight into the structures, processes and inter-professional relationships that facilitate development of clinical, educational and policy initiatives which aim to enhance local delivery of respiratory care.

Mind the gap between policy imperatives and service provision: a qualitative study of the process of respiratory service development in England and Wales.

BackgroundHealthcare systems globally are reconfiguring to address the needs of people with long-term conditions such as respiratory disease. Primary Care Organisations (PCOs) in England and Wales are charged with the task of developing cost-effective patient-centred local models of care. We aimed to investigate how PCOs in England and Wales are reconfiguring their workforce to develop respiratory services, and the background factors influencing service redesign.MethodsSemi-structured qualitative telephone interviews with the person(s) responsible for driving respiratory service reconfiguration in a purposive sample of 30 PCOs. Interviews were recorded, transcribed, coded and thematically analysed.ResultsWe interviewed representatives of 30 PCOs with diverse demographic profiles planning a range of models of care. Although the primary driver was consistently identified as the need to respond to a central policy to shift the delivery of care for people with long-term conditions into the community whilst achieving financial balance, the design and implementation of services were subject to a broad range of local, and at times serendipitous, influences. The focus was almost exclusively on the complex needs of patients at the top of the long-term conditions (LTC) pyramid, with the aim of reducing admissions. Whilst some PCOs seemed able to develop innovative care despite uncertainty and financial restrictions, most highlighted many barriers to progress, describing initiatives suddenly shelved for lack of money, progress impeded by reluctant clinicians, plans thwarted by conflicting policies and a PCO workforce demoralised by job insecurity.ConclusionFor many of our interviewees there was a large gap between central policy rhetoric driving workforce change, and the practical reality of implementing change within PCOs when faced with the challenges of limited resources, diverse professional attitudes and an uncertain organisational context. Research should concentrate on understanding these complex dynamics in order to inform the policymakers, commissioners, health service managers and professionals.

Patient Evaluation of a Community Pharmacy Medications Management Service

A patient-centered approach is increasingly recognized as an important component in the evaluation of healthcare services. To assess patient satisfaction with, attitudes toward, and expectations of or experience with community pharmacy in general, and to evaluate the effect of the community pharmacy-led medications management service on these factors. Postal questionnaire surveys were completed at baseline and after 12 months (follow-up) as part of a randomized controlled trial of the service. The setting was 9 primary care organizations in England. Patients with coronary heart disease were recruited from general practice registers and randomly allocated to the intervention (pharmacy-led medications management service) or control group. Survey response rates at baseline and follow-up were 88.4% (1232/1394) and 80.1% (1085/1355), respectively. The respondents indicated that they wanted pharmacists to provide dispensing, medications review, advice on medications and health, private consultation areas, and short visit times. At follow-up, intervention patients were more likely than control patients (p < 0.01) to rate the service provided by their pharmacist with a higher level of satisfaction, and most intervention patients stated a preference for seeing their physician to discuss their medications, although this was less marked than in control patients (76% vs 85%; p < 0.01). Intervention patients were also more willing than control patients to ask the pharmacist questions that they would be unable to ask a physician (20% vs 11%, respectively; p < 0.01), to ask the pharmacist questions about their medications (32% vs 18%, respectively; p < 0.01), and to recommend this practice to others (51% vs 40%, respectively; p < 0.01). Pharmacist intervention was associated with significant and positive changes in patient satisfaction. While patients probably continue to prefer a physician-led service, they value aspects of a pharmacy service. Patients generally preferred discussing medications with the family physician, but experiencing the community pharmacy-led service resulted in an attitudinal shift toward the pharmacist. These findings suggest a benefit in developing the community pharmacist's role as a reviewer of, and adviser on, patients' medications.

Management of obesity in primary care: nurses’ practices, beliefs and attitudes

This paper is a report of a study to investigate patterns of clinical practice, beliefs and attitudes of primary care nurses with respect to obesity management. Nurses in primary care potentially play a key role in managing obesity, which has become a priority issue. There have been few studies of either the extent of clinical practice of nurses, or their attitudes and beliefs in this setting. A correlational survey design was employed. Structured questionnaires were posted to 564 nurses and health visitors in primary care organizations in England. The response rate was 72.3%. The survey was conducted in April and May 2006. Very few respondents reported training in obesity management, and most did not believe that organizational support was in place. Only practice nurses reported substantial clinical activity in obesity management, accounting for almost 5% of their contracted hours. This activity, comprised of assessment, lifestyle change support and referral, occurred in one-to-one consultations. Other nurses and health visitors reported much less activity, although they believed obesity to be an important health issue and its management an appropriate part of their role. Whilst outright negative stereotypes were rare, there were nevertheless a range of potentially negative beliefs and attitudes relating to obesity and obese patients. These views were related to the respondent's own body mass index but not to gender, age, experience and occupation. Training and organizational support for obesity management are required by primary care nurses. Training should also address beliefs and attitudes about obesity and obese persons.

Pharmacist domiciliary visiting in England: identifying the characteristics associated with continuation

To characterize Pharmacist Domiciliary Visiting Services (PDVSs) in England. Primary Care Organizations (PCOs) in England which are groups providing primary care services to populations of similar health needs within defined geographical areas. A questionnaire was designed and posted to all PCOs in England in order to identify the number that had provided or were presently providing a PDVS and determine the nature of the services. PDVS characteristics that were related to long term continuation or termination were then identified. To quantify and describe the format of operational and terminated PDVSs across England and identify similarities and differences between operational and terminated PDVSs. A response rate of 81.5% was achieved (247/303) with 70% of PCOs reporting that to the best of their terminated services did so at or before 1 year of operation, several citing a lack of referrals as a contributing factor. PDVSs varied widely in design however, the only significant differences between operational and terminated PDVSs were that operational PDVSs incorporated a greater number of referral sources in the PDVS design which were more likely to be social services, general medical practitioners and community nurses. Most PDVSs had numerous characteristics in common however no two PDVSs were identical. Characteristics involved in the creation of service demand such as number and type of referral sources, are more likely to be associated with PDVS continuation.

The Department of Health's research governance framework remains an impediment to multi-centre studies: findings from a national descriptive study

We describe our experience of using the standard application form, designed to streamline applications for multi-centre research, to seek approval from all primary care organizations (PCOs) in England and Wales to undertake a single telephone interview with a health service manager. We sent applications (n=316), by email to each PCO, or consortium of PCOs, attaching a completed standard application form, the 15 required documents, and the approval we had been granted by the lead NHS organization. We maintained detailed records of the responses to our application, subsequent correspondence, additional paperwork requested, and time spent on the approval process. The UK Research Governance Framework, which regulates all research conducted in health and social care settings. All PCOs in England and Wales. None. Time taken to obtain approval to undertake a telephone interview with a health service manager. We were unable to establish contact with 13 (4%) PCOs. Six months after submitting our application we had received approval from 259/316 (82%) PCOs and were still awaiting a verdict from 41 (13%). The median time to approval was 56 days (IQR 42-72). Overall, an estimated 318 staff-hours were spent completing supplementary forms, providing additional information and chasing up dormant applications. Recent initiatives to 'streamline' research governance approval have failed to address the problems that face researchers undertaking multi-centre studies. There is an urgent need to develop a simpler process that allows low risk research to take place without threatening staff morale and endangering the quality of the research outputs. In the meantime, we advise researchers to allow far greater time than might reasonably be envisioned to obtain research governance approval.

The Department of Health's research governance framework remains an impediment to multi-centre studies: findings from a national descriptive study

We describe our experience of using the standard application form, designed to streamline applications for multi-centre research, to seek approval from all primary care organizations (PCOs) in England and Wales to undertake a single telephone interview with a health service manager.We sent applications (n=316), by email to each PCO, or consortium of PCOs, attaching a completed standard application form, the 15 required documents, and the approval we had been granted by the lead NHS organization. We maintained detailed records of the responses to our application, subsequent correspondence, additional paperwork requested, and time spent on the approval process.The UK Research Governance Framework, which regulates all research conducted in health and social care settings.All PCOs in England and Wales.None.Time taken to obtain approval to undertake a telephone interview with a health service manager.We were unable to establish contact with 13 (4%) PCOs. Six months after submitting our application we had received approval from 259/316 (82%) PCOs and were still awaiting a verdict from 41 (13%). The median time to approval was 56 days (IQR 42-72). Overall, an estimated 318 staff-hours were spent completing supplementary forms, providing additional information and chasing up dormant applications.Recent initiatives to 'streamline' research governance approval have failed to address the problems that face researchers undertaking multi-centre studies. There is an urgent need to develop a simpler process that allows low risk research to take place without threatening staff morale and endangering the quality of the research outputs. In the meantime, we advise researchers to allow far greater time than might reasonably be envisioned to obtain research governance approval.

The (un)‐certainties of district nurses in the context of cultural diversity

This paper is a report of part of a study exploring district nurses' understanding and practices in relation to discrimination and inequalities issues. Clients from minority ethnic groups continue to experience inequalities in health status and care provision. District nurses work with a wide range of clients, yet research has demonstrated inequities in service provision to clients from minority ethnic groups due to organizational, professional and personal constraints. A qualitative methodology was used to explore district nurses' understanding of discrimination and equalities issues in the context of their work. Semi-structured interviews were undertaken during 2003 with 18 district nurses employed in two primary care organizations in England providing healthcare services to a large and culturally diverse population. District nurses' accounts were marked by uncertainty, suggesting that many lacked confidence when discussing issues of ethnicity and cultural difference. There were marked differences in the extent to which they appeared to recognize or engage with clients' experiences of discrimination or inequalities, or to recognize inequitable service provision to clients from minority ethnic groups. Key issues were a lack of provision of district nursing services to some clients, and failures to meet clients' language and communication needs, and although reflecting organizational constraints, such continuing inequities were largely unquestioned. There is a need for further educational and practice developments to enable district nurses to provide more equitable care to clients from culturally diverse communities, ensuring that the key professional discourse of individual care and advocacy are fully realized in their work with all clients.

What can the Experiences of Primary Care Organisations in England, Scotland and New Zealand Suggest About the Potential Role of Divisions of General Practice and Primary Care Networks/Partnerships in Addressing Australian Challenges?

This paper focuses on what can be learnt from the experiences of Primary Care Organisations (PCOs) in England, Scotland and New Zealand about the potential role of Divisions of General Practice (DGPs) and Primary Health Care Networks/Partnerships (PCN/Ps) in Australia, in addressing the challenges of ensuring access to a comprehensive range of primary health care services that are well coordinated and address population health needs. Responsibility for contracting and commissioning gives PCOs considerable leverage to influence the availability and range of primary health care services. A capitation-based funding system and associated patient enrolment enables a population focus and care over time, while aligned regional and local planning boundaries between PCOs and other health service planning boundaries also help with more coordinated approaches to planning, service development and service delivery. These elements are largely absent in the Australian health care system and set significant limitations on the role of DGPs and PCN/Ps. While DGPs can contribute to improving general practice quality and access to multidisciplinary care, and PCN/Ps can improve coordination, their scope of responsibilities and authority will need to be significantly strengthened to enable them to take a comprehensive approach to ensuring access to primary health care, service coordination and addressing population health needs.

Primary care.

Primary care sites are proliferating on the internet. For example, NHS Alliance, the chief representative organisation of primary care organisations in England, operates a site at www.nhsalliance.org/ that supports development in primary care organisations.

Prescribing Incentive Schemes

From 2000 to 2004, primary care organisations (PCOs) in England were legally required to operate a prescribing incentive scheme for their general practices. A statutory framework specified the types of target, maximum rewards and use of 'good cause for failure' provisions that schemes should include. Our objective was to explore whether schemes might be a useful approach to encourage 'good quality' prescribing. We requested copies of the original schemes from all PCOs in England in 2001 and 2002. Data were extracted on the rewards offered, types of budgetary targets set and additional conditions specified. Many schemes had not been finalised, some PCOs had no scheme, and one scheme operated without rewards. Although schemes covered similar therapeutic areas, they varied considerably in their length, complexity, reward levels and reward structure. Over half the schemes contained no 'good cause for failure' provision. PCOs are offering diverse incentives to general practices and some have interpreted the statutory framework imaginatively. Better use of the 'good cause for failure' provision may help to overcome inflationary pressures on prescribing, but further research is needed to clarify the role of financial incentives in influencing prescribing.

An educational intervention to improve data recording in the management of ischaemic heart disease in primary care.

Gaps in computerized medical records and a lack of a systematic approach to data recording make progress towards achieving quality standards in primary care difficult to demonstrate. The aim of this study was to examine the effect of an educational intervention on data quality in primary care. A before-and-after study of key data quality measures was carried out in 87 general practices in eight primary care organizations in England in phase 1 and 84 general practices in phase 2. The subjects were 19,470 patients with ischaemic heart disease in phase 1 and 19,784 patients in phase 2. The main outcome measures were improvement in the completeness and quality of the computerized medical record. Anonymized data were extracted from clinical information systems and processed to produce comparative information on each practice. Data quality workshops were arranged, in which reflection can take place, backed up by summary statistics. Practice visits provided training and personalized feedback of patients needing intervention. In the patients with heart disease, nearly 16,000 new clinical entries were made in the key improvement areas. The percentage of patients advised to quit smoking increased by 49.3 per cent, from 23.6 per cent to 61.9 per cent. There were also significant improvements in many other aspects of management. Focused interventions that provide targeted and relevant clinical information can be implemented in primary care. Such interventions can lead to a rise in data quality in primary care, but their effectiveness needs to be further tested in more rigorous research settings such as randomized controlled trials.

Developing integrated CAM services in Primary Care Organisations

Objectives: To explore policy development and the provision of integrated NHS CAM therapy services following the reorganisation of UK primary care services in 1999. Design: Structured survey interviews with Chairpersons in a stratified random sample of 72 Primary Care Organisations (PCOs) in England in 1999 and 2000; semi-structured telephone interviews with purposive samples of (i) providers of primary care CAM services (mostly General Practitioners), and (ii) Commissioners of primary care services in two purposive sub-samples of PCOs involved in positive policy formation in relation to CAM. Results: By the end of 2000, it is estimated that 85% of PCOs in England (95% CI 78–91%) had discussed CAM at board level, and 37% (95% CI 26–48%) had at least one CAM policy in place. The dominant strategy that emerged was a policy of ‘provide and review’, particularly in practices that had managed their own budgets under the previous fundholding system. We found that a small number of PCOs were developing area-wide services. Positive influences or ‘drivers’ for CAM policy formation were identified as: existing services, local enthusiasm and expertise, patient demand, a willingness to consider the wider evidence-base for CAM, and a perception that complementary therapies could help the PCOs to meet national NHS targets. Negative influences included: the cost of ensuring equitable access to services, a perception that CAM lacks the credibility required for public funding, the need to prioritise services and the need to direct funding towards meeting national and local health objectives. Conclusions: Opportunities for development of integrated NHS services are most likely to occur where CAM provision is seen as a potential solution to an NHS problem. Locality-based, integrated CAM services that are responsive to NHS priorities may offer a model for the future development of CAMs in primary care.

The relationship between size and performance of primary care organisations in England

The relationship between size and performance of primary care organisations in England