Primary Care Trusts In England Research Articles

The impact of structural changes to community nursing services on the rate of emergency hospital use of older people: a longitudinal ecological study of based on 140 primary care trusts in England

PurposeIn 2011, community nursing services were reorganised in England in response to a national policy initiative, but little is known about the impact of these changes. A total of three dominant approaches emerged: (1) integration of community nursing services with an acute hospital provider, (2) integration with a mental health provider and (3) the establishment of a stand-alone organisation, i.e. without structural integration. The authors explored how these approaches influenced the trends in emergency hospital admissions and bed day use for older people.Design/methodology/approachThe methodology was a longitudinal ecological study using panel data over a ten-year period from April 2006 to March 2016. This study’s outcome measures were (1) emergency hospital admissions and (2) emergency hospital bed use, for people aged 65+ years in 140 primary care trusts (PCTs) in England.FindingsThe authors found no statistically significant difference in the post-intervention trend in emergency hospital admissions between those PCTS that integrated community nursing services with an acute care provider and those integrated with a mental health provider (IRR 0.999, 95% CI 0.986–1.013) or those that did not structurally integrate services (IRR 0.996, 95% CI 0.982–1.010). The authors similarly found no difference in the trends for emergency hospital bed use.Research limitations/implicationsPCTs were abolished in 2011 and replaced by clinical commissioning groups in 2013, but the functions remain.Practical implicationsThe authors found no evidence that any one structural approach to the integration of community nursing services was superior in terms of reducing emergency hospital use in older people.Originality/valueAs far as the authors are aware, previous studies have not examined the impact of alternative approaches to integrating community nursing services on healthcare use.

Changing trends in reproductive/lifestyle factors in UK women: descriptive study within the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS)

ObjectiveThere has been considerable interest in the impact of reproductive factors on health but there are little data on how these have varied over time. We explore trends in reproductive/lifestyle...

Ensuring excellence in immunization services

In order to increase uptake of measles, mumps and rubella (MMR) vaccine, a domiciliary immunization service was established in Dudley primary care trust in England in 2010. Parents of unimmunized children were offered vaccines at home. Uptake of MMR vaccine among 2 year olds rose from 89% in 2007/08 to 96.9% in 2015. Children were also given any other outstanding immunizations. The domiciliary immunization service reached vulnerable unimmunized children who may otherwise have remained unprotected against life threatening childhood illnesses. Domiciliary immunization service was set up in 2010 to reduce inequalities in uptake of MMR vaccine among children aged between 2 and 5 years.

A national benchmark for the initial assessment of men with LUTS: data from the 2010 Royal College of Physicians National Audit of Continence Care.

To assess the degree of adherence to the current National Institute for Health and Clinical Excellence (NICE) guidelines on the management of urinary incontinence (UI) in men. Retrospective survey of male patients with UI in primary and acute hospital (AH) care as part of a national audit. NHS AH and primary care (PC) trusts. Twenty-five men <65years old and 25 men ≥65years old from each participating site. All NHS trusts in England, Wales Northern Ireland and Channel Islands were eligible to participate. A web-based data collection form aligned to the NICE guidelines was constructed for the study. All data submitted to the audit were anonymous, and access to the web tool was password protected for confidentiality. Data were returned by 80% (128/161) of acute trusts and 52% (75/144) of PC trusts in England, and 71% (10/14) of combined trusts from Northern Ireland, Wales and the Channel Islands including data on 559 men <65 and 1271 65+ from 141 sites within acute hospitals and 445 men <65 and 826 men 65+ in PC, a total of 3101 participants. The majority of men seen within the NHS with LUTS do not receive management according to evidence-informed NICE guidelines; in general, older men are less likely to receive care that meets guideline standards than younger men.

Major geographical variations in elective coronary revascularization by stents or surgery in England.

Revascularization in stable coronary artery disease (CAD) can be achieved through percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) depending on the anatomical pattern of CAD, comorbidities and patient preference. Recent studies in the USA, Canada and Australia show marked local variation in the PCI/CABG ratio that is unexplained by patient-related factors. This current study assesses the geographical variation in elective coronary revascularization interventions across England and discusses its appropriateness. The rates and actual procedure numbers of total CABG, total PCIs and elective PCIs were collated for each of 151 primary care trusts (PCTs). The 'elective PCI/total CABG ratio' was taken as an indicator of elective coronary revascularization practices. The Index of Multiple Deprivation (IMD) for PCTs was taken as a marker of deprivation. In 2010/2011, the degree of variation in elective PCI/total CABG ratios across 151 PCTs in England was >13-fold (min = 0.36, max = 4.74, median = 1.19, interquartile range = 0.98, 1.73). The ratio was not correlated to the IMD 2010 rank of the PCTs (Spearman's ρ = 0.08, P = 0.36) and was not explained by the volume of interventions performed. Despite clear evidence-based guidelines for intervention, marked geographical variation in elective coronary revascularization practices also exists in England. This variation is unexplained by procedure volume or deprivation, suggesting the contribution of unwarranted influences which may include practitioner preference. To reduce this level of unwarranted variation, we suggest that all interventions should be underpinned by internationally recognized guidelines or approved by a multidisciplinary team approach (The Heart Team).

Effectiveness of a community pharmacy weight management programme.

Obesity is a growing problem in England with one quarter of the adult population being obese and around 60 % being overweight or obese. Given the high costs of treating obesity-related conditions such as coronary heart disease and type-2 diabetes the UK Government aims to reduce obesity through public health services including those provided by community pharmacists. To evaluate the effectiveness of a community pharmacy weight management clinic in assisting obese patients to reduce their weight. Community pharmacies across four Primary Care Trusts in England. Retrospective analysis of data collected by pharmacies providing weight management programmes. The service involved measurement with provision of advice and support. Data analysis consisted of frequency counts, percentages and means with standard deviations (SD) for demographic and biometric variables. Paired t tests were used to compare weight, waist circumference and blood pressure at 3 and 6 months. Weight change at 3 months. 281 patients attended the programme across four Primary Care Trusts. Three-quarters were female, mean age 52.8 years (SD ± 14.4) and mean baseline weight 96.3 kg (SD ± 15.7). At 3 months patients had lost weight (mean change = -3.07 kg) and waist circumference (mean change = -3.87 cm), but there was no difference in blood pressure. After 6 months weight and waist circumference were further reduced from baseline (mean change = -4.59 kg, -4.79 cm respectively) and there was a reduction in blood pressure (mean change systolic = -9.5 mmHg; diastolic = -4.7 mmHg). The study has demonstrated that reductions in weight and waist circumference can be achieved in patients who participate in a community pharmacy weight management programme.

Exposure of children with developmental delay to social determinants of poor health: cross‐sectional case record review study

Research on child development in general has highlighted the importance that the family environment plays in mediating the pathway between exposure to low socio-economic position (SEP) and child well-being. While child developmental models in intellectual disability have highlighted the interplay between social context, family environment and child development, little empirical work has attempted to formally evaluate the evidence in support of specific mediating pathways between low SEP and child outcomes. Secondary analysis of cross-sectional confidentialized needs analysis data collected in three Primary Care Trusts in England covering a total population of 1.25 million people. Case record reviews were undertaken for 46 023 households, 2236 (4.9%) of which contained a child in the target age range with developmental delay. Children with developmental delay, when compared with their non-disabled peers, were at significantly increased risk of poorer health outcomes and of being exposed to a wide range of social determinants of poor health. Controlling for between-group differences in exposure to social determinants of poor health reduced the risk of developmental delay being associated with poorer health outcomes by 45% for behaviour problems and 89% for risk of significant harm. For children with developmental delay, parenting difficulties appears to play a particularly significant role in partially mediating the effects of low SEP. The findings of the present study point to the potential effectiveness of family-focused early intervention to prevent the emergence and escalation of behavioural difficulties and health problems in children with developmental delay.

Funding for postbariatric body-contouring (bariplastic) surgery in England: a postcode lottery.

Background. With the increase in bariatric surgery in the UK, there has been a substantial increase in patients undergoing massive weight loss (MWL) seeking postbariatric body-contouring (bariplastic) surgery. However, there is a wide variation of availability on the National Health Service (NHS). Aims. To (1) review the funding policies of Primary Care Trusts (PCTs) in England for bariplastic surgery and (2) analyse the number of procedures funded in two consecutive financial years. Methods. We sent out questionnaires to all PCTs in England regarding their funding policies for bariplastic surgery and requested the number of procedures funded in 2008-09 and 2009-10. Findings. 121/147 (82%) PCTs replied to our questionnaires. 73 (60%) excluded all bariplastic procedures. 106/121 (87.6%) PCTs had referral guidelines for plastic surgery. 46/121 (38%) PCTs provided the total number of funded abdominoplasty-apronectomy (A-A) in the two financial years: total number of A-A applicants rose from 393 to 531, but approval for funding fell from 24.2% to 19.6%. Only 3 (2%) PCTs indicated increase in their future spending on bariplastic procedures in the next 5 years, with 67% planning to decrease or unsure about future funding. Conclusion. There exists a postcode lottery for bariplastic surgery in England and we feel the need for guidelines on provision of bariplastic procedures following MWL.

Electronic patient information systems and care pathways: The organisational challenges of implementation and integration

Our interest here is with the 'marriage' of e-patient information systems with care pathways in order to deliver integrated care. We report on the development and implementation of four such pathways within two National Health Service primary care trusts in England: (a) frail elderly care, (b) stroke care, (c) diabetic retinopathy screening and (d) intermediate care. The pathways were selected because each represents a different type of information and data 'couplings', in terms of task interdependency with some pathways/systems reflecting more complex coordinating patterns than others. Our aim here is identify and explain how health professionals and information specialists in two organisational National Health Service primary care trusts organisationally construct and use such systems and, in particular, the implications this has for issues of professional and managerial control and autonomy. The article is informed by an institutionalist analysis.

Can the relationship between ethnicity and obesity-related behaviours among school-aged children be explained by deprivation? A cross-sectional study

ObjectivesIt is unclear whether cultural differences or material disadvantage explain the ethnic patterning of obesogenic behaviours. The aim of this study was to examine ethnicity as a predictor of obesity-related...

Health behaviours and mental health status of parents with intellectual disabilities: cross sectional study

ObjectivesThe authors sought to: (1) estimate the prevalence of health behaviours, mental health and exposure to social determinants of poorer health among parents with and without intellectual disability; and (2) determine the extent to which between-group differences in health behaviours/status may be attributable to differential exposure to social determinants of poorer health. Study designCross sectional survey. MethodsSecondary analysis of confidentialized needs analysis data collected in three Primary Care Trusts in England on 46,023 households with young children. ResultsHouseholds containing a parent with intellectual disabilities are at increased risk of: (1) poorer parental mental health, parental drug and alcohol abuse and smoking; (2) exposure to a range of environmental adversities. Controlling for the latter eliminated the increased risk of poorer health for single parent households headed by a person with intellectual disabilities. For two parent headed households, risk of poorer parental mental health remained elevated. ConclusionsThe poorer health of parents with intellectual disability may be accounted for by their markedly greater risk of exposure to common social determinants of poorer health rather than being directly attributable to their intellectual disability.

Tackling disinvestment in health care services

The aims of this paper are to explore the experiences of budget holders within the English National Health Service (NHS), in their attempts to implement programmes of disinvestment, and to consider factors which influence the success (or otherwise) of this activity. Between 24 January and 15 March 2011 semi-structured, telephone interviews were conducted with representatives of 12 Primary Care Trusts in England. Interviews focussed on: understanding of the term "disinvestment"; current activities, and perceived determinants of successful disinvestment decision making and implementation. Data were organised into themes according to standard qualitative data coding practices. Findings indicate that experiences of disinvestment are varied and that organisations are currently adopting a range of approaches. There are a number of apparently influential determinants of disinvestment which relate to both health system features and organisational characteristics. According to the experiences of the interviewees, many of the easier disinvestment options have now been taken and more ambitious plans, which require wider engagement and more thorough project management, will be required in the future. Findings from the research suggest that issues around understanding and usage of disinvestment terminology should be addressed and that a more in-depth and ethnographic research agenda will be of most value in moving forward both the theory and practice of disinvestment. This research suggests that, in the English NHS at least, there is a disjuncture between common usage of the term "disinvestment" and the way that it has previously been understood by the wider research community. In addition to this, the research also highlights a broader range of potential determinants of disinvestment than are considered in the extant literature.

The effectiveness and cost-effectiveness of the Family Nurse Partnership home visiting programme for first time teenage mothers in England: a protocol for the Building Blocks randomised controlled trial.

BackgroundThe Nurse Family Partnership programme was developed in the USA where it is made available to pregnant young mothers in some socially deprived geographic areas. The related Family Nurse Partnership programme was introduced in England by the Department of Health in 2006 with the aim of improving outcomes for the health, wellbeing and social circumstances of young first-time mothers and their children.Methods / designThis multi-centre individually randomised controlled trial will recruit 1600 participants from 18 Primary Care Trusts in England, United Kingdom. The trial will evaluate the effectiveness of Family Nurse Partnership programme and usual care versus usual care for nulliparous pregnant women aged 19 or under, recruited by 24 weeks gestation and followed until the child’s second birthday. Data will be collected from participants at baseline, 34-36 weeks gestation, 6, 12, 18 and 24 months following birth. Routine clinical data will be collected from maternity, primary care and hospital episodes statistics. Four primary outcomes are to be reported from the trial: birth weight; prenatal tobacco use; child emergency attendances and/or admissions within two years of birth; second pregnancy within two years of first birth.DiscussionThis trial will evaluate the effectiveness and cost effectiveness of the Family Nurse Partnership in England. The findings will provide evidence on pregnancy and early childhood programme outcomes for policy makers, health professionals and potential recipients in three domains (pregnancy and birth, child health and development, and parental life course and self-sufficiency) up to the child’s second birthday.Trial registrationTrial registration number: ISRCTN 23019866

Demand management: misguided solutions?

Spiralling healthcare costs and demand, against a backdrop of financial austerity makes healthcare commissioning in England a real challenge. ‘Financial balance’ is a major priority, but, as reinforced by the Mid-Staffordshire NHS Foundation Trust failures, cost-cutting must not compromise patient safety and experience. Consequently, commissioners have looked to ‘demand management’ as a solution. This refers to methods used to monitor, direct, or regulate patient referrals from primary care to specialist, non-emergency care in hospital. In the UK, GPs act as gatekeepers and define which patients require referral to specialist care. As demand outstrips resources, the volume and appropriateness of these referrals becomes a major concern and much focus has been placed on managing rising demand. Indeed, in 2009, 91% of primary care trusts in England engaged in some form of referral diversion.1 However, the evidential basis for such interventions are lacking. Various strategies already tried have targeted primary care, specialist services, or infrastructure.2 These included encouraging ‘internal referrals’ within and between general practices, and task shifting clinical work from clinicians to nurses and other health professionals. Telephone triage systems have been used including large scale initiatives such as NHS Direct. Community-based specialist services, for example, heart failure nurses, chronic obstructive pulmonary disease (COPD) teams, and dementia teams, and ‘community matrons’ tasked with managing patients with long-term conditions, have been tried with varying success.3 Efforts were also made to empower patients to self-care such as the Expert …

Primary care trust commissioning of varicose vein intervention – New guidance needed?

In light of evidence of national variability in service commissioning of varicose vein intervention, our aim was to evaluate the current state of primary care trust commissioning for all forms of varicose vein intervention in England. We also sought to clarify the extent to which access to endovenous and surgical varicose vein services is being restricted. Under the Freedom of Information Act (2001), a structured email survey was sent to 108 primary care trusts in England. Trusts were asked how many elective endovenous laser therapy and open procedures were commissioned from 2008 to 2011 and they were asked to submit their commissioning policy for analysis. The 'qualifying criteria' expressed in each policy were analysed by theme and geographical region. Of 108 surveys, 95 (88%) were completed and returned. Of these, 91 (96%) stated that varicose vein interventions were actively commissioned. Eighty-eight (97%) of primary care trusts that commissioned varicose vein interventions stated that access was restricted. Qualifying criteria varied considerably between regions. Access to varicose vein intervention appears to be restricted, with national variation in commissioning across England. This might have an impact on patient care and surgical training. We propose that a national decision be made about which varicose vein patients should be offered funding for treatment on the National Health Service.

Patient and carer experience of obtaining regular prescribed medication for chronic disease in the English National Health Service: a qualitative study

BackgroundThe increasing burden of chronic disease is recognised globally. Within the English National Health Service, patients with chronic disease comprise of half of all consultations in primary care, and 70% of inpatient bed days. The cost of prescribing long-term medications for those with physical chronic diseases is rising and there is a drive to reduce medicine wastage and costs. While current policies in England are focused on the latter, there has been little previous research on patient experience of ordering and obtaining regular medication for their chronic disease. This paper presents findings from England of a qualitative study and survey of patients and their carers’ experiences of community and primary care based services for physical chronic diseases. Although not the primary focus of the study, the results highlighted particular issues around service delivery of repeat prescriptions.MethodsWe conducted 21 qualitative in-depth interviews with 30 patients and family carers’ in two Primary Care Trusts in England. Participants were receiving community based care for diabetes, respiratory, neurological or complex co-morbidities, and ranged in age from 39–92 years old. We used a broadly inductive approach to enable themes around patient experience to emerge from the data.ResultsWhile the study sought to gain an overview of patient experience, the findings suggested that the processes associated with ordering and obtaining regular medication – the repeat prescription, was most frequently described as a recurring hassle of managing a long-term condition. Issues for patients and carers included multiple journeys to the surgery and pharmacy, lack of synchrony and dissatisfaction with the length of prescriptions.ConclusionMuch literature exists around medication waste and cost, which led to encouragement from the NHS in England to reduce dosage units to a 28-day supply. While there has been an acknowledgement that longer supplies may be suitable for people with stable chronic conditions, it appears that there is limited evidence on the impact of shorter length prescriptions on patient and carer experience, adherence and health outcomes. Recent policy documents within England also fail to address possible links between patient experience, adherence and flaws within repeat prescription service delivery.

Mapping the Gypsy Traveller community in England: what we know about their health service provision and childhood immunization uptake

A series of reports over the last two decades have concluded that the overall health status of UK Gypsy Traveller Community is very poor when compared with the general population and relatively poor in comparison with other disadvantaged groups. Despite a government commitment to reducing health inequalities, differences in health outcomes and in healthcare access and service provision have persisted. In order to understand immunization services for Gypsy Travellers, the Health Protection Agency conducted a survey and mapping exercise of Primary Care Trusts in England to ascertain what is known about local Gypsy Traveller populations, estimate immunizations rates and describe current services to increase immunization as well as to address wider health issues. Despite improvements in the provision of specialist services for the Gypsy Traveller communities in England, there still remains a considerable number of areas where knowledge of population numbers is poor, service provision is not based on need and the uptake of immunization is low or not known. There is an ongoing need to improve knowledge of population numbers and the provision of and access to services that are culturally sensitive and responsive to the needs of Gypsy Traveller communities. Whilst we have focused on describing immunization uptake, immunization services are only one component of a wider strategy for improving the health of Gypsy Travellers through effective health and social care interventions.

Understanding the work done by NHS commissioning managers

The purpose of this paper is to explore the practical daily work undertaken by middle-level managers in Primary Care Trusts (PCTs), focusing upon the micro-processes by which these managers enact sensemaking in their organisations. The research took a case study approach, undertaking detailed case studies in four PCTs in England. Data collection included shadowing managers, meeting observations and interviews. The research elucidated two categories of enactment behaviour exhibited by PCT managers: presence/absence; and the production of artefacts. Being "present" in or "absent" from meetings enacted sensemaking over and above any concrete contribution to the meeting made by the actors involved. This paper explores the factors affecting these processes, and describes the situations in which enactment of sense is most likely to occur. Producing artefacts such as meeting minutes or PowerPoint slides also enacted sense in the study sites in addition to the content of the artefact. The factors affecting this are explored. The study has practical implications for all managers seeking to maximise their influence in their organisations. It also provides specific evidence relevant to managers working in the new Clinical Commissioning Groups currently being formed in England. The study expands the understanding of sensemaking in organisations in two important ways. Firstly, it moves beyond discourse to explore the ways in which behaviours can enact sense. Secondly, it explores the distinction between active and unconscious sensemaking.

Practice nurses want their leads and advisers' support to continue

Aim: To explore practice nurses' views of the practice nurse lead/adviser role and find out if they want this role to continue after the abolition of primary care trusts in England on 31 March 2013. Method: An online survey was conducted via SurveyMonkey®. One open-ended and four closed questions were asked to investigate practice nurses' views of the lead/adviser role. The survey was advertised in Practice Nursing journal, the Practice Nursing Update email newsletter, on the Practice Nursing website, in the Independent Nurse email newsletter and by word of mouth. Results: A total of 248 responses were received, of whom 184 (74.2%) reported having a practice nurse lead/adviser in their local area and 239 (96.4%) wanted the lead/adviser role to continue. Conclusions: Practice nurse respondents to this survey voiced overwhelming support for the practice nurse lead/adviser role to continue, with 92.7% taking the opportunity of this survey to express their views on the role's value and the consequences of losing it. Policy-makers, decision-makers and commissioners should take note of the strength of practice nurses' opinion on this issue (albeit from a small sample) and act to ensure that at least an equivalent level of professional support as that provided by PCTs is put in place for practice nurses across England as soon as possible after 1 April.

Structures and processes for priority-setting by health-care funders: a national survey of primary care trusts in England

Although explicit priority-setting is advocated in the health services literature and supported by the policies of many governments, relatively little is known about the extent and ways in which this is carried out at local decision-making levels. Our objective was to undertake a survey of local resource allocaters in the English National Health Services in order to map and explore current priority-setting activity. A national survey was sent to Directors of Commissioning in English Primary Care Trusts (PCTs). The survey was designed to provide a picture of the types of priority-setting activities and techniques that are in place and offer some assessment of their perceived effectiveness. There is variation in the scale, aims and methods of priority-setting functions across PCTs. A perceived strength of priority-setting processes is in relation to the use of particular tools and/or development of formal processes that are felt to increase transparency. Perceived weaknesses tended to lie in the inability to sufficiently engage with a range of stakeholders. Although a number of formal priority-setting processes have been developed, there are a series of remaining challenges such as ensuring priority-setting goes beyond the margins and is embedded in budget management, and the development of disinvestment as well as investment strategies. Furthermore, if we are genuinely interested in a more explicit approach to priority-setting, then fostering a more inclusive and transparent process will be required.