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1.  What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews 
BMJ : British Medical Journal  2004;329(7473):999.
Objectives To assess the extent and pattern of implementation of guidance issued by the National Institute for Clinical Excellence (NICE).
Design Interrupted time series analysis, review of case notes, survey, and interviews.
Setting Acute and primary care trusts in England and Wales.
Participants All primary care prescribing, hospital pharmacies; a random sample of 20 acute trusts, 17 mental health trusts, and 21 primary care trusts; and senior clinicians and managers from five acute trusts.
Main outcome measures Rates of prescribing and use of procedures and medical devices relative to evidence based guidance.
Results 6308 usable patient audit forms were returned. Implementation of NICE guidance varied by trust and by topic. Prescribing of some taxanes for cancer (P < 0.002) and orlistat for obesity (P < 0.001) significantly increased in line with guidance. Prescribing of drugs for Alzheimer's disease and prophylactic extraction of wisdom teeth showed trends consistent with, but not obviously a consequence of, the guidance. Prescribing practice often did not accord with the details of the guidance. No change was apparent in the use of hearing aids, hip prostheses, implantable cardioverter defibrillators, laparoscopic hernia repair, and laparoscopic colorectal cancer surgery after NICE guidance had been issued.
Conclusions Implementation of NICE guidance has been variable. Guidance seems more likely to be adopted when there is strong professional support, a stable and convincing evidence base, and no increased or unfunded costs, in organisations that have established good systems for tracking guidance implementation and where the professionals involved are not isolated. Guidance needs to be clear and reflect the clinical context.
PMCID: PMC524545  PMID: 15514342
2.  Public health professionals' perceptions toward provision of health protection in England: a survey of expectations of Primary Care Trusts and Health Protection Units in the delivery of health protection 
BMC Public Health  2006;6:297.
Background
Effective health protection requires systematised responses with clear accountabilities. In England, Primary Care Trusts and the Health Protection Agency both have statutory responsibilities for health protection. A Memorandum of Understanding identifies responsibilities of both parties, but there is a potential lack of clarity about responsibility for specific health protection functions. We aimed to investigate professionals' perceptions of responsibility for different health protection functions, to inform future guidance for, and organisation of, health protection in England.
Methods
We sent a postal questionnaire to all health protection professionals in England from the following groups: (a) Directors of Public Health in Primary Care Trusts; (b) Directors of Health Protection Units within the Health Protection Agency; (c) Directors of Public Health in Strategic Health Authorities and; (d) Regional Directors of the Health Protection Agency
Results
The response rate exceeded 70%. Variations in perceptions of who should be, and who is, delivering health protection functions were observed within, and between, the professional groups (a)-(d). Concordance in views of which organisation should, and which does deliver was high (≥90%) for 6 of 18 health protection functions, but much lower (≤80%) for 6 other functions, including managing the implications of a case of meningitis out of hours, of landfill environmental contamination, vaccination in response to mumps outbreaks, nursing home infection control, monitoring sexually transmitted infections and immunisation training for primary care staff. The proportion of respondents reporting that they felt confident most or all of the time in the safe delivery of a health protection function was strongly correlated with the concordance (r = 0.65, P = 0.0038).
Conclusion
Whilst we studied professionals' perceptions, rather than actual responses to incidents, our study suggests that there are important areas of health protection where consistent understanding of responsibility for delivery is lacking. There are opportunities to clarify the responsibility for health protection in England, perhaps learning from the approaches used for those health protection functions where we found consistent perceptions of accountability.
doi:10.1186/1471-2458-6-297
PMCID: PMC1712342  PMID: 17156421
3.  Clinical audit and the purchaser-provider interaction: different attitudes and expectations in the United Kingdom. 
Quality in Health Care  1996;5(2):97-103.
OBJECTIVES--To explore and describe the views on clinical audit of healthcare purchasers and providers, and in particular the interaction between them, and hence to help the future development of an appropriate interaction between purchasers and providers. DESIGN-- Semistructured interviews. SETTING--Four purchaser and provider pairings in the former Northern Region of the National Health Service (NHS) in England. SUBJECTS--Chief executives, contracts managers, quality and audit leaders, directors of public health, consultants, general practitioners, audit support staff, and practice managers (total 42). MAIN MEASURES--Attitudes on the present state and future development of clinical audit. RESULTS--Purchasers and providers shared common views on the purpose of clinical audit, but there were important differences in their views on the level and appropriateness of involvement of health care purchasers, integration with present NHS structures and processes (including contracting and the internal market), priority setting for clinical audit, the effects of clinical audit on service development and purchasing, change in behaviour, and the sharing of information on the outcomes of clinical audit. CONCLUSIONS--There are important differences in attitudes towards, and expectations of, clinical audit between health care purchasers and providers, at least in part due to the limited contact between them on audit to date. The nature of the relation and dialogue between purchasers and providers will be critical in determining whether clinical audit meets the differing aspirations of both groups, while achieving the ultimate goal of improving the quality of patient care.
PMCID: PMC1055372  PMID: 10158598
4.  Transitions to palliative care in acute hospitals in England: qualitative study 
Objective To explore how transitions to a palliative care approach are perceived to be managed in acute hospital settings in England.
Design Qualitative study.
Setting Secondary or primary care settings in two contrasting areas of England.
Participants 58 health professionals involved in the provision of palliative care in secondary or primary care.
Results Participants identified that a structured transition to a palliative care approach of the type advocated in UK policy guidance is seldom evident in acute hospital settings. In particular they reported that prognosis is not routinely discussed with inpatients. Achieving consensus among the clinical team about transition to palliative care was seen as fundamental to the transition being effected; however, this was thought to be insufficiently achieved in practice. Secondary care professionals reported that discussions about adopting a palliative care approach to patient management were not often held with patients; primary care professionals confirmed that patients were often discharged from hospital with “false hope” of cure because this information had not been conveyed. Key barriers to ensuring a smooth transition to palliative care included the difficulty of “standing back” in an acute hospital situation, professional hierarchies that limited the ability of junior medical and nursing staff to input into decisions on care, and poor communication.
Conclusion Significant barriers to implementing a policy of structured transitions to palliative care in acute hospitals were identified by health professionals in both primary and secondary care. These need to be addressed if current UK policy on management of palliative care in acute hospitals is to be established.
doi:10.1136/bmj.d1773
PMCID: PMC3230109  PMID: 21447572
5.  Underperforming doctors: a postal survey of the Northern Deanery 
BMJ : British Medical Journal  1998;316(7146):1705-1708.
Objectives: To discover the perceived size of pool of doctors considered to be underperforming in general practice in the Northern Deanery and to discover whether these perceptions are based on formal assessments.
Design: Postal questionnaire.
Setting: Area covered by the Northern Deanery.
Subjects: Seven health authority directors of primary care, seven secretaries of local medical committees, and 14 chief officers of community health councils.
Results: The response rate was 100% for directors of primary care and secretaries of local medical committees and, after one reminder, 92% for chief officers of community health councils. Numbers of doctors perceived to be underperforming ranged from none to over 15 in different health authority areas. Main areas for concern were communication skills, clinical skills, and management skills. Patients’ representatives were concerned about lack of power of patients and health authorities and doctors’ lack of accountability. Health authorities were concerned about lack of power, identification of underperforming doctors, and doctors’ professional loyalty. Local medical committees were concerned about the problem of identifying underperformance. A number of methods were used for identification, and there was no common method applied.
Conclusions: The number of doctors thought to be underperforming was small. Work still needs to be done on developing tools that can be used in everyday practice to enable doctors to confirm for themselves, their colleagues, and their patients that they are providing an adequate level of care.
Key messages To quantify the problem of underperforming general practitioners in the Northern Deanery, a postal survey was carried out among representatives of healthcare commissioners, doctors, and patients A small but not insignificant number of doctors were identified as providing a poor level of performance Main areas for concern were communication skills, clinical skills, and management skills. Various methods were used for identifying underperforming doctors, but there was no common method applied Perceived problems with the present system of dealing with underperforming doctors included identification, lack of power of patients and health authorities, and doctors’ professional loyalty and lack of accountability
PMCID: PMC28568  PMID: 9614017
6.  A national evaluation of specialists' clinics in primary care settings. 
BACKGROUND: Encouraged by the increased purchasing power of general practitioners (GPs), specialist-run clinics in general practice and community health care settings (known as specialist outreach clinics) have increased rapidly across England. The activities of local commissioning schemes within primary care groups are likely to accelerate this trend. AIM: To evaluate the costs, processes, and benefits of specialists' outreach clinics held in GPs' surgeries, compared with hospital outpatient clinics. DESIGN OF STUDY: A case-referent (comparative) study comparing the characteristics of outreach clinics (cases) with matched outpatient control clinics. SETTING: Thirty-eight outreach clinics, compared with 38 matched outpatient clinics as controls, covering 14 hospital trust areas across England. METHOD: Self-administered questionnaires were given to patients in both clinic settings. These covered processes, satisfaction, personal costs, and health status, with postal follow-up at six months to assess health outcomes. Self-administered questionnaires were also given to the specialists and GPs whose clinics were included in the study (individual patient clinical sheet and an attitude questionnaire), practice managers, and trust accountants (process and costs questionnaire). Evaluation of the costs, processes, and benefits of specialist outreach clinics versus hospital outpatient clinics was carried out by comparing questionnaire responses. RESULTS: In comparison with outpatients, outreach clinic patients spent less time on the waiting lists for appointments to see the specialist, they had shorter waiting times in clinics, fewer follow-up appointments, and were more likely to be completely discharged after the sampled attendance. Outreach patients were more satisfied than outpatients with the range of clinic process items asked about. Most doctors felt that the outreach clinic was 'worthwhile'. While patients' personal costs were lower in outreach than in outpatients clinics, NHS costs were more expensive per patient in outreach. The benefits of outreach clinics on patients' health status at six months' follow-up were relatively small. CONCLUSIONS: Outreach clinics are a means of improving access to specialist services for patients, in addition to improving the efficiency and quality of health care. Most results were similar across specialties and areas. The benefits of the outreach service need to be weighed against their substantially higher NHS costs, in comparison with outpatients clinics. Outreach clinics are unlikely to be financially justifiable for NHS funding given that the impact on patients' health status was small.
PMCID: PMC1313974  PMID: 11458477
7.  The Quality and Outcomes Framework and self-management dialogue in primary care consultations: a qualitative study 
The British Journal of General Practice  2011;61(591):e666-e673.
Background
Two key elements to improve the quality of care for people with long-term conditions in primary care are improved clinical information systems to support delivery of evidence-based care, and enhanced self-management support. Although both elements are viewed as necessary, their interaction is not well understood.
Aim
To explore the use of computer-based ‘disease management’ templates and their relevance to self-management dialogue within clinical encounters.
Design and setting
Qualitative study of general practices located in three primary care trusts in the north of England.
Method
A qualitative mixed methods study was conducted that included comparative analysis of (1) observations of general practice consultations (n = 86); and (2) interviews with health professionals in general practice (n = 17).
Results
The analysis suggested that use of the computer templates reinforced a checklist approach to consultations, which included professionals working through several self-management topics framed as discrete behaviours. As a consequence, conversation tended to become focused on the maintenance of the professional-patient relationship at the expense of expansion in self-management dialogue. The computer templates also shaped how patient-initiated self-management dialogue was managed when it arose, with a shift towards discussion around medical agendas.
Conclusion
In order to enhance the management of long-term conditions in primary care, the design and implementation of clinical information systems to improve evidence-based care need to take into account their potential impact on supporting self-management.
doi:10.3399/bjgp11X601389
PMCID: PMC3177136  PMID: 22152849
consultation; chronic disease; doctor-patient relations; primary care; self-management
8.  A qualitative study of the cultural changes in primary care organisations needed to implement clinical governance. 
BACKGROUND: It is commony claimed that changing the culture of health organisations is a fundamental prerequisite for improving the National Health Service (NHS). Little is currently known about the nature or importance of culture and cultural change in primary care groups and trusts (PCG/Ts) or their constituent general practices. AIMS: To investigate the importance of culture and cultural change for the implementation of clinical governance in general practice by PCG/Ts, to identify perceived desirable and undesirable cultural attributes of general practice, and to describe potential facilitators and barriers to changing culture. DESIGN: Qualitative: case studies using data derived from semi-structured interviews and review of documentary evidence. SETTING: Fifty senior non-clinical and clinical managers from 12 purposely sampled PCGs or trusts in England. RESULTS: Senior primary care managers regard culture and cultural change as fundamental aspects of clinical governance. The most important desirable cultural traits were the value placed on a commitment to public accountability by the practices, their willingness to work together and learn from each other, and the ability to be self-critical and learn from mistakes. The main barriers to cultural change were the high level of autonomy of practices and the perceived pressure to deliver rapid measurable changes in general practice. CONCLUSIONS: The culture of general practice is perceived to be an important component of health system reform and quality improvement. This study develops our understanding of a changing organisational culture in primary care; however, further work is required to determine whether culture is a useful practical lever for initiating or managing improvement.
PMCID: PMC1314382  PMID: 12171222
9.  Clinical decision support must be useful, functional is not enough: a qualitative study of computer-based clinical decision support in primary care 
Background
Health information technology, particularly electronic decision support systems, can reduce the existing gap between evidence-based knowledge and health care practice but professionals have to accept and use this information. Evidence is scant on which features influence the use of computer-based clinical decision support (eCDS) in primary care and how different professional groups experience it. Our aim was to describe specific reasons for using or not using eCDS among primary care professionals.
Methods
The setting was a Finnish primary health care organization with 48 professionals receiving patient-specific guidance at the point of care. Multiple data (focus groups, questionnaire and spontaneous feedback) were analyzed using deductive content analysis and descriptive statistics.
Results
The content of the guidance is a significant feature of the primary care professional’s intention to use eCDS. The decisive reason for using or not using the eCDS is its perceived usefulness. Functional characteristics such as speed and ease of use are important but alone these are not enough. Specific information technology, professional, patient and environment features can help or hinder the use.
Conclusions
Primary care professionals have to perceive eCDS guidance useful for their work before they use it.
doi:10.1186/1472-6963-12-349
PMCID: PMC3508894  PMID: 23039113
10.  Practitioners' views on managing childhood obesity in primary care: a qualitative study 
Background
In 2006 the Department of Health and the National Institute for Health and Clinical Excellence (NICE) published guidance on the management of childhood obesity, for use by primary care practitioners. Little is known, however, about practitioners' views and experiences of managing childhood obesity in primary care.
Aim
To explore practitioners' views of primary care as a setting in which to treat childhood obesity.
Design of study
Qualitative interview study.
Setting
Primary care and other community settings based in Bristol, England.
Method
Interviews explored practitioners' views and experiences of managing childhood obesity and their knowledge of the recent guidance provided by the Department of Health and NICE. Interviews were audiotaped and transcribed verbatim. Analysis was thematic and comparisons made both within and across the interviews.
Results
Thirty practitioners were interviewed: 12 GPs, 10 practice nurses, four school nurses, and four health visitors. Participants varied in their views about whether primary care is an appropriate treatment setting for childhood obesity. However, all described factors that limited the extent to which they could intervene effectively: a lack of expertise, resources, and contact with primary school children; the causes of childhood obesity; and the need to work with parents. It was also apparent that very few participants had knowledge of the recent guidance.
Conclusion
Practitioners do not currently view primary care as an effective treatment setting for childhood obesity and it is unlikely that the guidance from the Department of Health and NICE will have a meaningful impact on their management of this condition.
doi:10.3399/bjgp09X472269
PMCID: PMC2765837  PMID: 19712545
child health; obesity; primary health care; qualitative research
11.  Effects of an educational outreach campaign (IMPACT) on depression management delivered to general practitioners in one primary care trust 
Mental Health in Family Medicine  2009;6(3):155-162.
Objective An educational outreach initiative with general practitioners (GPs) within Walsall, led by pharmacists and aimed at delivering evidence‐based guidance on stepped care management of clinical depression.
Methods Standardised educational material was produced with key messages and contributions by experts on prescribing principles and management of clinical depression based on NICE guidance. The primary care pharmacists together with a psychiatrist or other professional delivered the training through initial face‐to‐face meetings with GP practices and carrying out follow‐up visits.
Evaluation Analysis of prescribing data (PACT) on antidepressants, which included prescribing of defined daily doses (DDD) and net ingredient cost (NIC) of commonly prescribed antidepressants for the whole of Walsall teaching Primary Care Trust (tPCT) and comparison with prescribing data for the West Midlands and for England during the period June 2000 to June 2006.
Results The use of Fluoxetine increased slightly and the prescribing of Dosulepin continued to fall. The prescribing of Escitalopram, which had steadily increased prior to the launch of campaign, showed decline, resulting in savings of over £50K in the year 2005 to 2006. This was in comparison to a relative increase in the prescribing for Escitalopram for the same time period in the West Midlands and nationally. Prescribing of Dosulepin continued to fall. The total cost of prescribing for the four antidepressants fell and theses changes were sustained over the following year.
Conclusions The educational outreach campaign successfully influenced prescribing behaviour in terms of adhering to NICE guidance and cost‐effective prescribing, and also facilitated improved communication among clinicians at the primary–secondary care interface.
PMCID: PMC2838650  PMID: 22477906
depression management; education; pharmacists; prescribing; primary care
12.  Implementing the NHS information technology programme: qualitative study of progress in acute trusts 
BMJ : British Medical Journal  2007;334(7608):1360.
Objectives To describe progress and perceived challenges in implementing the NHS information and technology (IT) programme in England.
Design Case studies and in-depth interviews, with themes identified using a framework developed from grounded theory. We interviewed personnel who had been interviewed 18 months earlier, or new personnel in the same posts.
Setting Four NHS acute hospital trusts in England.
Participants Senior trust managers and clinicians, including chief executives, directors of IT, medical directors, and directors of nursing.
Results Interviewees unreservedly supported the goals of the programme but had several serious concerns. As before, implementation is hampered by local financial deficits, delays in implementing patient administration systems that are compliant with the programme, and poor communication between Connecting for Health (the agency responsible for the programme) and local managers. New issues were raised. Local managers cannot prioritise implementing the programme because of competing financial priorities and uncertainties about the programme. They perceive a growing risk to patients' safety associated with delays and a loss of integration of components of the programme, and are discontented with Choose and Book (electronic booking for referrals from primary care).
Conclusions We recommend that the programme sets realistic timetables for individual trusts and advises managers about interim IT systems they have to purchase because of delays outside their control. Advice needs to be mindful of the need for trusts to ensure longer term compatibility with the programme and value for money. Trusts need assistance in prioritising modernisation of IT by, for example, including implementation of the programme in the performance management framework. Even with Connecting for Health adopting a different approach of setting central standards with local implementation, these issues will still need to be addressed. Lessons learnt in the NHS have wider relevance as healthcare systems, such as in France and Australia, look to realise the potential of large scale IT modernisation.
doi:10.1136/bmj.39195.598461.551
PMCID: PMC1906623  PMID: 17510104
13.  Barriers to Partnership Working in Public Health: A Qualitative Study 
PLoS ONE  2012;7(1):e29536.
Background
Public health provision in England is undergoing dramatic changes. Currently established partnerships are thus likely to be significantly disrupted by the radical reforms outlined in the Public Health White Paper. We therefore explored the process of partnership working in public health, in order to better understand the potential opportunities and threats associated with the proposed changes.
Methodology/Principal Findings
70 participants took part in an in-depth qualitative study involving 40 semi-structured interviews and three focus group discussions. Participants were senior and middle grade public health decision makers working in Primary Care Trusts, Local Authorities, Department of Health, academia, General Practice and Hospital Trusts and the third sector in England. Despite mature arrangements for partnership working in many areas, and much support for joint working in principle, many important barriers exist. These include cultural issues such as a lack of shared values and language, the inherent complexity of intersectoral collaboration for public health, and macro issues including political and resource constraints. There is particular uncertainty and anxiety about the future of joint working relating to the availability and distribution of scarce and diminishing financial resources. There is also the concern that existing effective collaborative networks may be completely disrupted as the proposed changes unfold. The extent to which the proposed reforms might mitigate or potentiate these issues remains unclear. However the threats currently remain more salient than opportunities.
Conclusions
The current re-organisation of public health offers real opportunity to address some of the barriers to partnership working identified in this study. However, significant threats exist. These include the breakup of established networks, and the risk of cost cutting on effective public health interventions.
doi:10.1371/journal.pone.0029536
PMCID: PMC3251584  PMID: 22238619
14.  The work of commissioning: a multisite case study of healthcare commissioning in England's NHS 
BMJ Open  2013;3(9):e003341.
Objective
To examine the work of commissioning care for people with long-term conditions and the factors inhibiting or facilitating commissioners making service change.
Design
Multisite mixed methods case study research, combining qualitative analysis of interviews, documents and observation of meetings.
Participants
Primary care trust managers and clinicians, general practice-based commissioners, National Health Service trust and foundation trust senior managers and clinicians, voluntary sector and local government representatives.
Setting
Three ‘commissioning communities’ (areas covered by a primary care trust) in England, 2010–2012.
Results
Commissioning services for people with long-term conditions was a long drawn-out process involving a range of activities and partners. Only some of the activities undertaken by commissioners, such as assessment of local health needs, coordination of healthcare planning and service specification, appeared in the official ‘commissioning cycle’ promoted by the Department of Health. Commissioners undertook a significant range of additional activities focused on reviewing and redesigning services and providing support for implementation of new services. These activities often involved partnership working with providers and other stakeholders and appeared to be largely divorced from contracting and financial negotiations. At least for long-term condition services, the time and effort involved in such work appeared to be disproportionate to the anticipated or likely service gains. Commissioners adopting an incremental approach to service change in defined and manageable areas of work appeared to be more successful in terms of delivering planned changes in service delivery than those attempting to bring about wide-scale change across complex systems.
Conclusions
Commissioning for long-term condition services challenges the conventional distinction between commissioners and providers with a significant amount of work focused on redesigning services in partnership with providers. Such work is labour-intensive and potentially unsustainable at a time of reduced finances. New clinical commissioning groups will need to determine how best to balance the relational and transactional elements of commissioning.
doi:10.1136/bmjopen-2013-003341
PMCID: PMC3773628  PMID: 24014483
Health Services Administration & Management; Qualitative Research
15.  Cluster randomised controlled trial of the effectiveness of primary care mental health workers 
Background
Mental health issues are a core part of the work of primary care and are the second most common reason for consultations. There is some evidence that the quality of primary care mental health provision is variable.
Aim
To evaluate the effectiveness of primary care mental health workers with regards to satisfaction with care, mental health symptoms, use of the voluntary sector, and cost effectiveness of care.
Design of study
Cluster randomised controlled trial.
Setting
Practices in the Heart of Birmingham Primary Care Trust, Birmingham, England.
Method
Nineteen practices and 368 patients (18 to 65 years of age) with a diagnosis of a new or ongoing common mental health problem were recruited. Sixteen practices and 284 patients completed the trial.
Results
Patients in intervention practices had a higher mean level of general satisfaction than those in control practices (difference between group scores of 8.3, 95% confidence interval = 1.3 to 15.3, P = 0.023). The two groups did not differ in mental health symptom scores or use of the voluntary sector.
Conclusion
For patients with common mental health problems, primary care mental health workers may be effective at increasing satisfaction with an episode of care.
PMCID: PMC2042545  PMID: 17359606
mental health; personal satisfaction; primary health care; treatment effectiveness
16.  Modifying dyspepsia management in primary care: a cluster randomised controlled trial of educational outreach compared with passive guideline dissemination. 
BACKGROUND: Quality improvement initiatives in health services rely upon the effective introduction of clinical practice guidelines. However, even well constructed guidelines have little effect unless supported by dissemination and implementation strategies. AIM: To test the effectiveness of 'educational outreach' as a strategy for facilitating the uptake of dyspepsia management guidelines in primary care. DESIGN OF STUDY: A pragmatic, cluster-randomised controlled trial of guideline introduction, comparing educational outreach with postal guideline dissemination alone. SETTING: One-hundred and fourteen general practices (233 general practitioners) in the Salford and Trafford Health authority catchment area in the northwest of England. METHOD: All practices received guidelines by post in July 1997. The intervention group practices began to receive educational outreach three months later. This consisted of practice-based seminars with hospital specialists at which guideline recommendations were appraised, and implementation plans formulated. Seminars were followed up with 'reinforcement' visits after a further 12 weeks. Outcome measures were: (a) the appropriateness of referral for; and (b) findings at, open access upper gastrointestinal endoscopy; (c) costs of GP prescriptions for acid-suppressing drugs, and (d) the use of laboratory-based serological tests for Helicobacter pylori. Data were collected for seven months before and/or after the intervention and analysed by intention-to-treat. RESULTS: (a) The proportion of appropriate referrals was higher in the intervention group in the six-month post-intervention period (practice medians: control = 50.0%, intervention = 63.9%, P < 0.05); (b) the proportion of major findings at endoscopy did not alter significantly; (c) there was a greater rise in overall expenditure on acid-suppressing drugs in the intervention as compared with the control group (+8% versus +2%, P = 0.005); and (d) the median testing rate per practice for H pylori in the post-intervention period was significantly greater in the intervention group (four versus O, P < 0.001). CONCLUSION: This study suggests that educational outreach may be more effective than passive guideline dissemination in changing clinical behaviour. It also demonstrates that unpredictable and unanticipated outcomes may emerge.
PMCID: PMC1314507  PMID: 12817353
17.  Primary care for tinnitus: practice and opinion among GPs in England 
Rationale, aim and objective
Effective tinnitus management starts with appropriate general practitioner (GP) triage, which in England can be guided by the Department of Health's Good Practice Guide (GPG). Despite the prevalence of the condition, there has never been a systematic survey of its management in primary care in England. We aimed to evaluate how people with tinnitus are assessed and managed in general practice, noting variation in practice across GPs and health authorities, and evaluating how closely typical practice aligns to the GPG for tinnitus.
Methods
A nine-item postal questionnaire was sent to 2000 GPs randomly selected to proportionally represent the number of primary care trusts and strategic health authorities in England.
Results
We received 368 responses. Responses indicated a mix of frequent and infrequent practices, for example, 90% of GPs assessed the impact of tinnitus on quality of life, but fewer examined cranial nerves (38%) or assessed for a carotid bruit (26%) during a tinnitus consultation. In the management of tinnitus, 83% routinely removed earwax, and 87% provided information-based advice. In contrast, only 4% of responders would offer antidepressant drugs or psychological therapies. Thematic analysis revealed a desire for concise training on tinnitus management.
Conclusions
GP assessment and management of tinnitus represents potential inequity of service for tinnitus patients. While the GPG aims to promote equity of care, it is only referred to by a minority of clinicians and so its utility for guiding service delivery is questionable. Although some GPs highlighted little demand for tinnitus management within their practice, many others expressed an unmet need for specific and concise GP training on tinnitus management. Further work should therefore evaluate current informational resources and propose effective modes of delivering educational updates.
doi:10.1111/j.1365-2753.2011.01696.x
PMCID: PMC3170708  PMID: 21707872
Department of Health; Good Practice Guidelines; GP education
18.  What do we know about how to do audit and feedback? Pitfalls in applying evidence from a systematic review 
Background
Improving the quality of health care requires a range of evidence-based activities. Audit and feedback is commonly used as a quality improvement tool in the UK National Health Service [NHS]. We set out to assess whether current guidance and systematic review evidence can sufficiently inform practical decisions about how to use audit and feedback to improve quality of care.
Methods
We selected an important chronic disease encountered in primary care: diabetes mellitus. We identified recommendations from National Institute for Clinical Excellence (NICE) guidance on conducting audit and generated questions which would be relevant to any attempt to operationalise audit and feedback in a healthcare service setting. We explored the extent to which a systematic review of audit and feedback could provide practical guidance about whether audit and feedback should be used to improve quality of diabetes care and, if so, how audit and feedback could be optimised.
Results
National guidance suggests the importance of securing the right organisational conditions and processes. Review evidence suggests that audit and feedback can be effective in changing healthcare professional practice. However, the available evidence says relatively little about the detail of how to use audit and feedback most efficiently.
Conclusion
Audit and feedback will continue to be an unreliable approach to quality improvement until we learn how and when it works best. Conceptualising audit and feedback within a theoretical framework offers a way forward.
doi:10.1186/1472-6963-5-50
PMCID: PMC1183206  PMID: 16011811
19.  Evaluation of total purchasing pilots in England and Scotland and implications for primary care groups in England: personal interviews and analysis of routine data 
BMJ : British Medical Journal  1998;317(7153):256-259.
Objectives: To evaluate the reported achievements of the 52 first wave total purchasing pilot schemes in 1996-7 and the factors associated with these; and to consider the implications of these findings for the development of the proposed primary care groups.
Design: Face to face interviews with lead general practitioners, project managers, and health authority representatives responsible for each pilot; and analysis of hospital episode statistics.
Setting: England and Scotland for evaluation of pilots; England only for consideration of implications for primary care groups.
Main outcome measures: The ability of total purchasers to achieve their own objectives and their ability specifically to achieve objectives in the service areas beyond fundholding included in total purchasing.
Results: The level of achievement between pilots varied widely. Achievement was more likely to be reported in primary than in secondary care. Reported achievements in reducing length of stay and emergency admissions were corroborated by analysis of hospital episode statistics. Single practice and small multipractice pilots were more likely than large multipractice projects to report achieving their objectives. Achievements were also associated with higher direct management costs per head and the ability to undertake independent contracting. Large multipractice pilots required considerable organisational development before progress could be made.
Conclusion: The ability to create effective commissioning organisations the size of the proposed primary care groups should not be underestimated. To be effective commissioners, these care groups will need to invest heavily in their organisational development and in the short term are likely to need an additional development budget rather than the reduction in spending on NHS management that is planned by the government.
Key messages The level of reported achievement between the total purchasing pilots in 1996-7 varied widely; achievement was more likely to occur in primary than in secondary care Single practice and small multipractice pilots were more likely than large multipractice pilots to report achieving their objectives in 1996/97; achievements were also associated with higher direct management costs per head Large multipractice pilots needed more time for organisational development before progress could be made Difficulties in creating effective commissioning organisations the size of the proposed primary care groups should not be underestimated Primary care groups will need to invest heavily in organisational development and are likely to need an additional development budget in the short term
PMCID: PMC28618  PMID: 9677217
20.  Primary care access and its relationship with emergency department utilisation: an observational, cross-sectional, ecological study 
The British Journal of General Practice  2011;61(593):e787-e793.
Background
Recent health service policies in the UK have focused on improving primary care access in order to reduce the use of costly emergency department services, even though the relationship between the two is based on weak or little evidence. Research is required to establish whether improving primary care access can influence emergency department attendance.
Aim
To ascertain whether a relationship exists between the degree of access to GP practices and avoidable emergency department attendances in an inner-London primary care trust (PCT).
Design and setting
Observational, cross-sectional ecological study in 68 general practices in Brent Primary Care Trust, north London, UK.
Method
GP practices were used as the unit of analysis and avoidable emergency department attendance as the dependent variable. Routinely collected data from GP practices, Hospital Episode Statistics, and census data for the period covering 2007–2009 were used across three broad domains: GP access characteristics, population characteristics, and health status aggregated to the level of the GP practice. Multiple linear regression was used to ascertain which variables account for the variation in emergency department attendance experienced by patients registered to each GP practice.
Results
None of the GP access variables accounted for the variation in emergency department attendance. The only variable that explained this variance was the Index of Multiple Deprivation (IMD). For every unit increase in IMD score of the GP practice, there would be an increase of 6.13 (95% CI = 4.56, 7.70) per 1000 patients per year in emergency department attendances. This accounted for 47.9% of the variance in emergency department attendances in Brent.
Conclusion
Avoidable emergency department attendance appears to be mostly driven by underlying deprivation rather than by the degree of access to primary care.
doi:10.3399/bjgp11X613124
PMCID: PMC3223776  PMID: 22137415
access to health care; health services; primary care
21.  An integrated care pathway for menorrhagia across the primary–secondary interface: patients' experience, clinical outcomes, and service utilisation 
Quality & Safety in Health Care  2007;16(2):110-115.
Background
“Referral” characterises a significant area of interaction between primary and secondary care. Despite advantages, it can be inflexible, and may lead to duplication.
Objective
To examine the outcomes of an integrated model that lends weight to general practitioner (GP)‐led evidence based care.
Design
A prospective, non‐random comparison of two services: women attending the new (Bridges) pathway compared with those attending a consultant‐led one‐stop menstrual clinic (OSMC). Patients' views were examined using patient career diaries, health and clinical outcomes, and resource utilisation. Follow‐up was for 8 months.
Setting
A large teaching hospital and general practices within one primary care trust (PCT).
Results
Between March 2002 and June 2004, 99 women in the Bridges pathway were compared with 94 women referred to the OSMC by GPs from non‐participating PCTs. The patient career diary demonstrated a significant improvement in the Bridges group for patient information, fitting in at the point of arrangements made for the patient to attend hospital (ease of access) (p<0.001), choice of doctor (p = 0.020), waiting time for an appointment (p<0.001), and less “limbo” (patient experience of non‐coordination between primary and secondary care) (p<0.001). At 8 months there were no significant differences between the two groups in surgical and medical treatment rates or in the use of GP clinic appointments. Significantly fewer (traditional) hospital outpatient appointments were made in the Bridges group than in the OSMC group (p<0.001).
Conclusion
A general practice‐led model of integrated care can significantly reduce outpatient attendance while improving patient experience, and maintaining the quality of care.
doi:10.1136/qshc.2005.016782
PMCID: PMC2653147  PMID: 17403756
primary–secondary care interface; menorrhagia; one‐stop clinic; delivery of health care
22.  Smoke-free hospitals – the English experience: results from a survey, interviews, and site visits 
Background
According to the provisions of the Health Act 2006, NHS acute Trusts had to become smoke-free by July 2007. Mental health Trusts were granted a further year before all indoor smoking areas have to be removed. This study was carried out to determine the extent of smoke-free policy implementation in English NHS acute and mental health Trusts, and to explore challenges and impacts related to policy implementation.
Methods
Questionnaire-based survey of all English NHS acute and mental health hospital settings, supplemented by semi-structured telephone interviews with 22 respondents and direct observation at a sample of 15 Trusts (22 different sites). Human Resources Directors of all 245 English NHS Trusts providing acute and/or mental health inpatient care were identified as potential study participants. Main outcome measures comprised the proportions of Trusts reporting smoke-free policy implementation; whether these relate to buildings only or to whole premises including grounds; most frequently reported exemptions; reported and observed frequencies of policy breaches.
Results
Smoke-free policies were reported to be implemented in all mental health and 98% of acute settings studied. They applied to whole premises including grounds in 84% of acute, and 64% of mental health settings. However, exemptions were granted by 50% of acute and 78% of mental health settings, typically for bereaved relatives or psychiatric patients, in sheltered outdoor areas and smoking rooms. Reported challenges included policy enforcement and related risks of abuse, and litter on premises and adjacent public grounds. Nearly two thirds of acute and over a third of mental health trusts reported that policy infringements occurred on a daily basis. Indeed, patients and visitors were observed smoking at 94% of acute sites visited and staff smoking at 35% of them.
Conclusion
NHS hospitals should play an exemplary role in making a smoke-free environment the norm. Although smoke-free policies have been implemented in nearly all English NHS hospitals, exemptions are frequently granted and policy breaches appear to be commonplace.
doi:10.1186/1472-6963-8-41
PMCID: PMC2266918  PMID: 18282278
23.  Issues Facing Pharmacy Leaders in 2013 
Hospital Pharmacy  2013;48(5):433-437.
The Director’s Forum provides directors of pharmacy practical ways to develop patient-centered pharmacy services. Pharmacy directors must understand the key issues facing their departments and incorporate strategies for these issues as part of their strategic planning process. Health care reform and the Affordable Care Act require that departments operate efficiently and closely monitor their drug expense. The American Society of Health-System Pharmacists’ Pharmacy Practice Model Initiative will serve as a valuable resource during 2013 to enhance the pharmacy practice model. By using their health care workforce, particularly pharmacy technicians, in an innovative way, pharmacy directors will allow the pharmacists to increase their clinical activity. By promoting the role of the hospital pharmacist to patients, directors will help to improve patients’ understanding of their medications and increase their satisfaction with their care. Finally by changing the activities of pharmacy students in practice models, the patient care role of the pharmacist can be expanded. Through a greater understanding of the issues facing them and their effect on the operations of the pharmacy, pharmacy directors will learn effective ways to develop patient-centered pharmacy services.
doi:10.1310/hpj4805-433
PMCID: PMC3839473  PMID: 24421500
24.  Leadership of healthcare commissioning networks in England: a mixed-methods study on clinical commissioning groups 
BMJ Open  2013;3(2):e002112.
Objective
To explore the relational challenges for general practitioner (GP) leaders setting up new network-centric commissioning organisations in the recent health policy reform in England, we use innovation network theory to identify key network leadership practices that facilitate healthcare innovation.
Design
Mixed-method, multisite and case study research.
Setting
Six clinical commissioning groups and local clusters in the East of England area, covering in total 208 GPs and 1 662 000 population.
Methods
Semistructured interviews with 56 lead GPs, practice managers and staff from the local health authorities (primary care trusts, PCT) as well as various healthcare professionals; 21 observations of clinical commissioning group (CCG) board and executive meetings; electronic survey of 58 CCG board members (these included GPs, practice managers, PCT employees, nurses and patient representatives) and subsequent social network analysis.
Main outcome measures
Collaborative relationships between CCG board members and stakeholders from their healthcare network; clarifying the role of GPs as network leaders; strengths and areas for development of CCGs.
Results
Drawing upon innovation network theory provides unique insights of the CCG leaders’ activities in establishing best practices and introducing new clinical pathways. In this context we identified three network leadership roles: managing knowledge flows, managing network coherence and managing network stability. Knowledge sharing and effective collaboration among GPs enable network stability and the alignment of CCG objectives with those of the wider health system (network coherence). Even though activities varied between commissioning groups, collaborative initiatives were common. However, there was significant variation among CCGs around the level of engagement with providers, patients and local authorities. Locality (sub) groups played an important role because they linked commissioning decisions with patient needs and brought the leaders closer to frontline stakeholders.
Conclusions
With the new commissioning arrangements, the leaders should seek to move away from dyadic and transactional relationships to a network structure, thereby emphasising on the emerging relational focus of their roles. Managing knowledge mobility, healthcare network coherence and network stability are the three clinical leadership processes that CCG leaders need to consider in coordinating their network and facilitating the development of good clinical commissioning decisions, best practices and innovative services. To successfully manage these processes, CCG leaders need to leverage the relational capabilities of their network as well as their clinical expertise to establish appropriate collaborations that may improve the healthcare services in England. Lack of local GP engagement adds uncertainty to the system and increases the risk of commissioning decisions being irrelevant and inefficient from patient and provider perspectives.
doi:10.1136/bmjopen-2012-002112
PMCID: PMC3586053  PMID: 23430596
Health Services Administration & Management; Qualitative Research
25.  Is housing a public health issue? A survey of directors of public health. 
BMJ : British Medical Journal  1991;302(6769):157-160.
OBJECTIVE--To determine the views of directors of public health on the importance of housing for public health and their departments' and health authorities' participation in housing issues. DESIGN--Postal self administered questionnaire survey. SETTING--All district health authorities in England and health boards in Wales, Scotland, and Northern Ireland. SUBJECTS--All 221 district directors of public health in England and chief administrative medical officers in Wales, Scotland, and Northern Ireland. MAIN OUTCOME MEASURE--Response to questionnaire consisting of fixed and open ended questions on housing issues. RESULTS--The response rate was 89% (196/221). Housing was perceived as a major health problem by 33% (65/196) of directors. Positive responses were most likely from inner city districts. In 47% (93/196) of departments there was a formal time commitment to housing issues with a median time of one session/week (range one per month to 10 per week). The main function was allocation of medical priority for public sector rehousing. Overall, 73% (144/196) reported some participation in this process. Reported participation in joint care planning and links with non-statutory housing organisations were uncommon. 53% (104/196) of directors had included housing issues in their annual health report. In 16% (32/196) of districts specific services for the homeless had been set up. CONCLUSIONS--Although concern about the impact of current housing policy on public health was shown by a substantial number of directors, the main activity was still allocation of medical priority despite a background of increasing housing need and homelessness. The underlying need is for greater advocacy to produce a healthy housing policy for all, and the annual public health report could be used to promote this objective.
PMCID: PMC1668824  PMID: 1995137

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