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1.  Family Doctor Responses to Changes in Incentives for Influenza Immunization under the U.K. Quality and Outcomes Framework Pay-for-Performance Scheme 
Health Services Research  2011;47(3 Pt 1):1117-1136.
To analyze the effect of setting higher targets, in a primary care pay-for-performance scheme, on rates of influenza immunization and exception reporting.
Study Setting
The U.K. Quality and Outcomes Framework links financial rewards for family practices to four separate influenza immunization rates for patients with coronary heart disease (CHD), chronic obstructive pulmonary disease, diabetes, and stroke. There is no additional payment for immunization rates above an upper threshold. Patients for whom immunization would be inappropriate can be excepted from the practice for the calculation of the practice immunization rate.
Practice-level information on immunizations and exceptions extracted from electronic records of all practices in England 2004/05 to 2009/10 (n = 8,212–8,403).
Study Design
Longitudinal random effect multilevel linear regressions comparing changes in practice immunization and exception rates for the four chronic conditions before and after the increase in the upper threshold immunization rate for CHD patients in 2006/07.
Principal Findings
The 5 percent increase in the upper payment threshold for CHD was associated with increases in the proportion of immunized CHD patients (0.41 percent, CI: 0.25–0.56 percent), and exception was reported (0.26 percent, CI: 0.12–0.40 percent).
Making quality targets more demanding can not only lead to improvement in quality of care but can also have other consequences.
PMCID: PMC3423175  PMID: 22171997
Quality and Outcomes Framework (QOF); influenza immunization; pay-for-performance; upper threshold
2.  Using natural experiments to evaluate population health interventions: new MRC guidance 
Natural experimental studies are often recommended as a way of understanding the health impact of policies and other large scale interventions. Although they have certain advantages over planned experiments, and may be the only option when it is impossible to manipulate exposure to the intervention, natural experimental studies are more susceptible to bias. This paper introduces new guidance from the Medical Research Council to help researchers and users, funders and publishers of research evidence make the best use of natural experimental approaches to evaluating population health interventions. The guidance emphasises that natural experiments can provide convincing evidence of impact even when effects are small or take time to appear. However, a good understanding is needed of the process determining exposure to the intervention, and careful choice and combination of methods, testing of assumptions and transparent reporting is vital. More could be learnt from natural experiments in future as experience of promising but lesser used methods accumulates.
PMCID: PMC3796763  PMID: 22577181
3.  "A powerful intervention: general practitioners'; use of sickness certification in depression" 
BMC Family Practice  2012;13:82.
Depression is frequently cited as the reason for sickness absence, and it is estimated that sickness certificates are issued in one third of consultations for depression. Previous research has considered GP views of sickness certification but not specifically in relation to depression.
This study aimed to explore GPs views of sickness certification in relation to depression.
A purposive sample of GP practices across Scotland was selected to reflect variations in levels of incapacity claimants and antidepressant prescribing. Qualitative interviews were carried out between 2008 and 2009.
A total of 30 GPs were interviewed. A number of common themes emerged including the perceived importance of GP advocacy on behalf of their patients, the tensions between stakeholders involved in the sickness certification system, the need to respond flexibly to patients who present with depression and the therapeutic nature of time away from work as well as the benefits of work. GPs reported that most patients with depression returned to work after a short period of absence and that it was often difficult to predict which patients would struggle to return to work.
GPs reported that dealing with sickness certification and depression presents distinct challenges. Sickness certificates are often viewed as powerful interventions, the effectiveness of time away from work for those with depression should be subject to robust enquiry.
PMCID: PMC3441202  PMID: 22877237
Depression; Mood disorder; Primary care; Occupational; Environmental medicine; Doctor-patient relationship; Mental health
4.  Differences in the quality of primary medical care services by remoteness from urban settlements 
Quality & Safety in Health Care  2007;16(6):446-449.
To examine if the quality of primary medical care varies with remoteness from urban settlements.
Cross‐sectional analysis of publicly available data of 18 process and intermediate outcome measures for people with coronary heart disease (CHD), diabetes and stroke.
Setting and participants
Populations registered with 912 general practices in Scotland grouped into three categories by level of remoteness from urban settlements: not remote, remote and very remote.
Main outcome measures
Mean percentages achieving quality indicators and interquartile range scores.
Remote and very remote practices were more likely to have characteristics associated with low Quality and Outcomes Framework (QOF) total points score (smaller, higher capitation income, dispensing practice, and had lower statin prescribing despite higher prevalence of cardiovascular disease and diabetes). However, in contrast with previous research, there was little evidence that quality of care was lower in more remote areas for the 18 process and intermediate outcome measures examined. The exception was significantly lower cholesterol measurement and control in people with CHD, diabetes and stroke attending very remote practices (p<0.01) and β‐blocker prescription in CHD (p = 0.01).
Under QOF, there are few differences in the quality of care delivered to patients in practices with different degrees of remoteness. The differences in achievement for cholesterol were consistent with lower rates of statin prescribing relative to disease burden in very remote practices. No differences were found for complex process measures such as retinopathy screening, implying that differences under QOF are more likely to be due to slower adoption of evidence‐based practice than access problems. Examining this will require analysis of individual patient data.
PMCID: PMC2653180  PMID: 18055889
5.  ‘A coal face option’: GPs' perspectives on the rise in antidepressant prescribing 
The British Journal of General Practice  2009;59(566):e299-e307.
Levels of antidepressant prescribing have dramatically increased in Western countries in the last two decades.
To explore GPs' views about, and explanations for, the increase in antidepressant prescribing in Scotland between 1995 and 2004.
Qualitative, interview study.
General practices, Scotland.
GPs in 30 practices (n = 63) purposively selected to reflect a range of practice characteristics and levels of antidepressant prescribing.
Interviews with GPs were taped and transcribed. Analysis followed a Framework Approach.
GPs offered a range of explanations for the rise in antidepressant prescribing in Scotland. Few doctors thought that the incidence of depression had increased, and many questioned the appropriateness of current levels of prescribing. A number of related factors were considered to have contributed to the increase. These included: the success of campaigns to raise awareness of depression; a willingness among patients to seek help; and the perceived safety of selective serotonin reuptake inhibitors, making it easier for GPs to manage depression in primary care. Many GPs believed that unhappiness, exacerbated by social deprivation and the breakdown of traditional social structures, was being ‘medicalised’ inappropriately.
Most antidepressant prescriptions in Scotland are issued by GPs, and current policy aims to reduce levels of prescribing. To meet this aim, GPs' prescribing behaviour needs to change. The findings suggest that GPs see themselves as responders to, rather than facilitators of, change and this has obvious implications for initiatives to reduce prescribing.
PMCID: PMC2734377  PMID: 19761658
depression; drugs; mental health; qualitative research; primary care
6.  Predicting which people with psychosocial distress are at risk of becoming dependent on state benefits: analysis of routinely available data 
Objectives To examine whether there was significant variation in levels of claiming incapacity benefit across general practices. To establish whether it is possible to identify people with mental health problems who are more at risk of becoming dependent on state benefits for long term health problems based on their general practice consulting behaviour.
Design Interrogation of routinely available data in the Scottish Health Surveys and the British Household Panel Survey.
Setting Scotland and the United Kingdom.
Participants Respondents to the Scottish Health Surveys in 1995, 1998, and 2003 (7932, 12 939 and 11 472 respondents, respectively). Respondents to the British Household Panel Survey, 1991-2007 (more than 5000 households).
Main outcome measures Intracluster correlation coefficient for probability of work incapacity by general practice. Caseness according to the general health questionnaire (GHQ-12) and frequency of consultation with general practitioner in years before and after starting to claim incapacity benefit.
Results There was a small and non-significant amount of variation across general practices in Scotland in rate of claims for incapacity benefit after adjustment for other explanatory variables (intracluster correlation coefficient 0.01, P=0.135). There was a significant increase in rates of GHQ-12 caseness from two years before the start of claiming incapacity benefit (odds ratio 1.6, 95% confidence interval 1.3 to 1.9) and an increase in frequent consultation with a general practitioner from three years before the start of claiming incapacity benefit (1.8, 1.3 to 2.4). People with GHQ-12 caseness showed a significant increase in frequent consultations with a general practitioner from two years before the start of claiming incapacity benefit (2.1, 1.4 to 3.2).
Conclusions There was no variation in levels of claiming incapacity benefit across general practices in Scotland after adjustment for differences in population characteristics and so initiatives targeted at practices with high levels are unlikely to be effective. People with mental health problems who are likely to have problems remaining in work can be identified up to three years before they transit on to long term benefits related to ill health.
PMCID: PMC2923293  PMID: 20716597
7.  Are Family Physicians Good for You? Endogenous Doctor Supply and Individual Health 
Health Services Research  2008;43(4):1128-1144.
To investigate the impact of family physician (FP) supply on individual health, adjusting for factors that affect both health and FPs' choice of location.
Study Population
A total of 49,541 individuals in 351 English local authorities (LAs).
Data Sources
Data on individual health and personal characteristics from three rounds (1998, 1999, and 2000) of the Health Survey for England were linked to LA data on FP supply.
Study Design
Three methods for analyzing self-reported health were used. FP supply, instrumented by house prices and by age-weighted capitation payments for patients on FP lists, was included in individual-level health regressions along with individual and LA covariates.
When no instruments are used FPs have a positive but statistically insignificant effect on health. When FP supply is instrumented by age-related capitation it has markedly larger and statistically significant effects. A 10 percent increase in FP supply increases the probability of reporting very good health by 6 percent.
After allowing for endogeneity, an increase in FP supply has a significant positive effect on self-reported individual health.
PMCID: PMC2517263  PMID: 18248406
Family physicians; health; instrumental variables; doctor supply
8.  Factors influencing variation in prescribing of antidepressants by general practices in Scotland 
The prescribing of antidepressants has been rising dramatically in developed countries.
As part of an investigation into the reasons for the rise and variation in the prescribing of antidepressants, this study aimed to describe, and account for, the variation in an age–sex standardised rate of antidepressant prescribing between general practices.
Design of study
Cross-sectional study involving analyses of routinely available data.
A total of 983 Scottish general practices.
Age–sex standardised prescribing rates were calculated for each practice. Univariate and multivariate regression analyses were undertaken to examine how the variation in prescribing was related to population, GP, and practice characteristics at individual practice level.
There was a 4.6-fold difference between the first and ninth deciles of antidepressant prescribing, standardised for registered patients' age and sex composition. The multivariate model explained 49.4% of the variation. Significantly higher prescribing than expected was associated with more limiting long-term illness (highly correlated with deprivation and the single most influential factor), urban location, and a greater proportion of female GPs in the practices. Significantly lower prescribing than expected was associated with single-handed practices, a higher than average list size, a greater proportion of GP partners born outside the UK, remote rural areas, a higher proportion of patients from minority ethnic groups, a higher mean GP age, and availability of psychology services. None of the quality-of-care indicators investigated was associated with prescribing levels.
Almost half of the variation in the prescription of antidepressants can be explained using population, GP, and practice characteristics. Initiatives to reduce the prescribing of antidepressants should consider these factors to avoid denying appropriate treatment to patients in some practices.
PMCID: PMC2629838  PMID: 19192364
antidepressants; clinical practice variation; family practice; Scotland
9.  Economic influences on GPs' decisions to provide out-of-hours care 
Introduction of the new general medical services contract offered UK general practices the option to discontinue providing out-of-hours (OOH) care. This aimed to improve GP recruitment and retention by offering a better work–life balance, but put primary care organisations under pressure to ensure sustainable delivery of these services. Many organisations arranged this by re-purchasing provision from individual GPs.
To analyse which factors influence an individual GP's decision to re-provide OOH care when their practice has opted out.
Design of study
Cross-sectional questionnaire survey.
Rural and urban general practices in Scotland, UK.
A postal survey was sent to all GPs working in Scotland in 2006, with analyses weighted for differential response rates. Analysis included logistic regression of individuals' decisions to re-provide OOH care based on personal characteristics, work and non-work time commitments, income from other sources, and contracting primary care organisation.
Of the 1707 GPs in Scotland whose practice had opted out, 40.6% participated in OOH provision. Participation rates of GPs within primary care organisations varied from 16.7% to 74.7%. Males with young children were substantially more likely to participate than males without children (odds ratio [OR] 2.44, 95% confidence interval [CI] = 1.36 to 4.40). GPs with higher-earning spouses were less likely to participate. This effect was reinforced if GPs had spouses who were also GPs (OR 0.52, 95% CI = 0.37 to 0.74). GPs with training responsibilities (OR 1.36, 95% CI = 1.09 to 1.71) and other medical posts (OR 1.38, 95% CI = 1.09 to 1.75) were more likely to re-provide OOH services.
The opportunity to opt out of OOH care has provided flexibility for GPs to raise additional income, although primary care organisations vary in the extent to which they offer these opportunities. Examining intrinsic motivation is an area for future study.
PMCID: PMC2605544  PMID: 19105906
health care reform; out-of-hours medical care; primary care; workforce
10.  Measuring inequalities in health: the case for healthy life expectancy 
To evaluate healthy life expectancy (HLE) as a measure of health inequalities by comparing geographical and area‐based deprivation‐related inequalities in healthy and total life expectancy (TLE).
Life table analysis based on ecological cross‐sectional data.
Setting and population
Council area quarters and postcode sector‐based deprivation fifths in Scotland.
Main outcome measures
Expectation of life in good self‐assessed general health, or free from limiting long‐term illness, and TLE, for females and males at birth.
Women in Scotland have a life expectation of 70.3 years in good health, 61.6 years free from limiting long‐term illness, and a TLE of 78.9 years. Comparable figures for men are 66.3, 58.6 and 73.5 years. TLE and HLE decrease with increasing area deprivation. Differences are substantially wider for HLE. A 4.7‐year difference is seen in TLE between women living in the most and least deprived fifth of areas. The difference in HLE is 10.7 years in good health and 11.6 years free from limiting long‐term illness. The degree of deprivation‐related inequality in HLE is 2.5 times wider for women and 1.8 times wider for men than in TLE.
Differences in TLE underestimate health inequalities substantially. By including morbidity and mortality, HLE reflects the excess burden of ill health experienced by disadvantaged populations better. Inequalities in length of life and health status during life should be taken into account while monitoring inequalities in population health.
PMCID: PMC2465513  PMID: 17108308
11.  Has payment by results affected the way that English hospitals provide care? Difference-in-differences analysis 
Objective To examine whether the introduction of payment by results (a fixed tariff case mix based payment system) was associated with changes in key outcome variables measuring volume, cost, and quality of care between 2003/4 and 2005/6.
Setting Acute care hospitals in England.
Design Difference-in-differences analysis (using a control group created from trusts in England and providers in Scotland not implementing payment by results in the relevant years); retrospective analysis of patient level secondary data with fixed effects models.
Data sources English hospital episode statistics and Scottish morbidity records for 2002/3 to 2005/6.
Main outcome measures Changes in length of stay and proportion of day case admissions as a proxy for unit cost; growth in number of spells to measure increases in output; and changes in in-hospital mortality, 30 day post-surgical mortality, and emergency readmission after treatment for hip fracture as measures of impact on quality of care.
Results Length of stay fell more quickly and the proportion of day cases increased more quickly where payment by results was implemented, suggesting a reduction in the unit costs of care associated with payment by results. Some evidence of an association between the introduction of payment by results and growth in acute hospital activity was found. Little measurable change occurred in the quality of care indicators used in this study that can be attributed to the introduction of payment by results.
Conclusion Reductions in unit costs may have been achieved without detrimental impact on the quality of care, at least in as far as these are measured by the proxy variables used in this study.
PMCID: PMC2733950  PMID: 19713233
12.  Analysis of consultants' NHS and private incomes in England in 2003/4 
Consultants employed by the NHS in England are allowed to undertake private practice to supplement their NHS income. Until the introduction of a new contract from October 2003, those employed on full-time contracts were allowed to earn private incomes no greater than 10% of their NHS income. In this paper we investigate the magnitude and determinants of consultants' NHS and private incomes.
Quantitative analysis of financial data.
A unique, anonymized, non-disclosive dataset derived from tax returns for a sample of 24,407 consultants (92.3% of the total) in England for the financial year 2003/4.
Main outcome methods
The conditional mean total, NHS and private incomes earned by age group, type of contract, specialty and region of place of work.
The mean annual total, NHS and private incomes across all consultants in 2003/4 were £110,773, £76,628 and £34,144, respectively. Incomes varied by age, type of contract, specialty and region of place of work. The ratio of mean private to NHS income for consultants employed on a full-time contract was 0.26. The mean private income across specialties ranged from £5,144 (for paediatric neurology) to £142,723 (plastic surgery). There was a positive association between mean private income and NHS waiting lists across specialties.
Consultants employed on full-time contracts on average exceeded the limits on private income stipulated by the 10% rule. Specialty is a more important determinant of income than the region in which the consultant works. Further work is required to explore the association between mean private income and waiting lists.
PMCID: PMC2442143  PMID: 18591691
13.  What impact did the creation of Local Health Care Co-operatives have on indicators of practice resources and activity? 
The creation of Local Health Care Cooperatives (LHCCs) in Scotland in 1999 was typical of attempts to encourage voluntary integration and co-operation between health care providers. One of the three stated objectives of their introduction was to tackle inequalities and improve access to care.
We used administrative data on all general practices in 1999 and 2003 to examine whether LHCCs had any measurable impact on six indicators of practice resources and activity. We compare three groups (participant, non-participant, and ineligible practices) through regression analysis of changes over time in group means and within-group inequality (measured using Gini coefficients). In addition, for participants we measure changes in the variation between and within LHCCs.
Despite having similar registered populations to participants, non-participants had lower levels of resources at the start of the period and this differential widened over time. The changes over time in the activity indicators were similar across the three groups. There was little evidence that inequality between LHCC practices narrowed more than in the other two groups. Practices within LHCCs appear to be become more homogenous while variation increased between LHCCs.
The mixed messages from our examination of resources and activity indicators demonstrates that there are likely to be important lessons to be learned from the brief experiment with LHCCs. Clear objectives that are evaluated using a battery of simple performance indicators may help to ensure demonstrable change in future initiatives to foster integration and co-operation.
PMCID: PMC2409319  PMID: 18485213
14.  Workload and reward in the Quality and Outcomes Framework of the 2004 general practice contract 
The Quality and Outcomes Framework (QOF) of the 2004 UK General Medical Services (GMS) contract links up to 20% of practice income to performance measured against 146 quality indicators.
To examine the distribution of workload and payment in the clinical domains of the QOF, and to compare payment based on true prevalence to the implemented system applying an adjusted prevalence factor. We aimed also to assess the performance of the implemented payment system against its three stated objectives: to reduce variation in payment compared to a system based on true prevalence, to fairly link reward to workload, and finally, to help tackle health inequalities.
Design of study
Retrospective analysis of publicly available QOF data.
Nine hundred and three GMS general practices in Scotland.
Comparison of payment under the implemented Adjusted Disease Prevalence Factor, and under an alternative True Disease Prevalence Factor.
Variation in total clinical QOF payment per 1000 patients registered is significantly reduced compared to a payment system based on true prevalence. Payment is poorly related to workload in terms of the number of patients on the disease register, with up to 44 fold variation in payment per patient on the disease register for practices delivering the same quality of care. Practices serving deprived populations are systematically penalised under the implemented payment system, compared to one based on true prevalence.
The implemented adjustment for prevalence succeeds in its aim of reducing variation in practice income, but at the cost of making the relationship between workload and reward highly inequitable and perpetuating the inverse care law.
PMCID: PMC1927091  PMID: 17132350
family practice; quality healthcare; physician incentive plans; workload
15.  Exploring potential explanations for the increase in antidepressant prescribing in Scotland using secondary analyses of routine data 
Antidepressant prescribing in general practice has dramatically increased since the beginning of the last decade.
To determine if the increase in antidepressants prescribed in Scotland between 1995 and 2001 was due to increase in incidence, prevalence, care-seeking behaviour by patients, or identification by GPs of depression.
Secondary analysis of routine data. Prescribing information was obtained from Information and Statistics Division Scotland, psychosocial morbidity from the Scottish Health Surveys of 1995 and 1998 and GP consultations from the continuous morbidity recording (CMR) dataset. Annual trends in antidepressant prescribing for prescriptions, gross ingredient cost and defined daily doses (DDDs) were examined for all Scottish Practices and 54 stable CMR practices (175 955 patients). Prevalence of psychological morbidity in responders with a General Health Questionnaire score ≥4, their contact probability and contact frequency was compared in the 1995 and 1998 Scottish Health Surveys. Changes in diagnostic and GP consultation patterns in CMR practices were compared.
Total prescriptions for antidepressants increased from 1.5 million in 1995–1996 to 2.8.million in 2000–2001. The gross ingredient cost increased from £20 to £44 million and total DDDs from 44.5 to 93.2 million. Prescription trends in CMR practices were similar. Overall prevalence of psychological morbidity was the same in the 1995 and 1998 Scottish Health Surveys. Percentage of consultations in CMR practices for new diagnoses of depression decreased from 1.7 to 1.3%, the depression-related contact rate decreased and annual prevalence rates for depressive illness were stable between 1998–1999 and 2000–2001.
There is no evidence of an increase in incidence, prevalence, care-seeking behaviour or identification of depression during the period of a sharp increase in antidepressant prescribing. Further work is required to explain the increase.
PMCID: PMC1839016  PMID: 16762123
depression; drugs; health services; mental health; primary care
16.  Differences in the quality of primary medical care for CVD and diabetes across the NHS: evidence from the quality and outcomes framework 
Health policy in the UK has rapidly diverged since devolution in 1999. However, there is relatively little comparative data available to examine the impact of this natural experiment in the four UK countries. The Quality and Outcomes Framework of the 2004 General Medical Services Contract provides a new and potentially rich source of comparable clinical quality data through which we compare quality of primary medical care for coronary heart disease (CHD), stroke, hypertension and diabetes across the four UK countries.
A cross-sectional analysis was undertaken involving 10,064 general practices in England, Scotland, Wales and Northern Ireland. The main outcome measures were prevalence rates for CHD, stroke, hypertension and diabetes. Achievement on 14 simple process, 3 complex process, 9 intermediate outcome and 5 treatment indicators for the four clinical areas.
Prevalence varies by up to 28% between the four UK countries, which is not reflected in resource distribution between countries, and penalises practices in the high prevalence countries (Wales and Scotland). Differences in simple process measures across countries are small. Larger differences are found for complex process, intermediate outcome and treatment measures, most notably for Wales, which has consistently lower quality of care. Scotland has generally higher quality than England and Northern Ireland is most consistently the highest quality.
Previously identified weaknesses in Wales related to waiting times appear to reflect a more general quality problem within NHS Wales. Identifying explanations for the observed differences is limited by the lack of comparable data on practice resources and organisation. Maximising the value of cross-jurisdictional comparisons of the ongoing natural experiment of health policy divergence within the UK requires more detailed examination of resource and organisational differences.
PMCID: PMC1891099  PMID: 17535429
17.  Determinants of primary medical care quality measured under the new UK contract: cross sectional study 
BMJ : British Medical Journal  2006;332(7538):389-390.
Objective To identify factors associated with the quality of primary medical care incentivised under the new UK general medical services contract.
Design Cross sectional study.
Setting NHS Ayrshire and Arran area, Scotland.
Participants 60 general practices.
Main outcome measures Quality scores reflecting the total points achieved on the 10 clinical domains and holistic care. Univariate and multivariate regression analyses were used to relate quality scores to measures of population characteristics, urban-rural location, general practitioner characteristics, clinical team size and composition, practice characteristics, and income from other sources.
Results Deprivation was associated with higher scores. Quality scores increased with the size of the clinical team. Practices with higher income from other sources had lower quality scores. Practices that were accredited, had training status, or contained younger general practitioners had higher quality scores, but these effects were explained by other associated factors. 53% of the variation in quality scores was explained by a multivariate model, which included measures of deprivation, clinical team size and composition, and financial incentives.
Conclusions Population characteristics showed little association with the quality of primary medical care incentivised under the UK general medical services contract. Larger clinical teams delivered higher quality clinical care, but the nurse-doctor composition of the clinical team did not influence quality. Practices that were more likely to respond to financial incentives because of previous behaviour or lower income from other sources recorded higher quality. If generalisable, the results suggest that initiatives to improve primary medical care quality should focus on the structure and resourcing of providers.
PMCID: PMC1370969  PMID: 16467345

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