PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (29)
 

Clipboard (0)
None

Select a Filter Below

Journals
more »
Year of Publication
more »
1.  Psychometric properties of the patient assessment of chronic illness care measure: acceptability, reliability and validity in United Kingdom patients with long-term conditions 
Background
The Patient Assessment of Chronic Illness Care (PACIC) is a US measure of chronic illness quality of care, based on the influential Chronic Care Model (CCM). It measures a number of aspects of care, including patient activation; delivery system design and decision support; goal setting and tailoring; problem-solving and contextual counselling; follow-up and coordination. Although there is developing evidence of the utility of the scale, there is little evidence about its performance in the United Kingdom (UK). We present preliminary data on the psychometric performance of the PACIC in a large sample of UK patients with long-term conditions.
Method
We collected PACIC, demographic, clinical and quality of care data from patients with long-term conditions across 38 general practices, as part of a wider longitudinal study. We assess rates of missing data, present descriptive and distributional data, assess internal consistency, and test validity through confirmatory factor analysis, and through associations between PACIC scores, patient characteristics and related measures.
Results
There was evidence that rates of missing data were high on PACIC (9.6% - 15.9%), and higher than on other scales used in the same survey. Most PACIC sub-scales showed reasonable levels of internal consistency (alpha = 0.68 – 0.94), responses did not demonstrate high skewness levels, and floor effects were more frequent (up to 30.4% on the follow up and co-ordination subscale) than ceiling effects (generally <5%). PACIC demonstrated preliminary evidence of validity in terms of measures of long-term condition care. Confirmatory factor analysis suggested that the five factor PACIC structure proposed by the scale developers did not fit the data: reporting separate factor scores may not always be appropriate.
Conclusion
The importance of improving care for long-term conditions means that the development and validation of measures is a priority. The PACIC scale has demonstrated potential utility in this regard, but further assessment is required to assess low levels of completion of the scale, and to explore the performance of the scale in predicting outcomes and assessing the effects of interventions.
doi:10.1186/1472-6963-12-293
PMCID: PMC3526462  PMID: 22938193
Long term conditions; Chronic disease; Patient assessments; Primary care; Quality improvement
2.  A spatial analysis of the expanding roles of nurses in general practice 
BMC Nursing  2012;11:13.
Background
Changes to the workforce and organisation of general practice are occurring rapidly in response to the Australian health care reform agenda, and the changing nature of the medical profession. In particular, the last five years has seen the rapid introduction and expansion of a nursing workforce in Australian general practices. This potentially creates pressures on current infrastructure in general practice.
Method
This study used a mixed methods, ‘rapid appraisal’ approach involving observation, photographs, and interviews.
Results
Nurses utilise space differently to GPs, and this is part of the diversity they bring to the general practice environment. At the same time their roles are partly shaped by the ways space is constructed in general practices.
Conclusion
The fluidity of nursing roles in general practice suggests that nurses require a versatile space in which to maximize their role and contribution to the general practice team.
doi:10.1186/1472-6955-11-13
PMCID: PMC3488547  PMID: 22870933
General practice; Private practice nursing; Physicians office; Spatial analysis; Skill mix
3.  Professional values and reported behaviours of doctors in the USA and UK: quantitative survey 
BMJ quality & safety  2011;20(6):515-521.
Background
The authors aimed to determine US and UK doctors' professional values and reported behaviours, and the extent to which these vary with the context of care.
Method
1891 US and 1078 UK doctors completed the survey (64.4% and 40.3% response rate respectively). Multivariate logistic regression was used to compare responses to identical questions in the two surveys.
Results
UK doctors were more likely to have developed practice guidelines (82.8% UK vs 49.6% US, p<0.001) and to have taken part in a formal medical error-reduction programme (70.9% UK vs 55.7% US, p<0.001). US doctors were more likely to agree about the need for periodic recertification (completely agree 23.4% UK vs 53.9% US, p<0.001). Nearly a fifth of doctors had direct experience of an impaired or incompetent colleague in the previous 3 years. Where the doctor had not reported the colleague to relevant authorities, reasons included thinking that someone else was taking care of the problem, believing that nothing would happen as a result, or fear of retribution. UK doctors were more likely than US doctors to agree that significant medical errors should always be disclosed to patients. More US doctors reported that they had not disclosed an error to a patient because they were afraid of being sued.
Discussion
The context of care may influence both how professional values are expressed and the extent to which behaviours are in line with stated values. Doctors have an important responsibility to develop their healthcare systems in ways which will support good professional behaviour.
doi:10.1136/bmjqs.2010.048173
PMCID: PMC3102540  PMID: 21383386
Culture; health policy
4.  Following the funding trail: Financing, nurses and teamwork in Australian general practice 
Background
Across the globe the emphasis on roles and responsibilities of primary care teams is under scrutiny. This paper begins with a review of general practice financing in Australia, and how nurses are currently funded. We then examine the influence on funding structures on the role of the nurse. We set out three dilemmas for policy-makers in this area: lack of an evidence base for incentives, possible untoward impacts on interdisciplinary functioning, and the substitution/enhancement debate.
Methods
This three year, multimethod study undertook rapid appraisal of 25 general practices and year-long studies in seven practices where a change was introduced to the role of the nurse. Data collected included interviews with nurses (n = 36), doctors (n = 24), and managers (n = 22), structured observation of the practice nurse (51 hours of observation), and detailed case studies of the change process in the seven year-long studies.
Results
Despite specific fee-for-service funding being available, only 6% of nurse activities generated such a fee. Yet the influence of the funding was to focus nurse activity on areas that they perceived were peripheral to their roles within the practice.
Conclusions
Interprofessional relationships and organisational climate in general practices are highly influential in terms of nursing role and the ability of practices to respond to and utilise funding mechanisms. These factors need to be considered, and the development of optimal teamwork supported in the design and implementation of further initiatives that financially support nursing in general practice.
doi:10.1186/1472-6963-11-38
PMCID: PMC3050696  PMID: 21329506
5.  Direct access to diagnostic services 
The British Journal of General Practice  2009;59(562):e144-e145.
doi:10.3399/bjgp09X420563
PMCID: PMC2673180  PMID: 19401006
6.  Routine care provided by specialists to children and adolescents in the United States (2002-2006) 
Background
Specialist physicians provide a large share of outpatient health care for children and adolescents in the United States, but little is known about the nature and content of these services in the ambulatory setting. Our objective was to quantify and characterize routine and co-managed pediatric healthcare as provided by specialists in community settings.
Methods
Nationally representative data were obtained from the National Ambulatory Medical Care Survey for the years 2002-2006. We included office based physicians (excluding family physicians, general internists and general pediatricians), and a representative sample of their patients aged 18 or less. Visits were classified into mutually exclusive categories based on the major reason for the visit, previous knowledge of the health problem, and whether the visit was the result of a referral. Primary diagnoses were classified using Expanded Diagnostic Clusters. Physician report of sharing care for the patient with another physician and frequency of reappointments were also collected.
Results
Overall, 41.3% out of about 174 million visits were for routine follow up and preventive care of patients already known to the specialist. Psychiatry, immunology and allergy, and dermatology accounted for 54.5% of all routine and preventive care visits. Attention deficit disorder, allergic rhinitis and disorders of the sebaceous glands accounted for about a third of these visits. Overall, 73.2% of all visits resulted in a return appointment with the same physician, in half of all cases as a result of a routine or preventive care visit.
Conclusion
Ambulatory office-based pediatric care provided by specialists includes a large share of non referred routine and preventive care for common problems for patients already known to the physician. It is likely that many of these services could be managed in primary care settings, lessening demand for specialists and improving coordination of care.
doi:10.1186/1472-6963-9-221
PMCID: PMC2797004  PMID: 19961581
7.  What evidence is there to support skill mix changes between GPs, pharmacists and practice nurses in the care of elderly people living in the community? 
Background
Workforce shortages in Australia are occurring across a range of health disciplines but are most acute in general practice. Skill mix change such as task substitution is one solution to workforce shortages. The aim of this systematic review was to explore the evidence for the effectiveness of task substitution between GPs and pharmacists and GPs and nurses for the care of older people with chronic disease. Published, peer reviewed (black) and non-peer reviewed (grey) literature were included in the review if they met the inclusion criteria.
Results
Forty-six articles were included in the review. Task substitution between pharmacists and GPs and nurses and GPs resulted in an improved process of care and patient outcomes, such as improved disease control. The interventions were either health promotion or disease management according to guidelines or use of protocols, or a mixture of both. The results of this review indicate that pharmacists and nurses can effectively provide disease management and/or health promotion for older people with chronic disease in primary care. While there were improvements in patient outcomes no reduction in health service use was evident.
Conclusion
When implementing skill mix changes such as task substitution it is important that the health professionals' roles are complementary otherwise they may simply duplicate the task performed by other health professionals. This has implications for the way in which multidisciplinary teams are organised in initiatives such as the GP Super Clinics.
doi:10.1186/1743-8462-6-23
PMCID: PMC2749853  PMID: 19744350
8.  An implementation research agenda 
In October 2006, the Chief Medical Officer (CMO) of England asked Professor Sir John Tooke to chair a High Level Group on Clinical Effectiveness in response to the chapter 'Waste not, want not' in the CMOs 2005 annual report 'On the State of the Public Health'. The high level group made recommendations to the CMO to address possible ways forward to improve clinical effectiveness in the UK National Health Service (NHS) and promote clinical engagement to deliver this. The report contained a short section on research needs that emerged from the process of writing the report, but in order to more fully identify the relevant research agenda Professor Sir John Tooke asked Professor Martin Eccles to convene an expert group – the Clinical Effectiveness Research Agenda Group (CERAG) – to define the research agenda. The CERAG's terms of reference were 'to further elaborate the research agenda in relation to pursuing clinically effective practice within the (UK) National Health Service'. This editorial presents the summary of the CERAG report and recommendations.
doi:10.1186/1748-5908-4-18
PMCID: PMC2671479  PMID: 19351400
9.  Authors' response 
doi:10.3399/bjgp08X277366
PMCID: PMC2249798
10.  Profile of English salaried GPs: labour mobility and practice performance 
Background
Recent national policy changes have provided greater flexibility in GPs' contracts. One such policy is salaried employment, which offers reduced hours and freedom from out-of-hours and administrative responsibilities, aimed at improving recruitment and retention in a labour market facing regional shortages.
Aim
To profile salaried GPs and assess their mobility within the labour market.
Design of study
Serial cross-sectional study.
Setting
All GPs practising in England during the years 1996/1997, 2000/2001, and 2004/2005.
Method
Descriptive analyses, logistic regression.
Results
Salaried GPs tended to be either younger (<35 years) or older (≥65 years), female, or overseas-qualified; they favoured part-time working and personal medical services contracts. Salaried GPs were more mobile than GP principals, and have become increasingly so, despite a trend towards reduced overall mobility in the GP workforce. Practices with salaried GPs scored more Quality and Outcomes Framework points and were located in slightly more affluent areas.
Conclusion
Salaried status appears to have reduced limitations in the labour market, leading to better workforce deployment from a GP's perspective. However, there is no evidence to suggest it has relieved inequalities in GP distribution.
doi:10.3399/bjgp08X263776
PMCID: PMC2148234  PMID: 18186992
career mobility; England; general practitioners; health manpower; primary health care
11.  Effect of the new contract on GPs' working lives and perceptions of quality of care: a longitudinal survey 
Background
An ambitious pay-for-performance system was implemented in UK general practice in 2004 amid doubts that it could improve both the working lives of doctors and quality of care.
Aim
To evaluate doctors' perceptions of their working lives and quality of care before and after the new contract.
Design of study
Longitudinal questionnaire survey.
Setting
England, UK.
Method
A longitudinal postal survey of English GPs in February 2004 and September 2005. Measures included reported job satisfaction (7-point scale), hours worked, income, and impact of the contract.
Results
Responses were available from 2105 doctors in 2004 and 1349 in 2005. Mean overall job satisfaction increased from 4.58 out of 7 in 2004 to 5.17 in 2005. The greatest improvements in satisfaction were with remuneration and hours of work. Mean reported hours worked fell from 44.5 to 40.8. Mean income increased from an estimated £73 400 in 2004 to £92 600 in 2005. Most GPs reported that the new contract had increased their income (88%), but decreased their professional autonomy (71 %), and increased their administrative (94%) and clinical (86%) workloads. After the introduction of the contract doctors were more positive than they had anticipated about its impact on quality of care.
Conclusion
GPs' job satisfaction increased after the introduction of the new contract, despite perceptions of negative consequences for workload and autonomy. GPs reported working fewer hours with a higher income, and their expectations regarding the impact of the contract on quality of care had been exceeded.
doi:10.3399/bjgp08X263758
PMCID: PMC2148232  PMID: 18186990
job satisfaction; primary care; quality of health care; workforce
12.  Developing guided self-help for depression using the Medical Research Council complex interventions framework: a description of the modelling phase and results of an exploratory randomised controlled trial 
BMC Psychiatry  2008;8:91.
Background
Current guidelines for the management of depression suggest the use of guided self-help for patients with mild to moderate disorders. However, there is little consensus concerning the optimal form and delivery of this intervention. To develop acceptable and effective interventions, a phased process has been proposed, using a modelling phase to examine and develop an intervention prior to preliminary testing in an exploratory trial. This paper (a) describes the modelling phase used to develop a guided self-help intervention for depression in primary care and (b) reports data from an exploratory randomised trial of the intervention.
Methods
A guided self-help intervention was developed following a modelling phase which involved a systematic review, meta synthesis and a consensus process. The intervention was then tested in an exploratory randomised controlled trial by examining (a) fidelity using analysis of taped guided self-help sessions (b) acceptability to patients and professionals through qualitative interviews (c) effectiveness through estimation of the intervention effect size.
Results
Fifty eight patients were recruited to the exploratory trial. Seven professionals and nine patients were interviewed, and 22 tapes of sessions analysed for fidelity. Generally, fidelity to the intervention protocol was high, and the professionals delivered the majority of the specific components (with the exception of the use of feedback). Acceptability to both professionals and patients was also high. The effect size of the intervention on outcomes was small, and in line with previous analyses showing the modest effect of guided self-help in primary care. However, the sample size was small and confidence intervals around the effectiveness estimate were wide.
Conclusion
The general principles of the modelling phase adopted in this study are designed to draw on a range of evidence, potentially providing an intervention that is evidence-based, patient-centred and acceptable to professionals. However, the pilot outcome data did not suggest that the intervention developed was particularly effective. The advantages and disadvantages of the general methods used in the modelling phase are discussed, and possible reasons for the failure to demonstrate a larger effect in this particular case are outlined.
doi:10.1186/1471-244X-8-91
PMCID: PMC2596776  PMID: 19025646
13.  Workforce participation among international medical graduates in the National Health Service of England: a retrospective longitudinal study 
Background
Balancing medical workforce supply with demand requires good information about factors affecting retention. Overseas qualified doctors comprise 30% of the National Health Service (NHS) workforce in England yet little is known about the impact of country of qualification on length of stay. We aimed to address this need.
Methods
Using NHS annual census data, we calculated the duration of 'episodes of work' for doctors entering the workforce between 1992 and 2003. Survival analysis was used to examine variations in retention by country of qualification. The extent to which differences in retention could be explained by differences in doctors' age, sex and medical specialty was examined by logistic regression.
Results
Countries supplying doctors to the NHS could be divided into those with better or worse long-term retention than domestically trained doctors. Countries in the former category were generally located in the Middle East, non-European Economic Area Europe, Northern Africa and Asia, and tended to be poorer with fewer doctors per head of population, but stronger economic growth. A doctor's age and medical specialty, but not sex, influenced patterns of retention.
Conclusion
Adjusting workforce participation by country of qualification can improve estimates of the number of medical school places needed to balance supply with demand. Developing countries undergoing strong economic growth are likely to be the most important suppliers of long stay medical migrants.
doi:10.1186/1478-4491-6-9
PMCID: PMC2432073  PMID: 18513401
14.  GP job satisfaction in view of contract reform: a national survey 
Background
Job satisfaction has been associated with intentions to quit and aspects of quality of care. In 2001, GP job satisfaction in England had fallen to its lowest point for over a decade.
Aim
To assess GP job satisfaction and stressors immediately prior to implementation of the 2004 contract.
Design of study
National survey of a random sample of GPs.
Setting
England.
Method
One thousand, nine hundred and fifty principal and salaried GPs surveyed in February 2004 were compared with 1828 principals surveyed in 1998 and 1841 principal and salaried GPs surveyed in 2001. Job satisfaction and stressor scores were adjusted for 2004 age–sex distributions. Determinants of overall satisfaction were examined through ordinary least squares regression.
Results
The 2004 response rate was 53%. GPs were most dissatisfied with hours of work, recognition for good work and remuneration, and experienced most pressure from paperwork, increasing workloads and having insufficient time. The majority of doctors were satisfied with their job overall. Satisfaction was higher than in 2001 and approximately the same as in 1998. Overall stress in 2004 was lower than in 2001 but still higher than in 1998. After allowing for personal, practice and job characteristics, higher satisfaction was associated with lower job stress, involvement in decision making, increasing job interest and ability to meet conflicting demands.
Conclusions
Despite recent initiatives to enhance workforce capacity and working lives for GPs, workload, time pressures and job control remain potential areas of concern. Addressing such issues may be key to maintaining morale as the new contract is implemented.
PMCID: PMC1828251  PMID: 16464320
contracts; general practitioner; job satisfaction; workforce
15.  Impact of nurse practitioners on workload of general practitioners: randomised controlled trial 
BMJ : British Medical Journal  2004;328(7445):927.
Objective To examine the impact on general practitioners' workload of adding nurse practitioners to the general practice team.
Design Randomised controlled trial with measurements before and after the introduction of nurse practitioners.
Setting 34 general practices in a southern region of the Netherlands.
Participants 48 general practitioners.
Intervention Five nurses were randomly allocated to general practitioners to undertake specific elements of care according to agreed guidelines. The control group received no nurse.
Main outcome measures Objective workload, derived from 28 day diaries, included the number of contacts per day for each of three conditions (chronic obstructive pulmonary disease or asthma, dementia, cancer), by type of consultation (in practice, telephone, home visit), and by time of day (surgery hours, out of hours). Subjective workload was measured by using a validated questionnaire. Outcomes were measured six months before and 18 months after the intervention.
Results The number of contacts during surgery hours increased in the intervention group compared with the control group (P < 0.06), particularly for patients with chronic obstructive pulmonary disease or asthma (P < 0.01). The number of consultations out of hours declined slightly in the intervention group compared with the control group, but this difference did not reach significance. No significant changes became apparent in subjective workload.
Conclusion Adding nurse practitioners to general practice teams did not reduce the workload of general practitioners, at least in the short term. This implies that nurse practitioners are used as supplements, rather than substitutes, for care given by general practitioners.
doi:10.1136/bmj.38041.493519.EE
PMCID: PMC390208  PMID: 15069024
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.  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
18.  National survey of job satisfaction and retirement intentions among general practitioners in England 
BMJ : British Medical Journal  2003;326(7379):22.
Objectives
To measure general practitioners' intentions to quit direct patient care, to assess changes between 1998 and 2000, and to investigate associated factors, notably job satisfaction.
Design
Analysis of national postal surveys conducted in 1998 and 2001.
Setting
England.
Participants
1949 general practitioner principals, of whom 790 were surveyed in 1998 and 1159 in 2001.
Main outcome measures
Overall job satisfaction and likelihood of leaving direct patient care in the next five years.
Results
The proportion of doctors intending to quit direct patient care in the next five years rose from 14% in 1998 to 22% in 2001. In both years, the main factors associated with an increased likelihood of quitting were older age and ethnic minority status. Higher job satisfaction and having children younger than 18 years were associated with a reduced likelihood of quitting. There were no significant differences in regression coefficients between 1998 and 2001, suggesting that the effect of factors influencing intentions to quit remained stable over time. The rise in intentions to quit was due mainly to a reduction in job satisfaction (1998 mean 4.64, 2001 mean 3.96) together with a slight increase in the proportion of doctors from ethnic minorities and in the mean age of doctors. Doctors' personal and practice characteristics explained little of the variation in job satisfaction within or between years.
Conclusions
Job satisfaction is an important factor underlying intention to quit, and attention to this aspect of doctors' working lives may help to increase the supply of general practitioners.
What is already known on this topicEarly retirement is one of the factors contributing to a shortage of general practitioners in the NHSWhat this study addsThe proportion of general practitioners intending to quit direct patient care within five years rose from 14% in 1998 to 22% in 2001A decrease in overall job satisfaction is the most important factor underlying this riseImproving the quality of doctors' working lives might help improve retention
PMCID: PMC139500  PMID: 12511457
19.  Attitudes to the public release of comparative information on the quality of general practice care: qualitative study 
BMJ : British Medical Journal  2002;325(7375):1278.
Objectives
To examine the attitudes of service users, general practitioners, and clinical governance leads based in primary care trusts to the public dissemination of comparative reports on quality of care in general practice, to guide the policy and practice of public disclosure of information in primary care.
Design
Qualitative focus group study using mock quality report cards as prompts for discussion.
Setting
12 focus groups held in an urban area in north west England and a semirural area in the south of England.
Participants
35 service users, 24 general practitioners, and 18 clinical governance leads.
Results
There was general support for the principle of publishing comparative information, but all three stakeholder groups expressed concerns about the practical implications. Attitudes were strongly influenced by experience of comparative reports from other sectors—for example, school league tables. Service users distrusted what they saw as the political motivation driving the initiative, expressed a desire to “protect” their practices from political and managerial interference, and were uneasy about practices being encouraged to compete against each other. General practitioners focused on the unfairness of drawing comparisons from current data and the risks of “gaming” the results. Clinical governance leads thought that public disclosure would damage their developmental approach to implementing clinical governance. The initial negative response to the quality reports seemed to diminish on reflection.
Conclusions
Despite support for the principle of greater openness, the planned publication of information about quality of care in general practice is likely to face considerable opposition, not only from professional groups but also from the public. A greater understanding of the practical implications of public reporting is required before the potential benefits can be realised.
What is already known on this topicDisclosure of information about quality of care in the NHS has been strongly influenced by the report card movement in the United StatesThis was based largely on hospital data, with no evidence to determine the attitudes of the British public to the publication of quality reports in general practiceWhat this study addsThe public and health professionals are in favour in principle of publishing information about quality in general practice but are concerned about the consequences for themselves, the practices, and the health systemPeople regard public disclosure as a political initiative and are more inclined to trust their own experience or that of friends and family than to trust comparative dataGeneral practitioners perceive comparative reports as a burden, and clinical governance leads are concerned that the reports might damage their facilitative approach to improving quality
PMCID: PMC136927  PMID: 12458248
20.  House dust mite barrier bedding for childhood asthma: randomised placebo controlled trial in primary care [ISRCTN63308372] 
BMC Family Practice  2002;3:12.
Background
The house dust mite is the most important environmental allergen implicated in the aetiology of childhood asthma in the UK. Dust mite barrier bedding is relatively inexpensive, convenient to use, and of proven effectiveness in reducing mattress house dust mite load, but no studies have evaluated its clinical effectiveness in the control of childhood asthma when dispensed in primary care. We therefore aimed to evaluate the effectiveness of house dust mite barrier bedding in children with asthma treated in primary care.
Methods
Pragmatic, randomised, double-blind, placebo controlled trial conducted in eight family practices in England. Forty-seven children aged 5 to 14 years with confirmed house dust mite sensitive asthma were randomised to receive six months treatment with either house dust mite barrier or placebo bedding. Peak expiratory flow was the main outcome measure of interest; secondary outcome measures included asthma symptom scores and asthma medication usage.
Results
No difference was noted in mean monthly peak expiratory flow, asthma symptom score, medication usage or asthma consultations, between children who received active bedding and those who received placebo bedding.
Conclusions
Treating house dust mite sensitive asthmatic children in primary care with house dust mite barrier bedding for six months failed to improve peak expiratory flow. Results strongly suggest that the intervention made no impact upon other clinical features of asthma.
doi:10.1186/1471-2296-3-12
PMCID: PMC116603  PMID: 12079502
21.  Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. II: Cost effectiveness 
BMJ : British Medical Journal  2000;321(7273):1389-1392.
Objective
To compare the cost effectiveness of general practitioner care and two general practice based psychological therapies for depressed patients.
Design
Prospective, controlled trial with randomised and patient preference allocation arms.
Setting
General practices in London and greater Manchester.
Participants
464 of 627 patients presenting with depression or mixed anxiety and depression were suitable for inclusion.
Interventions
Usual general practitioner care or up to 12 sessions of non-directive counselling or cognitive-behaviour therapy provided by therapists.
Main outcome measures
Beck depression inventory scores, EuroQol measure of health related quality of life, direct treatment and non-treatment costs, and cost of lost production.
Results
197 patients were randomly assigned to treatment, 137 chose their treatment, and 130 were randomised only between the two psychological therapies. At four months, both non-directive counselling and cognitive-behaviour therapy reduced depressive symptoms to a significantly greater extent than usual general practitioner care. There was no significant difference in outcome between treatments at 12 months. There were no significant differences in direct costs, production losses, or societal costs between the three treatments at either four or 12 months. Sensitivity analyses did not suggest that the results depended on particular assumptions in the statistical analysis.
Conclusions
Within the constraints of available power, the data suggest that both brief psychological therapies may be significantly more cost effective than usual care in the short term, as benefit was gained with no significant difference in cost. There are no significant differences between treatments in either outcomes or costs at 12 months.
PMCID: PMC27543  PMID: 11099285
22.  Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. I: Clinical effectiveness 
BMJ : British Medical Journal  2000;321(7273):1383-1388.
Objective
To compare the clinical effectiveness of general practitioner care and two general practice based psychological therapies for depressed patients.
Design
Prospective, controlled trial with randomised and patient preference allocation arms.
Setting
General practices in London and greater Manchester.
Participants
464 of 627 patients presenting with depression or mixed anxiety and depression were suitable for inclusion.
Interventions
Usual general practitioner care or up to 12 sessions of non-directive counselling or cognitive-behaviour therapy provided by therapists.
Main outcome measures
Beck depression inventory scores, other psychiatric symptoms, social functioning, and satisfaction with treatment measured at baseline and at 4 and 12 months.
Results
197 patients were randomly assigned to treatment, 137 chose their treatment, and 130 were randomised only between the two psychological therapies. All groups improved significantly over time. At four months, patients randomised to non-directive counselling or cognitive-behaviour therapy improved more in terms of the Beck depression inventory (mean (SD) scores 12.9 (9.3) and 14.3 (10.8) respectively) than those randomised to usual general practitioner care (18.3 (12.4)). However, there was no significant difference between the two therapies. There were no significant differences between the three treatment groups at 12 months (Beck depression scores 11.8 (9.6), 11.4 (10.8), and 12.1 (10.3) for non-directive counselling, cognitive-behaviour therapy, and general practitioner care).
Conclusions
Psychological therapy was a more effective treatment for depression than usual general practitioner care in the short term, but after one year there was no difference in outcome.
PMCID: PMC27542  PMID: 11099284
24.  Systematic review of the effect of on-site mental health professionals on the clinical behaviour of general practitioners 
BMJ : British Medical Journal  2000;320(7235):614-617.
Objectives
To review the published literature concerning the effects of on-site mental health professionals on general practitioners' management of mental health.
Design
Systematic review of controlled trials.
Setting
Primary care.
Participants
General practitioners and mental health professionals.
Main outcome measures
Consultation rates, prescribing of psychotropics, and referrals to secondary care mental health services by general practitioners.
Results
The effect of on-site mental health professionals on consultation rates was inconsistent. Referral to a mental health professional reduced the likelihood of a patient receiving a prescription for psychotropics or being referred to secondary care, although the effects were not consistent. An on-site mental health professional did not alter prescribing and referral behaviour towards patients in the wider practice population.
Conclusions
The secondary effects of mental health professionals on the clinical behaviour of general practitioners are comparatively modest and inconsistent and seem to be restricted to patients directly under the care of the mental health professional.
PMCID: PMC27305  PMID: 10698881
25.  Randomising groups of patients 
BMJ : British Medical Journal  1998;316(7148):1898-1900.
PMCID: PMC1113368  PMID: 9632417

Results 1-25 (29)