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1.  Implementation of pay for performance in primary care: a qualitative study 8 years after introduction 
The British Journal of General Practice  2013;63(611):e408-e415.
Pay for performance is now a widely adopted quality improvement initiative in health care. One of the largest schemes in primary care internationally is the English Quality and Outcomes Framework (QOF).
To obtain a longer term perspective on the implementation of the QOF.
Design and setting
Qualitative study with 47 health professionals in 23 practices across England.
Semi-structured interviews.
Pay for performance is accepted as a routine part of primary care in England, with previous more individualistic and less structured ways of working seen as poor practice. The size of the QOF and the evidence-based nature of the indicators are regarded as key to its success. However, pay for performance may have had a negative impact on some aspects of medical professionalism, such as clinical autonomy, and led a significant minority of GPs to prioritise their own pay rather than patients’ best interests. A small minority of GPs tried to increase their clinical autonomy with further unintended consequences.
Pay for performance indicators are now welcomed by primary healthcare teams and GPs across generations. Almost all interviewees wanted to see a greater emphasis on involving front line practice teams in developing indicators. However, almost all GPs and practice managers described a sense of decreased clinical autonomy and loss of professionalism. Calibrating the appropriate level of clinical autonomy is critical if pay for performance schemes are to have maximal impact on patient care.
PMCID: PMC3662458  PMID: 23735412
health services research; primary health care; pay for performance; professionalism
2.  Red Roses 
PMCID: PMC3582970
3.  The James Mackenzie Lecture 2012: Bothering about Billy 
The British Journal of General Practice  2013;63(608):e232-e234.
PMCID: PMC3582983  PMID: 23561791
4.  Brave new world 
PMCID: PMC3338050
5.  Service users' views of moving on from early intervention services for psychosis: a longitudinal qualitative study in primary care 
The British Journal of General Practice  2012;62(596):e183-e190.
The role of primary care for young people with psychosis, and transitions between specialist mental health services and primary care, are underexplored areas, both clinically and in research terms.
To explore service users' perspectives of early intervention services and primary care, in-depth and over time.
Design and setting
Longitudinal qualitative methodology in five geographically diverse sites across England.
Semi-structured interviews with 21 young people with first-episode psychosis at two time points.
Early intervention services are highly prized by service users; however, the ‘gold standard’ nature of the care is difficult to replicate in other services and may lead to unrealistic expectations. Flexibility in terms of the timing of discharge does appear to be happening in practice, but continuity is not always well established before discharge. Primary care seems to be under-utilised, both as a location of care during time with the early intervention service and as a skill set, particularly for physical health problems. Service users expected GPs to advocate for and navigate the health system, particularly at times of crisis or relapse.
Early intervention services should focus on actively establishing relationships between service users and either the community mental health team or the GP in the months leading up to discharge, and ensuring that service users' expectations about access and availability of care are ‘realistic’. Primary care could be better utilised, even when service users are actively engaged with early intervention services, to help ensure physical health needs are met from the start of treatment.
PMCID: PMC3289824  PMID: 22429435
continuity of care; health; primary care; psychoses; qualitative research
6.  Ubi Scientia in the midst of the cosy cardigans of Caritas 
PMCID: PMC3223750  PMID: 22137390
7.  Generation Y 
PMCID: PMC3162167  PMID: 22152743
8.  Exception reporting in the Quality and Outcomes Framework: views of practice staff – a qualitative study 
The British Journal of General Practice  2011;61(585):e183-e189.
Exception reporting allows practices to exclude eligible patients from indicators or an entire clinical domain of the Quality and Outcomes Framework (QOF). It is a source of contention, viewed by some as a ‘gaming’ mechanism.
To explore GP and practice staff views and experiences of exception reporting in the QOF.
Design of study
Qualitative semi-structured interviews.
Interviews with 24 GPs, 20 practice managers, 13 practice nurses, and nine other staff were conducted in 27 general practices in the UK.
Semi-structured interviews, analysed using open explorative thematic coding.
Exception reporting was seen as a clinically necessary part of the QOF. Exempting patients, particularly for discretionary reasons, was seen as an ‘exception to the rule’ that was justified either in terms of practising patient-centred care within a framework of population-based health measures or because of the poor face validity of the indicators. Rates in all practices were described as minimal and the threat of external scrutiny from primary care trusts kept rates low. However, GPs were happy to defend using discretionary exception codes for individual patients. Exception reporting was used, particularly at the end of the payment year, to meet unmet targets and to prevent the practice being penalised financially. Overt gaming was seen as something done by ‘other’ practices. Only two GPs admitted to occasional inappropriate exception reporting.
Exception reporting is seen by most GPs and practice staff as an important and defensible safeguard against inappropriate treatment or over-treatment of patients. However, a minority of practitioners also saw it as a gaming mechanism.
PMCID: PMC3063047  PMID: 21439176
primary care; qualitative research; quality indicators
9.  Commentary 
PMCID: PMC2673169
10.  A rose by any other name 
PMCID: PMC2673177  PMID: 19401032
12.  Nothing about me without me …? 
PMCID: PMC3252530  PMID: 22520678
14.  Good enough care? 
PMCID: PMC3080220
15.  Getting the little things right 
PMCID: PMC3020066
16.  Princes Gate: in memoriam 
PMCID: PMC2930242
17.  Primary Medical Care Provider Accreditation (PMCPA): pilot evaluation 
The British Journal of General Practice  2010;60(576):e295-e304.
While practice-level or team accreditation is not new to primary care in the UK and there are organisational indicators in the Quality and Outcomes Framework (QOF) organisational domain, there is no universal system of accreditation of the quality of organisational aspects of care in the UK.
To describe the development, content and piloting of version 1 of the Primary Medical Care Provider Accreditation (PMCPA) scheme, which includes 112 separate criteria across six domains: health inequalities and health promotion; provider management; premises, records, equipment, and medicines management; provider teams; learning organisation; and patient experience/involvement, and to present the results from the pilot service evaluation focusing on the achievement of the 30 core criteria and feedback from practice staff.
Design of study
Observational service evaluation using evidence uploaded onto an extranet system in support of 30 core summative pilot PMCPA accreditation criteria.
Thirty-six nationally representative practices across England, between June and December 2008.
Study population: interviews with GPs, practice managers, nurses and other relevant staff from the participating practices were conducted, audiotaped, transcribed, and analysed using a thematic approach. For each practice, the number of core criteria that had received either a‘good’or‘satisfactory’rating from a RCGP-trained assessment team, was counted and expressed as a percentage.
Thirty-two practices completed the scheme, with nine practices passing 100% of core criteria (range: 27–100%). There were no statistical differences in achievement between practices of different sizes and in different localities. Practice feedback highlighted seven key issues: (1) overall view of PMCPA; (2) the role of accreditation; (3) different motivations for taking part; (4) practice managers dominated the workload associated with implementing the scheme; (5) facilitators for implementation; (6) patient benefit — relevance of PMCPA to quality improvement; (7) recommendations for improving the scheme.
Version 1 of PMCPA has been piloted as a primary care accreditation scheme and shown to be relevant to different types of practice. The scheme is undergoing revision in accordance with the findings from the pilot and ongoing consultation.
PMCID: PMC2894404
accreditation; primary care; quality of health care
18.  To whom it may concern 
PMCID: PMC2858550
19.  A stitch in time 
PMCID: PMC2801799  PMID: 20040182
20.  The present state and future direction of primary care: a qualitative study of GPs' views 
Over the past decade there has been a sharp increase in the number of non-profit-sharing salaried doctors employed by practices. This has been accompanied by the introduction of mechanisms to facilitate the entry of other providers into the primary care market.
To explore the views of GP principals and salaried doctors on current working practices and the future direction of primary care in England.
Design of study
Qualitative study using semi-structured interviews.
Twenty-two nationally representative practices across England, between February and August 2007.
Interviews were conducted with 22 principals and seven salaried doctors. A topic guide included questions on motivations for working in primary care, descriptions of working lives, the way in which clinical time was spent, and predictions for future working conditions.
Significant changes to GP working arrangements were identified, including increasing pursuit of specialist clinical interests by GP principals and increasing employment of salaried GPs. These developments were reported as improving the working lives of principals but also creating a hierarchical structure at practice level that led to resentment among salaried doctors. Many of the salaried GPs felt disenfranchised and disillusioned by the difference in status and autonomy in decision making and the type of work they performed in the practice. Almost all GPs felt uncertain about the future of primary care and were concerned about the potential threat of private providers delivering primary care within the NHS through a largely salaried workforce.
By failing to recognise the problems of employing an increasingly disenfranchised salaried labour force, GP principals may be undermining the very ethos of general practice they otherwise advocate and recreating smaller versions of the private provider organisations they suggest threaten to corrode NHS primary care.
PMCID: PMC2784528  PMID: 19889257
primary care; salaried GP; workforce
21.  What next? 
PMCID: PMC2734373
22.  Facing unpalatable truths: part 1 
PMCID: PMC2688065
23.  REDIRECT: cluster randomised controlled trial of GP training in first-episode psychosis 
The British Journal of General Practice  2009;59(563):e183-e190.
Delays in accessing care for young people with a first episode of psychosis are significantly associated with poorer treatment response and higher relapse rates.
To assess the effect of an educational intervention for GPs on referral rates to early-intervention services and the duration of untreated psychosis for young people with first-episode psychosis.
Design of study
Stratified cluster randomised controlled trial, clustered at practice level.
Birmingham, England.
Practices with access to the three early-intervention services in three inner-city primary care trusts in Birmingham were eligible for inclusion. Intervention practices received an educational intervention addressing GP knowledge, skills, and attitudes about first-episode psychosis. The primary outcome was the difference in the number of referrals to early-intervention services between practices. Secondary outcomes were duration of untreated psychosis, time to recovery, use of the Mental Health Act, and GP consultation rate during the developing illness.
A total of 110 of 135 eligible practices (81%) were recruited; 179 young people were referred, 97 from intervention and 82 from control practices. The relative risk of referral was not significant: 1.20 (95% confidence interval [CI] = 0.74 to 1.95; P = 0.48). No effect was observed on secondary outcomes except for ‘delay in reaching early-intervention services’, which was statistically significantly shorter in patients registered in intervention practices (95% CI = 83.5 to 360.5; P = 0.002).
GP training on first-episode psychosis is insufficient to alter referral rates to early-intervention services or reduce the duration of untreated psychosis; however, there is a suggestion that training facilitates access to the new specialist teams for early psychosis.
PMCID: PMC2688067  PMID: 19520016
education; primary health care; psychosis
24.  Careers of magical thinking? 
PMCID: PMC2605543
25.  Whose life is it anyway? 
PMCID: PMC2529222  PMID: 18801301

Results 1-25 (35)