The impact of NHS Health Checks on the prevalence of disease in general practices: a controlled study.

BACKGROUND: NHS Health Checks is a national case-finding and vascular risk assessment programme in England. No research has been published to assess the impact of NHS Health Checks on the prevalence of chronic disease in GP practices. AIM: To examine the impact of NHS Health Checks on the prevalence of hypertension, coronary heart disease (CHD), chronic kidney disease (CKD), atrial fibrillation (AF), and diabetes within practices, and compare this with usual medical care. DESIGN AND SETTING: A non-randomised controlled study in a mixed rural and urban county in England. METHOD: Thirty-eight GP practices provided NHS Health Checks over a 3-year period. Forty-one practices that did not provide Health Checks acted as controls. t-tests and multiple linear regression were used to assess the difference in prevalence of disease between intervention group and control group practices, and the impact of NHS Health Checks on this. RESULTS: Throughout the duration of the study, 1142 previously undiagnosed cases of disease were detected through a total of 16 669 NHS Health Checks. Despite this, there were no significant differences in the change to the prevalence of diabetes, hypertension, CHD, CKD, and AF in practices providing NHS Health Checks compared with control practices. Regression analysis did not demonstrate that there was any significant association between the proportion of the eligible population of a practice having completed NHS Health Checks and changes in the prevalence of the five conditions studied. CONCLUSION: In practices providing NHS Health Checks, the change in the reported prevalence of diabetes, hypertension, CHD, CKD, and AF did not differ from that of practices providing usual care.

What is an expert? A systems perspective on expertise.

Expert knowledge is a valuable source of information with a wide range of research applications. Despite the recent advances in defining expert knowledge, little attention has been given to how to view expertise as a system of interacting contributory factors for quantifying an individual's expertise. We present a systems approach to expertise that accounts for many contributing factors and their inter-relationships and allows quantification of an individual's expertise. A Bayesian network (BN) was chosen for this purpose. For illustration, we focused on taxonomic expertise. The model structure was developed in consultation with taxonomists. The relative importance of the factors within the network was determined by a second set of taxonomists (supra-experts) who also provided validation of the model structure. Model performance was assessed by applying the model to hypothetical career states of taxonomists designed to incorporate known differences in career states for model testing. The resulting BN model consisted of 18 primary nodes feeding through one to three higher-order nodes before converging on the target node (Taxonomic Expert). There was strong consistency among node weights provided by the supra-experts for some nodes, but not others. The higher-order nodes, "Quality of work" and "Total productivity", had the greatest weights. Sensitivity analysis indicated that although some factors had stronger influence in the outer nodes of the network, there was relatively equal influence of the factors leading directly into the target node. Despite the differences in the node weights provided by our supra-experts, there was good agreement among assessments of our hypothetical experts that accurately reflected differences we had specified. This systems approach provides a way of assessing the overall level of expertise of individuals, accounting for multiple contributory factors, and their interactions. Our approach is adaptable to other situations where it is desirable to understand components of expertise.

Increasing the QOF upper payment threshold in general practices in England: impact of implementing government proposals.

BACKGROUND: General practices in the UK receive incentive payments for managing patients with selected chronic conditions under the Quality and Outcomes Framework (QOF) scheme. Payments are made when a negotiated threshold percentage of patients receive the appropriate intervention. AIM: From 2013-2014 in England the Department of Health has proposed that this negotiated threshold is replaced with a value equal to the 75th percentile of national performance to attract maximum payments. This is an investigation of the potential impact of this change on practice income and workload. DESIGN AND SETTING: Analysis of 2011-2012 QOF dataset (the latest available) which covers 8123 GP practices and 55.5 million patients in England. METHOD: The 75th percentile of performance was calculated for 52 clinical indicators and applied to 2011-2012 performance. Estimations were made of financial and workload impacts on practices, and whether practices with different characteristics would be disproportionately affected. RESULTS: The proposed changes will result in an increase in the upper payment threshold of each clinical indicator by a mean of 7.47% (range 2.16-38.87%). If performance remains static practices would lose a mean of 47.68 (0-108.33) QOF points, equivalent to a mean financial change of -£279.60 (-£35 352.50 to +£19 957.78) per practice for these 52 indicators. CONCLUSION: Increasing the QOF upper payment threshold to the 75th percentile of national performance will, if clinical performance remains static, substantially reduce the mean number of QOF points achieved per practice. However, this translates into only a small mean loss of income per practice.

Mixed methods evaluation of targeted case finding for cardiovascular disease prevention using a stepped wedged cluster RCT.

BACKGROUND: A pilot project cardiovascular prevention was implemented in Sandwell (West Midlands, UK). This used electronic primary care records to identify untreated patients at high risk of cardiovascular disease then invited these high risk patients for assessment by a nurse in their own general practice. Those found to be eligible for treatment were offered treatment. During the pilot a higher proportion of high risk patients were started on treatment in the intervention practices than in control practices. Following the apparent success of the prevention project, it was intended to extend the service to all practices across the Sandwell area. However the pilot project was not a robust evaluation. There was a need for an efficient evaluation that would not disrupt the planned rollout of the project. METHODS/DESIGN: Project nurses will sequentially implement targeted cardiovascular case finding in a phased way across all general practices, with the sequence of general practices determined randomly. This is a stepped wedge randomised controlled trial design. The target population is patients aged 35 to 74, without diabetes or cardiovascular disease whose ten-year cardiovascular risk, (determined from data in their electronic records) is ≥ 20%. The primary outcome is the number of high risk patients started on treatment, because these data could be efficiently obtained from electronic primary care records. From this we can determine the effects of the case finding programme on the proportion of high risk patients started on treatment in practices before and after implementation of targeted case finding. Cost-effectiveness will be modelled from the predicted effects of treatments on cardiovascular events and associated health service costs. Alongside the implementation it is intended to interview clinical staff and patients who participated in the programme in order to determine acceptability to patients and clinicians. Practical considerations meant that 26 practices in Sandwell could be randomised, including about 6,250 patients at high risk of cardiovascular disease. This gives sufficient power for evaluation. DISCUSSION: It is possible to design a stepped wedge randomised controlled trial using routine data to determine the primary outcome to evaluate implementation of a cardiovascular prevention programme.

Changes in recruitment to public health consultant posts and hospital consultant posts in England: potential impact on the sustainability of the Public Health system.

BACKGROUND: The UK government has proposed major changes to the Public Health system in England. This study aims quantify increasing anecdotal concern that the number of Public Health consultant posts advertised has plummeted since the publication of these plans. METHODS: The archives of BMJ careers were interrogated for hospital and Public Health consultant posts advertised October 2008 and May 2011. Statistical process control charts were used to compare differences in recruitment over time and the ratio of Public Health:hospital consultant posts. RESULTS: We found a highly significant reduction in the mean number of advertisements for Public Health consultant posts from 27.9 posts per month in the period October 2008-Novermber 2009 to 6.3 posts per month between December 2009 and May 2010 (P< 0.005). The ratio of Public Health:hospital consultant posts fell from 3.3 to 0.9 Public Health consultant posts per 100 hospital consultant posts (P< 0.005). CONCLUSIONS: This study confirms the anecdotal concern that there has been a significant reduction in the advertisement, and by extrapolation, recruitment to Public Health consultants posts in England around the time of the publication of the government's reform plans. Public Health consultant posts have been disproportionately affected by this reduction compared to hospital consultant posts.

Estimating the future healthcare costs of an aging population in the UK: expansion of morbidity and the need for preventative care.

BACKGROUND: The healthcare costs of an aging population have major consequences for healthcare organizations and have major implication for strategic planning of services. An impending freeze in budgets in the UK makes these consequences especially significant. METHODS: We present a methodology of estimating the future healthcare costs to an organization due to an aging population that takes account of the excess costs in the years before death and the effect of morbidity compression or expansion. The performance of three different models is evaluated. RESULTS: The three models all give markedly different estimated costs. Models failing to take into account both the cost burden towards the end of life and compression or expansion of morbidity can vastly under- or overestimate the most accurate estimates of healthcare expenditure due to an aging population with annual increases in costs varying from 0.48 to 1.12%. CONCLUSION: The importance of being able to accurately predict demand and costs of health care within the NHS cannot be underestimated. Making over simplistic assumptions and not using well-established principles in these models leads to greatly different outcomes that have the potential to have massive organizational consequences in terms of short-to-medium term strategic planning.

GPs' opinions on the NHS and HPA response to the first wave of the influenza A/H1N1v pandemic.

The first wave of influenza A/H1N1v resulted in a significant demand on primary care services. This cross-sectional study describes GPs' opinions of how information was communicated to them during this period and the overall response of the NHS and Health Protection Agency. Accessibility of current guidance and ease of obtaining antiviral medication were perceived as strengths, but clarity of the information provided was consistently perceived as poor. The majority of GPs supported the introduction of the National Pandemic Flu Service, although many raised concerns about its safety.

Suicide prevention: is more demographic information the answer?

Suicide is an important health issue and its prevention is prioritized in government targets. PCTs in England and Wales are also required to carry out audits of suicide deaths by the Healthcare Commission (HCC). We present findings of a 6-year analysis of suicide deaths between 2002 and 2008 in Birmingham and Solihull, the second largest urban conurbation in the UK. After extensive analysis, no demographic group was shown to have a significantly greater risk of suicide and no geographical area had significantly higher rates than another. Despite the large population examined (c.1.3 million), these findings are likely to be due to the rarity of suicides as an outcome. We discuss the practical implications of these findings for local health organizations charged with reducing suicide rates, the value to local suicide audits and the use of a new suicide audit tool developed for use by PCTs. We conclude that ever increasing collection of information surrounding suicide deaths is unlikely to result in the discovery of local groups amenable to targeted suicide prevention interventions and that the HCC may want to reconsider its performance indicator around suicide audits to allow valuable resources to be used more effectively elsewhere.