Organizational strategies to tackle health-care disparities in the USA.

US health policy is beginning to address health-care disparities, mainly in terms of racial/ethnic groups and access to care for vulnerable groups. Though not widespread, policies are engaging a wide range of organizations, including federal, state and local government, insurers, providers and philanthropic foundations. It initially seems strange that US health-care organizations (HCOs) are seeking to tackle disparities, as the system itself generates huge disparities. This article reviews the reasons underlying growing interest in disparities in the USA, examines the barriers and opportunities facing such initiatives and considers their likely impact. Demographic changes, efforts to widen access to care and to remedy health-care discrimination are the primary factors in driving these initiatives. HCOs (and others) are faced with implementation barriers including structural impediments of the health-care system, the limited extent to which the issue has permeated within HCOs, and data collection. Opportunities for progress can be garnered from the mounting evidence base, the various programmes being implemented, and emerging links with quality improvement initiatives. The USA is faced with ongoing efforts to keep the issue on the (policy and managerial) agenda, to integrate strategies into organizational systems and processes, and to monitor the effects of such strategies.

The role of performance indicators in changing the autonomy of the general practice profession in the UK.

Performance indicators (PIs) are widely used across the UK public sector, but they have only recently been applied to clinical care. In doing so, they challenge a previously guarded aspect of clinical autonomy-the assessment of work performance. This "challenge" is specific to a primary care setting and in the general practice profession. This paper reviews the qualitative findings from an empirical study within one English primary care group on the response to a set of clinical PIs relating to general practitioners (GPs) in terms of the effect upon their clinical autonomy. Prior to interviews with GPs, primary care teams received feedback on their clinical performance as judged by indicators. Five themes were crucial in understanding GPs responses: the credibility of PIs, the growing need to demonstrate competence, perceptions of autonomy, the ulterior purpose of PIs, and the identity of the assessor of their performance. PIs are playing a key role in changing the locus of performance assessment along two dimensions: location and expertise. As the locus helps to determine the nature of clinical autonomy, it is likely to have implications for the nature of the general practice profession.

Primary care in the UK: understanding the dynamics of devolution.

The United Kingdom is ostensibly one country and yet public policy often varies between its constituent territories - England, Scotland, Wales and Northern Ireland. Health policy illustrates the dilemmas inherent in an apparently unitary system that permits scope for territorial variation. Administrative devolution has now been accompanied by political devolution but their interaction has yet to produce policy outcomes. This paper describes recent health policy reform with regard to primary care in terms of the tension inherent in current policy between notions of a 'one nation NHS' and the territorial diversity wrought by devolution. The paper provides a framework for understanding the emergent outcomes by exploring various concepts. In particular, the existing character of territorial policy networks, the properties of policies in devolved territories and intergovernmental relations are considered from various disciplines to examine whether greater diversity or uniformity will result from the dual reform process. Whilst this evaluation can, at this stage, only be preliminary, the paper provides a framework to appraise the emerging impact of devolution upon primary care in the UK.

Developing a UK health equity network.

The UK Health Equity Network (HEN) was established in 1999 to encourage and facilitate multidisciplinary and multi-stakeholder collaboration in health inequalities research. This paper briefly details the history, objectives and location of HEN.

Two at the top: relations between Chairs and Chief Executives in the NHS.

The relationship between the Chair and Chief Executives of Health Authorities (and Boards) and NHS Trusts denote the managerial and political character of the NHS, creating an organizational apex with 'two at the top'. This article considers the nature of relationships between Chairs and Chief Executives in a variety of different NHS organizations according to two theoretical perspectives: role theory and negotiated order. Empirical evidence addresses the views of the roles of Chairs and Chief Executives, the content of their roles and the local and national factors which influence them (including critical incidents). Conclusions are drawn about the conceptualization of this crucial relationship in the NHS and also on the association between the Chair-Chief Executive relationship and organizational effectiveness.

Clinical governance in primary care groups: the feasibility of deriving evidence-based performance indicators.

OBJECTIVES: To test the feasibility of deriving comparative indicators in all the practices within a primary care group. DESIGN: A retrospective audit using practice computer systems and random note review. SETTING: A primary care group in southern England. SUBJECTS: All 18 general practices in a primary care group. MAIN OUTCOME MEASURES: Twenty six evidence-based process indicators including aspirin therapy in high risk patients, detection and control of hypertension, smoking cessation advice, treatment of heart failure, raised cholesterol levels in those with established cardiovascular disease, and the treatment of atrial fibrillation. Feasibility was tested by examining whether it was possible to derive these indicators in all the practices; the problems and constraints incurred when collecting data; the variations in indicator values between practices in both their identification of diseases and in the uptake of various interventions; the possible reasons for these variations; and the cost of generating such indicators. RESULTS: It was possible to derive eight indicators in all practices and in three practices all 26 indicators. The median number of indicators derived was 12 with two practices able to generate eight. There was considerable variation in the use of computers between practices and in the ability and ease of various practice computer systems to generate indicators. Practices varied greatly in the identification of diseases and in the uptake of effective interventions. Variation in identification of ischaemic heart disease could not be explained by a higher prevalence in practices with a more deprived population. The cost of generating these indicators was 5300 Pounds. CONCLUSION: Comparative evidence-based indicators, used as part of clinical governance in primary care groups, could have the potential to turn evidence into everyday practice, to improve the quality of patient care, and to have an impact on the population's health. However, to derive such indicators and to be able to make meaningful comparisons primary care groups need greater conformity and compatibility of computer systems, improved computer skills for practice staff, and appropriate funding.

Reactions to the use of evidence-based performance indicators in primary care: a qualitative study.

OBJECTIVES: To investigate reactions to the use of evidence-based cardiovascular and stroke performance indicators within one primary care group. DESIGN: Qualitative analysis of semi-structured interviews. SETTING: Fifteen practices from a primary care group in southern England. PARTICIPANTS: Fifty two primary health care professionals including 29 general practitioners, 11 practice managers, and 12 practice nurses. MAIN OUTCOME MEASURES: Participants' perceptions towards and actions made in response to these indicators. The barriers and facilitators in using these indicators to change practice. RESULTS: Barriers to the use of the indicators were their data quality and their technical specifications, including definitions of diseases such as heart failure and the threshold for interventions such as blood pressure control. Nevertheless, the indicators were sufficiently credible to prompt most of those in primary care teams to reflect on some aspect of their performance. The most common response was to improve data quality through increased or improved accuracy of recording. There was a lack of a coordinated team approach to decision making. Primary care teams placed little importance on the potential for performance indicators to identify and address inequalities in services between practices. The most common barrier to change was a lack of time and resources to act upon indicators. CONCLUSION: For the effective implementation of national performance indicators there are many barriers to overcome at individual, practice, and primary care group levels. Additional training and resources are required for improvements in data quality and collection, further education of all members of primary care teams, and measures to foster organisational development within practices. Unless these barriers are addressed, performance indicators could initially increase apparent variation between practices.

The shape of things to come.

Geographical boundaries have always been significant in the NHS. The planned reconfiguration of NHS regions including the establishment of a pan-London region, will have consequences across the whole of the service. The proposed changes will strengthen the power of central government in terms of policy and resource allocation. It is not clear whether boundary changes have any impact on patient care. Boundary changes create pressure for further reorganizations.

The contribution of coterminosity to joint purchasing in health and social care.

This article examines the context within which coterminosity (the coincidence of geographical boundaries between two or more organisations) is currently being re-defined, given the development of purchasing in health and social care agencies in the British welfare system. It explores the current trends within purchasing and especially the notion of "locality" as a means of promoting "joint working" between purchasing agencies. In particular, the emergence of general practice as a focus of purchasing is explored with reference to its involvement in joint purchasing (or joint commissioning) and its interaction with the "locality". The article concludes that coterminosity has a contribution to purchasing organisations but increasingly at a local level such as the general practice or locality. This local manifestation of coterminosity may minimise the effects of fragmentation and encourage inter-agency collaboration.