Do marginal investments made by NHS healthcare commissioners in the UK produce the outcomes they hope to achieve? Observational study.

OBJECTIVE: To investigate the effect of targeted marginal annual investments by local healthcare commissioners on the outcomes they expected to achieve with these investments. DESIGN: Controlled before and after study. SETTING: 152 commissioning organisations (primary care trusts) in England. METHODS: National surveys of commissioning managers in 2009 and 2010 to identify: the largest marginal investments made in four key conditions/services (diabetes, coronary heart disease, chronic pulmonary airways disease and emergency and urgent care) in 2008/2009 and 2009/2010; the outcomes commissioners expected to achieve with these investments; and the processes commissioners used to develop these investments. Collation of routinely available data on outcomes commissioners expected from these investments over the period 2007/2008 to 2010/2011. RESULTS: 51% (77/152) of commissioners agreed to participate in the survey in 2009 and 60% (91/152) in 2010. Around half reported targeted marginal investments in each condition/service each year. Routine data on many of the outcomes they expected to achieve through these investments were not available. Also, commissioners expected some outcomes to be achieved beyond the time scale of our study. Therefore, only a limited number of outcomes of investments were tested. Outcomes included directly standardised emergency admission rates for the four conditions/services, and the percentage of patients with diabetes with glycated haemoglobin <7. There was no evidence that targeted marginal investments reduced emergency admission rates. There was evidence of an improvement in blood glucose management for diabetes for commissioners investing to improve diabetes care but this was compromised by a change in how the outcome was measured in different years. This investment was unlikely to be cost-effective. CONCLUSIONS: Commissioners made marginal investments in specific health conditions and services with the aim of improving a wide range of outcomes. There was little evidence of impact on the limited number of outcomes measured.

Commissioning processes in primary care trusts: a repeated cross-sectional survey of health care commissioners in England.

OBJECTIVES: To determine the extent to which primary care trusts (PCTs) in England employed processes associated with quality commissioning and to assess whether changes occurred in these processes during a policy drive to improve commissioning. METHODS: Telephone surveys of PCT managers leading commissioning for diabetes, chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), and emergency and urgent care in all 152 PCTs in both 2009 and 2010. RESULTS: The response rate was 51% (77/152) of PCTs in 2009 and 60% (91/152) in 2010. Two-thirds of commissioners had commissioned initiatives starting in the previous financial year. Over half of initiatives starting in 2008/09 had been instigated by the PCT alone. This reduced to a third in 2010, showing a shift towards partnership working. Commissioners reported that a large proportion of initiatives had been developed and shaped with the involvement of general practitioners (GPs) with direct links to the PCT and of specialist clinicians (70%), but that a lower proportion of initiatives had involvement from other GPs (40%). Patients or the public were less likely to be involved in initiatives than clinicians, but there was evidence of increasing involvement over the two years from 35% (52/149) to 51% (67/132) of initiatives. There was no evidence of changes in whether needs assessment was undertaken, how evidence was used or how initiatives were led and performance managed. CONCLUSIONS: PCT commissioners reported clinical engagement in the majority of commissioning initiatives, a shift towards partnership commissioning, and increased involvement of patients and public in the development of initiatives. The new model of commissioning in England through clinical commissioning groups will need to improve on these processes if it is to demonstrate a higher quality approach to commissioning.

The impact of Advanced Access on antibiotic prescribing: a controlled before and after study.

Advanced Access practices provide quicker access to appointments and this may lead to patients being seen earlier in the course of acute self-limiting illnesses, and therefore increased antibiotic prescribing. We examined the impact of Advanced Access on antibiotic prescribing. We undertook a controlled before and after study in 24 Advanced Access and 24 control practices, examining monthly antibiotic prescribing data. We found no significant change in prescribing rates between Advanced Access and control practices. There was no evidence that Advanced Access alters antibiotic prescribing behaviour.

The Multiple Sclerosis Risk Sharing Scheme Monitoring Study--early results and lessons for the future.

BACKGROUND: Risk sharing schemes represent an innovative and important approach to the problems of rationing and achieving cost-effectiveness in high cost or controversial health interventions. This study aimed to assess the feasibility of risk sharing schemes, looking at long term clinical outcomes, to determine the price at which high cost treatments would be acceptable to the NHS. METHODS: This case study of the first NHS risk sharing scheme, a long term prospective cohort study of beta interferon and glatiramer acetate in multiple sclerosis (MS) patients in 71 specialist MS centres in UK NHS hospitals, recruited adults with relapsing forms of MS, meeting Association of British Neurologists (ABN) criteria for disease modifying therapy. Outcome measures were: success of recruitment and follow up over the first three years, analysis of baseline and initial follow up data and the prospect of estimating the long term cost-effectiveness of these treatments. RESULTS: Centres consented 5560 patients. Of the 4240 patients who had been in the study for a least one year, annual review data were available for 3730 (88.0%). Of the patients who had been in the study for at least two years and three years, subsequent annual review data were available for 2055 (78.5%) and 265 (71.8%) patients respectively. Baseline characteristics and a small but statistically significant progression of disease were similar to those reported in previous pivotal studies. CONCLUSION: Successful recruitment, follow up and early data analysis suggest that risk sharing schemes should be able to deliver their objectives. However, important issues of analysis, and political and commercial conflicts of interest still need to be addressed.

Impact of same-day appointments on patient satisfaction with general practice appointment systems.

Following recent concerns about patients' inability to book appointments in advance, this study examined the relationship between the proportion of GP appointments reserved for same-day booking, and patient satisfaction with appointment systems. In a survey of 12,825 patients in 47 practices, it was found that a 10% increase in the proportion of same-day appointments was associated with an 8% reduction in the proportion of patients satisfied. Practices should be wary of increasing the level of same-day appointments to meet access targets.

Implementation of Advanced Access in general practice: postal survey of practices.

BACKGROUND: Advanced Access has been strongly promoted as a means of improving access to general practice. Key principles include measuring demand, matching capacity to demand, managing demand in different ways and having contingency plans. Although not advocated by Advanced Access, some practices have also restricted availability of pre-booked appointments. AIM: This study compares the strategies used to improve access by practices which do or do not operate Advanced Access. DESIGN OF STUDY: Postal survey of practices. SETTING: Three hundred and ninety-one practices in 12 primary care trusts. METHOD: Questionnaires were posted to practice managers to collect data on practice characteristics, supply and demand of appointments, strategies employed to manage demand, and use of Advanced Access. RESULTS: Two hundred and forty-five from 391 (63%) practices returned a questionnaire and 162/241(67%) claimed to be using Advanced Access. There were few differences between characteristics of practices operating Advanced Access or not. Both types of practice had introduced a wide range of measures to improve access. The proportion of doctors' appointments only available for booking on the same day was higher in Advanced Access practices (40 versus 16%, difference = 24%, 95% CI = 16% to 32%). Less than half the practices claiming to operate Advanced Access ((63/140; 45%) used all four of this model's key principles. CONCLUSION: The majority of practices in this sample claim to have introduced Advanced Access, but the degree of implementation is very variable. Advanced Access practices use more initiatives to measure and improve access than non-Advanced Access practices.

Advanced access: more than just GP waiting times?

BACKGROUND: Advanced access has been forwarded as a strategy for reducing waiting times in primary care; however, previous evaluations have raised important issues regarding its appropriateness. OBJECTIVES: The objectives of this paper are to assess the impact of advanced access on patient access to primary care services, and its broader effects on stakeholders. METHODS: A quantitative analysis of appointment data on 462 practices implementing advanced access, together with qualitative analysis of open survey responses and interviews with 28 practice staff. Appointment data recorded time to third available appointment for GP and practice nurse, together with the percentage of patients seen on their day of choice. Themes were identified from the interviews and survey responses and related to issues identified in previous research. RESULTS: The implementation of advanced access was associated with reductions in time to see practice nurses as well as GPs, and increases in the proportion of patients being seen on their day of choice. Interviewee and survey responses suggested that practice population characteristics may impact on the model, and some patient groups may be disadvantaged from the changes in the appointment systems seen in this study. Whilst experiences were mixed, the potential for broader changes to working practices of all practice staff was evident. CONCLUSIONS: In general, these results suggest that advanced access can have a positive impact across several aspects of primary care services, and not just the availability of GP appointments. However, it also highlights some problems, in that waiting times worsened in some practices and there were concerns that some vulnerable groups may be disadvantaged.

Why are patients removed from their doctors' lists? A comparison of patients' and doctors' accounts of removal.

BACKGROUND: GPs in the UK may remove a patient from their list without supplying a reason to the patient or the local health authority. Little is known of the events that lead to such removal decisions, nor of patients' views of their removal. OBJECTIVE: Our aim was to describe the events that lead to a removal from both the doctor and patient perspectives. METHODS: An anonymized postal survey of 204 GPs and 319 patients with recent experience of removal was carried out. RESULTS: Violent, threatening or abusive behaviour was the most common reason for removal given by GPs (64%, 57 out of 89), with almost half of instances involving verbal abuse towards receptionists (42 out of 89). However, fewer than a fifth of patients admitted to threatening or abusive behaviour towards practice staff (15 out of 76). Although GPs reported giving patients a reason for the removal in 59% (44 out of 75) of cases, only 36% (26 out of 72) of patients reported receiving a reason. Patients often appeared not to understand why they had been removed. CONCLUSIONS: While doctors and patients frequently give differing accounts of the events which lead to removal, both emphasize relationship breakdown and loss of trust. Financial issues appear negligible. Since few removals seem preventable by policy measures, the distress of removal might best be reduced by trying to improve the removal process-probably through improved communication-rather than prevent removals.

Evaluation of advanced access in the national primary care collaborative.

BACKGROUND: An aim of the National Primary Care Collaborative is to improve quality and access for patients in primary care using principles of Advanced Access. AIMS: To determine whether Advanced Access led to improved availability of appointments with general practitioners (GPs) and to examine GPs' views of the process. DESIGN: Observational study. SETTING: Four hundred and sixty-two general practices in England participating in four waves of the collaborative during 2000 and 2001. METHOD: Regression analysis of the collaborative's monthly data on the availability of GP appointments for the 352 practices in waves 1-3, and a postal survey of lead GPs in all four waves. The main outcome measures were the change in mean time to the third available appointment with GPs, and the proportion of GPs thinking it worthwhile participating in the collaborative. RESULTS: The time to the third available appointment improved from a mean of 3.6 to 1.9 days, difference = 1.7 days, 95% confidence interval (CI)= 1.4 to 2.0 days. It improved in two-thirds of practices (66% [219/331]), remained the same in 16% (53/331), and worsened in 18% (59/331). The majority of GPs in all four waves, 83% (308/371, 95% CI = 79 to 87), felt that it was worthwhile participating in the collaborative, although one in 12 practices would not recommend it. One-fifth of GPs cited a lack of resources as a constraint, and some expressed concerns about the trade-off between immediate access and continuity of care. CONCLUSION: Advanced Access helped practices to improve availability of GP appointments, and was well received by the majority of practices.