Search

Purpose - The purpose of this paper is to discuss the impact of contracts on general practise in the UK National Health Service. In particular, it is concerned with the response of practitioners to the apparent flexibilities offered in the new contract with its focus on outcomes rather than processes. Design/methodology/approach - Ethnographic studies of two general practices, using non-participant observation, documents and interviews with staff over a five-month period. Findings - Conclusions suggest that the new contracts, far from encouraging flexibility and responsiveness from general practitioners, have tended to strengthen bureaucratic forms in the way the contract is implemented. Originality/value - The new contract has introduced greater clarity regarding roles and responsibilities within practises. At the same time, when operating in financially tight conditions, the contract can make rationing more explicit. Decisions are made not in accordance with the targets but in light of local pressures and constraints, causing tensions between primary and tertiary care. [ABSTRACT FROM AUTHOR]

Objective To review the evidence on commissioning schemes involving clinicians in the United Kingdom National Health Service, between 1991 and 2010; report on the extent and impact of clinical engagement; and distil lessons for the development of such schemes both in the UK and elsewhere. Methods A review of published evidence. Five hundred and fourteen abstracts were obtained from structured searches and screened. Full-text papers were retrieved for UK empirical studies exploring the relationship between commissioners and providers with clinician involvement. Two hundred and eighteen published materials were reviewed. Results The extent of clinical engagement varied between the various schemes. Schemes allowing clinicians to act autonomously were more likely to generate significant engagement, with ‘virtuous cycles’ (experience of being able to make changes feeding back to encourage greater engagement) and ‘vicious cycles’ (failure to influence services generating disengagement) observed. Engagement of the wider general practitioner (GP) membership was an important determinant of success. Most impact was seen in GP prescribing and the establishment of services in general practices. There was little evidence of GPs engaging more widely with public health issues. Conclusion Evidence for a significant impact of clinical engagement on commissioning outcomes is limited. Initial changes are likely to be small scale and to focus on services in primary care. Engagement of GP members of primary care commissioning organizations is an important determinant of progress, but generates significant transaction costs. [ABSTRACT FROM AUTHOR]

Background: 'Neoliberal' work policies, austerity, NHS restructuring, and increased GP consultation rates provide the backdrop against increasing reports of GP burnout and an impending shortage of GPs.Aim: To explore GPs' experiences of workplace challenges and stresses, and their coping strategies, particularly focusing on understanding the impact of recent NHS workplace change.Design and Setting: Study design was qualitative, with data collected from two focus groups and seven one-to-one telephone interviews.Method: Focus groups and one-to-one telephone interviews explored the experiences of GPs currently practising in England, recruited through convenience sampling. Data were collected using a semi-structured interview approach and analysed using thematic analysis.Results: There were 22 GP participants recruited: focus groups (n = 15) and interviews (n = 7). Interviewees understood GPs to be under intense and historically unprecedented pressures, which were tied to the contexts in which they work, with important moral implications for 'good' doctoring. Many reported that being a full-time GP was too stressful: work-related stress led to mood changes, sleep disruption, increases in anxiety, and tensions with loved ones. Some had subsequently sought ways to downsize their clinical workload. Workplace change resulted in little time for the things that helped GP resilience: a good work-life balance and better contact with colleagues. Although some GPs were coping better than others, GPs acknowledged that there was only so much an individual GP could do to manage their stress, given the external work issues they faced.Conclusion: GPs experience their emotional lives and stresses as being meaningfully shaped by NHS factors. To support GPs to provide effective care, resilience building should move beyond the individual to include systemic work issues. [ABSTRACT FROM AUTHOR]

This article focuses on issues related to primary health care in Great Britain as of June 1989. The way in which primary health care is provided in Great Britain was set by the 1911 National Health Insurance Act and based on a capitation system of payment to general practitioners. When the National Health Service was set up in 1948 the service was extended to the whole population. In 1966 the family doctors' charter was introduced as a result of considerable pressure from the general practitioners who were demoralised by the emphasis on capitation payments. This encouraged general practitioners to compete fiercely for patients but, having registered them, gave no incentive to provide a good service--the more doctors invested in better services for their patients, the lower was their own net income. Further, the 1987 White Paper on Primary Health Care was intended to improve the methods of monitoring standards, increase consumer choice, lay greater emphasis on health promotion, and preventive medicine and deal with the problems of inner city general practice.

Background: Laboratory tests are extensively used for diagnosis and monitoring in UK primary care. Test usage by GPs, and associated costs, have grown substantially in recent years. Aim: This study aimed to quantify temporal growth and geographic variation in utilisation of laboratory tests. Design and setting: Retrospective cohort study using data from general practices in the UK. Method: Data from the General Practice Research Database, including patient demographics, clinical details, and laboratory test results, were used to estimate rates of change in utilisation between 2005 and 2009, and identify tests with greatest inter-regional variation, by fitting random-effects Poisson regression models. The study also investigated indications for test requests, using diagnoses and symptoms recorded in the 2 weeks before each test. Results: Around 660 000 tests were recorded in 230 000 person-years of follow-up. Test use increased by 24.2%, from 23 872 to 29 644 tests per 10 000 person-years, between 2005 and 2009. Tests with the largest increases were faecal occult blood (121%) and C-reactive protein (86%). There was substantial geographic variation in test utilisation; GPs in some regions requested tests such as plasma viscosity and cardiac enzymes at a rate more than three times the national average. Conclusion: Increases in the use of laboratory tests have substantial resource implications. Rapid increases in particular tests may be supported by evidence-based guidelines, but these are often vague about who should be tested, how often, and for how long. Substantial regional variation in test use may reflect uncertainty about diagnostic accuracy and appropriate indications for the laboratory test. There is a need for further research on the diagnostic accuracy, therapeutic impact, and effect on patient health outcomes of the most rapidly increasing and geographically variable tests. [ABSTRACT FROM AUTHOR]

As general practice nurses (GPNs) now perform many activities formerly undertaken by general practitioners (GPs), the paperwork and process of the Scottish GP appraisal scheme may be usefully replicated for GPN appraisal. Method Eight GPNs adapted paperwork. Ten GP appraisers in NHS Lanarkshire were invited to interview their GPN(s) using the adapted paperwork. Both groups evaluated the project from 'descriptive' (participation and process) and 'reflective' or qualitative perspectives. Results Eight GPs appraised 11 GPNs using a ten-page document. GPNs reported that the documentation was helpful in preparing for and participating in the interview, as well as the planning of future objectives and development. GPs reported that the appraisal interview incorporated GPNs' views, the content was relevant, and their approach nonjudgemental and developmental. Some expressed concern that their participation had not helped them identify ways of addressing GPN learning needs. There was clear indication from GPNs that trained colleagues rather than GP employers are preferred appraisers. Improvements in the paperwork would be required. Discussion There is potential to replicate the paperwork and processes used in GP appraisal to GPNs, subject to refinement of the paperwork and engagement of trained nurse colleagues in the process. This may reduce the effect of collusion, inhibition or conflict of interest. However, GPN personal development still must be reconciled with practice priorities and development. Conclusion The results of this pilot indicate a positive response in terms of participation and process. Further research should examine GPN appraisal using an external nurse appraiser, training issues and resource implications. [ABSTRACT FROM AUTHOR]