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Objectives: To understand the impact on equity of giving patients a choice of provider. Methods: A postal survey of 5997 patients in four areas of England about choice at their recent referral and, using a discrete choice experiment, how they would choose in hypothetical situations. Binary logistic regression and a series of multinomial and nested logit models were used to analyse the data to discover whether patients with particular characteristics were more likely to: think choice is important; be offered a choice; and, choose a non-local provider. Results: The response rate was 36%. Choice was more important to older patients aged 51-80 years, patients from non-white backgrounds, women, those with no qualifications and those with a bad past experience of their local hospital. There were no significant differences in who was offered a choice in terms of education, age group or ethnicity. In both real and hypothetical situations patients with no formal qualifications and those living in urban centres were more likely to choose their local hospital, and patients with a bad or mixed past experience at the local hospital were more likely to choose an alternative. In hypothetical choices those who do not normally travel by car and without Internet access were more likely to choose their local hospital irrespective of that hospital's characteristics. Conclusions: More educated, affluent patients were no more likely to be offered a choice than other population groups, but there does appear to be a social gradient in who chose to travel beyond the local area for treatment. If these results were replicated across England, there is at least the potential risk that when local hospitals are failing, patient choice could result in inequitable access to high quality care, rather than enhancing equity as the policy's architects had hoped. [ABSTRACT FROM AUTHOR]

Objectives: To identify factors that explain patient satisfaction with general practice physicians and hence that may drive patients' choice of practice. Methods: Logistic regression analysis of English National Health Service national patient survey data is used to identify the aspects of general practice care that are associated with high levels of overall satisfaction among patients. Results: Confidence and trust in the doctor is the most important factor in explaining the variation in overall patient satisfaction (predicting 82% of satisfaction levels accurately). The seven variables relating to the relationship between patient and doctor have stronger explanatory power than other aspects of the general practitioner (GP) experience. The variables with the lowest overall predictive power are whether the patient was told how long they would have to wait in the surgery (72%), the length of time they had to wait after their appointment time (74%) and ability to get through to the surgery on the phone (74%). Conclusions: Patients value the quality of their relationship with their doctor more than the appearance of the surgery, accessibility of appointments and their experience in the waiting room. This suggests that, if current restrictions on choice of GP were removed, we would in theory expect a patient's choice to be driven by the quality of the doctor-patient relationship. Once a patient establishes a good relationship with a GP, however, we might expect them to be loyal and therefore unlikely to change practice unless the relationship with the doctor breaks down. Although relationship factors are important to the satisfaction of patients, it is not clear that they will lead large numbers of people to change their GP. [ABSTRACT FROM AUTHOR]

Transition metal catalysed reactions of CO and ethene can lead to a variety of products ranging from small molecules to perfectly alternating long chain polyketones. In this review, we discuss the formation of small molecules with chain lengths up to 12 C atoms. Palladium based complexes of monodentate tertiary phosphines tend to give methyl propanoate under most conditions, but the selectivity can be varied by altering the electron donating power of the ligand or the nature of added acid co-catalysts. In addition to methyl propanoate, the major products can be co-oligomers, 3-pentanone or propanal. Using rhodium catalysts, the same products can be obtained, but the different selectivities depend upon the electron donating power of the ligand and the potential for chelate binding. In some cases, the extra H atoms required for the formation of 3-pentanone or oligoketones can be abstracted from the solvent, whereas in others they come from hydrogen formed by the water–gas shift reaction. The different reaction selectivities are discussed in terms of the reaction mechanisms operating. [Copyright &y& Elsevier]

The credibility of a regulator could be threatened if stakeholders perceive that assessments of performance made by its inspectors are unreliable. Yet there is little published research on the reliability of inspectors’ assessments of health care organizations’ services. Objectives We investigated the inter-rater reliability of assessments made by inspectors inspecting acute hospitals in England during the piloting of a new regulatory model implemented by the Care Quality Commission (CQC) during 2013 and 2014. Multi-professional teams of inspectors rated service provision on a four-point scale for each of five domains: safety; effectiveness; caring; responsiveness; and leadership. Methods In an online survey, we asked individual inspectors to assign a domain and a rating to each of 10 vignettes of service information extracted from CQC inspection reports. We used these data to simulate the ratings that might be produced by teams of inspectors. We also observed inspection teams in action, and interviewed inspectors and staff from hospitals that had been inspected. Results Levels of agreement varied substantially from vignette to vignette. Characteristics such as professional background explained only a very small part of the variation. Overall, agreement was higher on ratings than on domains, and for groups of inspectors compared with individual inspectors. A number of potential causes of disagreement were identified, such as differences regarding the weight that should be given to contextual factors and general uncertainty about interpreting the rating and domain categories. Conclusion Groups of inspectors produced more reliable assessments than individual inspectors, and there is evidence to support the utility of appropriate discussions between inspectors in improving reliability. The reliability of domain allocations was lower than for ratings. It is important to define categories and rating levels clearly, and to train inspectors in their use. Further research is needed to replicate these results now that the model has been fully implemented, and to understand better the impact that inspector uncertainty and disagreement may have on published CQC ratings. [ABSTRACT FROM AUTHOR]

Objective: To analyse how competition is experienced and characterized by NHS and independent sector acute care providers in the English National Health Service (NHS). Methods: Semi-structured interviews with 49 senior staff in 15 NHS trusts and independent sector providers between November 2008 and April 2009, in England. Results: The market was predominantly defined based on geographical proximity. Competition was mainly on the periphery of catchment areas but markets were differentiated based on the scope and type of services. Niche providers, specialist hospitals and tertiary centres did not directly compete with district general hospital-type providers. Competitors were increasingly primary and community care providers, while there was little perceived threat from the private sector. There were many examples of how different providers (both NHS and independent sector) were co-operating and collaborating. Patients and general practitioners (GPs) appeared to be loyal to local providers. Conclusion: The providers' view of the market and the relevance of historical relationships and loyalties suggest fine grained variations in competition which is consistent with a relational rather than structural approach to competition. Also the evidence on embeddedness of relationships implies that collaboration might be a strong lever for quality improvement locally. Finally, some of the agreements found might be deemed in breach of the rules of competition but they may well be in the interests of patients and taxpayers, with implications for regulation in publicly funded health care systems. [ABSTRACT FROM AUTHOR]

To provide a baseline and assess the potential of changes brought about under the Affordable Care Act, this study estimates the number of US adults who were underinsured or uninsured in 2010. Using indicators of medical cost exposure relative to income, we find that 44 percent (81 million) of adults ages 19-64 were either uninsured or underinsured in 2010-up from 75 million in 2007 and 61 million in 2003. Adults with incomes below 250 percent of the federal poverty level account for sizable majorities of those at risk of becoming uninsured or underinsured. If reforms succeed in increasing the affordability of care for people in this income range, we could expect a 70 percent drop in the number of underinsured people and a steep drop in the number of uninsured people. [ABSTRACT FROM AUTHOR]

Background: High profile failures of care in the NHS have raised concerns about regulatory systems for health‐care professionals and organizations. In response, the Care Quality Commission (CQC), the regulator of health and social care in England overhauled its regulatory regime. It moved to inspections which made much greater use of expert knowledge, data and views from a range of stakeholders, including service users. Objective: We explore the role of service users and citizens in health and social care regulation, including how CQC involved people in inspecting and rating health and social care providers. Design: We analyse CQC reports and documents, and 61 interviews with CQC staff and representatives of groups of service users and citizens and voluntary sector organizations to explore the place of service user voice in regulatory processes. Results: Care Quality Commission invited comments and facilitated the sharing of existing service user experiences and engaged with representatives of groups of service users and voluntary sector organizations. CQC involved service users in their inspections as "experts by experience." Information from service users informed both the inspection regime and individual inspections, but CQC was less focused on giving feedback to service users who contributed to these activities. Discussion and conclusions: Service users can make an important contribution to regulation by sharing their experiences and having their voices heard, but their involvement was somewhat transactional, and largely on terms set by CQC. There may be scope for CQC to build more enduring relationships with service user groups and to engage them more effectively in the regulatory regime. [ABSTRACT FROM AUTHOR]

The authors reflects on the implementation of practice based commissioning in medical care in Great Britain. They suggest that it is happening in the country but very slowly and without a great deal of assessment of its progress. They argue that any assessment of the commissioning's progress is connected to the effectiveness and fate of the government's overall health policy and the country's National Health Service.