Search

Objective: To explore the impact of financial incentives for quality of care on practice organisation, clinical autonomy, and internal motivation of doctors and nurses working in primary care., Design: Ethnographic case study., Setting: Two English general practices., Participants: 12 general practitioners, nine nurses, four healthcare assistants, and four administrative staff., Main Outcome Measure: Observation of practices over a five month period after the introduction of financial incentives for quality of care introduced in the 2004 general practitioner contract., Results: After the introduction of the quality and outcomes framework there was an increase in the use of templates to collect data on quality of care. New regimens of surveillance were adopted, with clinicians seen as "chasers" or the "chased," depending on their individual responsibility for delivering quality targets. Attitudes towards the contract were largely positive, although discontent was higher in the practice with a more intensive surveillance regimen. Nurses expressed more concern than doctors about changes to their clinical practice but also appreciated being given responsibility for delivering on targets in particular disease areas. Most doctors did not question the quality targets that existed at the time or the implications of the targets for their own clinical autonomy., Conclusions: Implementation of financial incentives for quality of care did not seem to have damaged the internal motivation of the general practitioners studied, although more concern was expressed by nurses.

Objective: To measure changes in quality of care for three major chronic diseases (coronary heart disease, asthma, and type 2 diabetes) between 1998 and 2003., Design: Longitudinal cohort study., Setting: 42 general practices in six geographical areas of England (Avon, Bury/Rochdale, Enfield, Oldham, Somerset, South Essex)., Participants: Medical record data for 2300 patients with diabetes, asthma, or coronary heart disease in 1998, and 1495 patients in 2003., Main Outcome Measure: Quality of care assessed against predefined evidence based review criteria., Results: Between 1998 and 2003, quality of care improved markedly in terms of maximum possible scores on the review criteria, from 60.5% to 78.1% for coronary heart disease (change = 17.6, 95% confidence interval 13.9 to 21.4; P < 0.001), 60.1% to 70.3% for asthma (10.2, 4.6 to 15.8; P = 0.001), and 70.4% to 77.7% for diabetes (7.3, 3.5 to 11.1; P = 0.001). Important changes occurred to several indicators potentially related to improved health outcomes. These included improved control of serum cholesterol (to < or = 5 mmol/l) from 17.6% to 61.4% in coronary heart disease and from 21.5% to 52% in diabetes and control of blood pressure to < or = 150/90 in coronary heart disease from 47.3% to 72.2% and to < or = 145/85 in diabetes from 21.8% to 35.8%. A small, non-significant improvement in glycaemic control occurred among diabetic patients (37.9% to 39.7% with HbA1c < 7.4%). Significant improvements also occurred in the recording of exercise capacity and diet and weight advice for patients with coronary heart disease; of smoking advice, peak flow, and symptoms for patients with asthma; and of creatinine, weight, and HbA(1c) for patients with diabetes. Over the five years, more improvement in coronary heart disease care occurred in large practices and practices in affluent areas., Conclusions: Substantial improvements were seen in quality of care for the three conditions studied between 1998 and 2003, a time of systematic quality improvement initiatives in the NHS. The changes were most marked for coronary heart disease. English general practices could be expected to achieve high clinical quality scores in the initial year of a new contact, which provides financial incentives for high quality care from 2004.

Objectives: To assess variation in the quality of care in general practice and identify factors associated with high quality care., Design: Observational study., Setting: Stratified random sample of 60 general practices in six areas of England., Outcome Measures: Quality of management of chronic disease (angina, asthma in adults, and type 2 diabetes) and preventive care (rates of uptake for immunisation and cervical smear), access to care, continuity of care, and interpersonal care (general practice assessment survey). Multiple logistic regression with multilevel modelling was used to relate each of the outcome variables to practice size, routine booking interval for consultations, socioeconomic deprivation, and team climate., Results: Quality of clinical care varied substantially, and access to care, continuity of care, and interpersonal care varied moderately. Scores for asthma, diabetes, and angina were 67%, 21%, and 17% higher in practices with 10 minute booking intervals for consultations compared with practices with five minute booking intervals. Diabetes care was better in larger practices and in practices where staff reported better team climate. Access to care was better in small practices. Preventive care was worse in practices located in socioeconomically deprived areas. Scores for satisfaction, continuity of care, and access to care were higher in practices where staff reported better team climate., Conclusions: Longer consultation times are essential for providing high quality clinical care. Good teamworking is a key part of providing high quality care across a range of areas and may need specific support if quality of care is to be improved. Additional support is needed to provide preventive care to deprived populations. No single type of practice has a monopoly on high quality care: different types of practice may have different strengths.

Objectives: To identify prescribing indicators based on prescribing analysis and cost (PACT) data that have face validity for measuring quality or cost minimisation., Design: Modified two round Delphi questionnaire requiring quantitative and qualitative answers., Setting: Health authorities in England., Participants: All health authority medical and pharmaceutical advisers in the first round and lead prescribing advisers for each health authority in the second round., Main Outcome Measures: Face validity (median rating of 7-9 on a nine point scale without disagreement) and reliability (rating 8 or 9) of indicators for assessing quality and cost minimisation., Results: Completed second round questionnaires were received from 79 respondents out of 99. The median rating was 7 for cost minimisation and 6 for quality, and in all except four cases individual respondents rated indicators significantly higher for cost than for quality. Of the 41 indicators tested, only seven were rated valid and reliable for cost minimisation and five for quality., Conclusion: The 12 indicators rated as valid by leading prescribing advisers had a narrow focus and would allow only a limited examination of prescribing at a general practice, primary care group, or health authority level.

Objective: To compare the process of out of hours care provided by general practitioners from patients' own practices and by commercial deputising services., Design: Randomised controlled trial., Setting: Four urban areas in Manchester, Salford, Stockport, and Leicester., Subjects: 2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals) who responded to those requests., Main Outcome Measures: Response to call, time to visit, prescribing, and hospital admissions., Results: 1046 calls were dealt with by practice doctors and 1106 by deputising doctors. Practice doctors were more likely to give telephone advice (20.2% v 0.72% of calls) and to visit more quickly than deputising doctors (median delay 35 minutes v 52 minutes). Practice doctors were less likely than deputising doctors to issue a prescription (56.1% v 63.2% of patients) or to prescribe an antibiotic (43.7% v 61.3% of prescriptions issued) and more likely to prescribe genetic drugs (58.4% v 32.1% of drugs prescribed), cheaper drugs (mean cost per prescription pounds 3.28 v pounds 5.04), and drugs in a predefined out of hours formulary (49.8% v 41.1% of drugs prescribed). There was no significant difference in the number of hospital admissions., Conclusions: By contrast with practice doctors, deputising doctors providing out of hours care less readily give telephone advice, take longer to visit at home, and have patterns of prescribing that may be less discriminating.

Objective: To compare the outcome of out of hours care given by general practitioners from patients' own practices and by commercial deputising services., Design: Randomised controlled trial., Setting: Four urban areas in Manchester, Salford, Stockport, and Leicester., Subjects: 2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals in general practice) who responded to the requests., Main Outcome Measures: Health status outcome, patient satisfaction, and subsequent health service use., Results: Patients seen by deputising doctors were less satisfied with the care they received. The mean overall satisfaction score for practice doctors was 70.7 (95% confidence interval 68.1 to 73.2) and for deputising doctors 61.8 (59.9 to 63.7). The greatest difference in satisfaction was with the delay in visiting. There were no differences in the change in health or overall health status measured 24 to 120 hours after the out of hours call or subsequent use of the health service in the two groups., Conclusions: Patients are more satisfied with the out of hours care provided by practice doctors than that provided by deputising doctors. Organisation of doctors into large groups may produce lower levels of patient satisfaction, especially when associated with increased delays in the time taken to visit. There seem to be no appreciable differences in health outcome between the two types of service.

Objectives: To study the number, demography, and clinical details of patients who agreed or refused to attend centralised primary care centres for out of hours medical care and to study the satisfaction with the service of those who attended., Design: Data collected by telephonists and doctors. Satisfaction questionnaires given to patients who attended., Setting: Five out of hours primary care centres in the United Kingdom., Subjects: All patients contacting the deputising service to request medical help out of hours who were asked to attend a primary care centre. The study terminated when 1000 patients had agreed to attend (200 from each centre). 1000 patients not agreeing to attend were also sampled., Results: The attendance rate varied from 8.9% to 52.3% in the five centres. The overall standardised attendance rate was 22.4%. The attendance rate was highest in children under 5 (465/2380, 19.5%) and fell with increasing age. Of the 1000 sampled non-attenders, 403 said that they had no transport and 345 said that they were too ill to attend. Those who attended were seen by the doctor more quickly. There was no significant difference between the groups in the number who received a prescription (810 attenders v 820 non-attenders, P = 0.57) or who were admitted to hospital (59 v 52, P = 0.5). Satisfaction with the service among those who attended was very high; 95% (694/731) said that they would be prepared to attend under similar circumstances in the future., Conclusion: Most patients are not able or prepared to attend a central facility for primary care out of hours. Substantial cultural change will be necessary and careful consideration given to planning if such centres are to provide a major part of out of hours care.