Friday 23 December 2011

Primary Colours Issue 47

The latest monthly round up of primary care news, Issue 47 is available to download now

Tuesday 20 December 2011

No incentive

The practice of offering financial inducements to encourage health behaviour change is put under the spotlight by a team from the University of Newcastle in Australia. In this review of reviews, the authors identify key principles for deciding on use of financial incentives to achieve public health aims. Another study looks at how the Locally Enhanced Service system has worked in relation to preventive services in primary care.

Monday 19 December 2011

Customer turned commissioner

A study from the Joseph Rowntree Foundation looks at recent evidence of involving older people in commissioning health and social care. There's particular focus on the experience of programmes in Salford and Dorset. The Royal Pharmaceutical Society has published a discussion paper on involvement, shared decision making and medicines, highlighting the gap between the rhetoric and the present reality. Meanwhile, the Health Foundation has launched a self management resource support centre, offering an introduction to the theory behind and evidence for self care. A study in Journal of Public Health assesses the merits of using discrete choice experiements to incorporate public views into healthcare priority setting.

Friday 9 December 2011

Patients, consumers or guinea pigs?

The need for effective public engagement is never more pressing than in this chilly economic climate, argues thinktank Involve. The NHS Confederation offers some advice to CCGs on how to make this work in the new commissioning landscape. Pressure Group the Patients Association has also done some research on the matter and amongst its concerns is how to reward and support patient representatives in CCGs. Elsewhere, the announcement that the government wants to foster innovation by releasing NHS patient data to researchers has not played brilliantly. Some have pointed out that the proposal to make every NHS patient "a research patient" does not sit particularly well with the patient empowerment agenda.

Thursday 8 December 2011

Joined up thinking

The need to integrate adult social care and health care is made from an economic viewpoint by the Audit Commission in a briefing and accompanying benchmarking tool. A systematic review of integrated working between health services and care homes finds a rather limited field of evidence, with integration happening mostly at patient level and very much health service led. Trafford PCT's faltering efforts to develop integrated care are analysed in a report from the Nuffield Trust. A batch of articles from the journal of integrated care examine inclusion of people with sight loss, a pilot in Norfolk addressing teenage pregnancy rates and the various models of integration used in Devon. RCGP offers guidance on commissioning integrated urgent and emergency care.

Wednesday 7 December 2011

Supply your own punchline

What's the difference between a target and an outcome? The list of 60 outcomes in the new outcomes framework announced today looks a lot like a set of targets by another name, some have suggested. Others have focused on the attention these indicators pay to GPs' performance. Best of all is the hierarchical formula at the end, though, that begins in Tolkein mode but then gets a bit carried away:

One framework defining how the NHS will be accountable for outcomes
Five domains articulating the responsibilities of the NHS
Twelve overarching indicators covering the broad aims of each domain
Twenty-seven improvement areas looking in more detail at key areas within each domain
Sixty indicators in total measuring overarching and improvement area outcomes

Cancer survival rates

Improvements in cancer survival rates over the past 40 years in the UK are charted by Macmillan Cancer Support in a study undertaken by the London School of Hygiene and Tropical Medicine. Huge improvements for some cancers are contrasted with an absence of change for others, particularly lung, brain and pancreatic cancers. NHS Information Centre has published data on bowel cancer care that highlights the continuing problem with late diagnosis. A policy briefing from Breast Cancer Care takes a look at inequalities in care, especially amongst older women.

Tuesday 6 December 2011

Quod erat demonstrandum

The waiting is up for the Whole System Demonstrator programme to report its findings and the headline is a careful yes to telecare: "if delivered properly, telehealth can substantially reduce mortality, reduce the need for admissions to hospital, lower the number of bed days spent in hospital and reduce the time spent in A&E." Started in 2008, this was the largest telecare RCT, covering 6191 patients and 238 GP practices in three areas (Kent, Newham and Cornwall) and covering three major long-term conditions, diabetes, heart failure and COPD . The figures look encouraging: in addition to reductions of 15% in A&E visits, 20% in emergency admissions and 14% in elective admissions, there's a 45% drop in mortality rates. However, this is only the top level data - the small print is yet to be released. The caveat of "if used properly" may constitute something of a warning: last month the King's Fund suggested that there's danger in the technology leading where the organisations cannot effectively follow without substantial change. DH has indicated that the yes is enough: its new campaign, "3 million lives," is aimed at "providing national leadership, strategic direction, and advice to NHS and social care organisations" in implementing telecare more widely. Again, the detail is to follow "in due course."

Friday 2 December 2011

Commissioning round-up

A resource pack from Liverpool PCT points the way to effective commissioning for outcomes in health and social care, surveying appropriate use of a variety of models in programme planning and delivery. Thinktank Reform has published papers from their recent conference An NHS for patients: making commissioning work. The NHS Alliance's Nurses in Commissioning network considers the case for involving nurses in commissioning. Also from the NHS Alliance, a paper looking at commissioning urgent care and the scope for integration.

Thursday 24 November 2011

Modelling

Predictive risk models are used to predict such potentially avoidable and costly events as unplanned hospital admissions. They form a key element in wider strategies to address chronic illness. DH has made it clear that it does not intend to commission updates to the Patients at Risk of Re-hospitalisation tool (PARR++) or the Combined Predictive Model, so the Nuffield Trust has stepped into the breach and offers a guide to help commissioners choose appropriate models.

Monday 14 November 2011

At arm's length

Ahead of the long-awaited reporting from the UK Whole System Demonstrator (WSD) telehealth projects, Audit Scotland provides a review of the issues and looks at programmes north of the border. There's some compelling evidence on the use of telehealth to avoid hospital admissions for people with COPD. The King's Fund has published the third in a series of papers on the experience of implementing telecare and telehealth across the 12 WSD Action Network sites, which takes a more cautious view of the options for implementing telecare nationally. According to the King's Fund, significant cultural and organisational barriers may present more of a challenge than the development of the technology. Meanwhile the Good Governance Institute takes a much more bullish approach, although, like the King's Fund report, does suggest that this will only work if accompanied by systemic change.

Friday 11 November 2011

Clash of the Titans

GP Online offers a useful summary of current guidance for GP commissioners on conflicts of interest. The Health and Social Care Bill makes it clear that CCGs must deal effectively with conflicts of interest, but so far, no guidance has been forthcoming from DH. This article summarises that provided by RCGP and BMA. RCGP has also produced guidance on ethical issues in commissioning.

Thursday 10 November 2011

Feel the benefit

The Department for Work and Pensions has issued a useful-looking guide on the benefits system for GPs and other healthcare professionals and there's also further guidance on their website.

Tuesday 1 November 2011

May contain ...

How consumers/patients respond to labelling foods with "may contain" warnings is the subject of a qualitative study in BMC Public Health. A study from the US suggests that consumers' self reported attention to nutrition labelling doesn't match the reality. Published in the Journal of the American Dietetic Association, the study used an eye-tracking device to measure behaviour, particularly considering label positioning. Closer to home, the Coeliac Society offers commissioners some guidance on community pharmacy supply of gluten free foods.

Monday 31 October 2011

Quality street

New conditions added to the national clinical audit programme commissioned by the Healthcare Quality Improvement Partnership (HQIP) include prostate cancer, learning disabilities and COPD. HQIP has also made public (rather ahead of schedule) guidance on what makes a good or effective clinical audit. At the somewhat more theoretical level a paper from the RAND Corporation asks How do quality improvement interventions succeed?

Friday 28 October 2011

Cancer update

Radiotherapy following breast cancer surgery is beneficial, according to a meta analysis published in the Lancet, with recurrence rates over 10 years halved and death rates over 15 years reduced by about a sixth. Analysis of geographical variations in cancer survival in England from the Cancer Network suggests that although the North-South divide has become less marked over time, geographical inequalities nevertheless persist. the study's authors suggest that the trend in breast cancer survival, where geographical inequalities are lessening, may be followed by other cancers in time. The Whitehall II study continues to offer up opportunities for new analysis: amongst which an assessment of risk factors for colorectal cancer. This 40 year follow up finds smoking to be a significant risk.

Thursday 27 October 2011

You say you want a revolution

The NHS information revolution was the focus of a conference hosted by the King's Fund recently. You can catch up with some of the presentations online, via the King's Fund webpages. Highlights include a paper on meeting the information needs of Clinical Commissioning Groups (CCGs) and another on the relationship between information, patients and choice, as well as a keynote address from Sir Muir Gray on what he is pleased to call the third healthcare revolution of knowledge, information and value. Also at the conference Giles Wilmore, Director of Quality Framework and QUIPP Programmes at DH, announced that publication of DH's new information strategy could not be expected before next spring (a second deferral for the unveiling of these plans). The Health Service Ombudsman's rather critical report on complaints handling in the NHS includes a plea for the information revolution to spread to information about complaints.

Wednesday 26 October 2011

False positives

The debate over the value of the UK Breast Cancer Screening programme reached a wider audience today, as the media picked up Mike Richards' announcement in the BMJ of an independent review. A recent Cochrane review has suggested that screening for breast cancer "seems likely to reduce breast cancer mortality" but the level of reduction is small. Moreover the extent of disbenefit from unnecessary treatment for misdiagnosed healthy women, along with psychological distress, means that it is "not clear whether screening does more good than harm."

Tuesday 25 October 2011

Nothing about me ...

... was well on the way to becoming reality as Andrew Lansley launched the Right Care shared decision making programme. Under the lovely mantra "Right Care, Right Patient, Right Place, Right Time," the thinking behind this policy is driven by the patient empowerment agenda that has run through the government's health reforms. The NHS Right Care site provides an update on the roll-out of the programme and the publication of Patient Decision Aids (hosted by NHS Direct). A team from Imperial College's School of Public Health asks whether shared decision making involving patients with chronic musculoskeletal pain and various healthcare professionals improve patient care.

Monday 24 October 2011

Take care

There's a week for everything, and from 14th to 20th November it's National Self Care Week. This year's campaign is being run in partnership with the Self Care Forum.
Meanwhile, here's an update of recently published work on self management:
The crucial role of information in supporting self care is examined in a review of how self management is applied in conditions like heart disease and kidney disease. Another review looks at evidence for patient self-management and access to healthcare services for ethnic minority groups living with diabetes. The British Journal of Cardiac Nursing offers a descriptive study of self management behaviours amongst patients with heart failure in Scotland. A qualititative study of primary care practices in the north of England assesses how self management issues are handled in general practice consultations where computer based disease management templates are also used.

Friday 21 October 2011

Just checking

The idea of a postcode lottery often claims attention: a recent article in BMC Public Health considers how far this term can be applied to the outworkings of the Health Check as delivered in North West London. The study looked at how NHS Health Checks worked in 8 PCTs in the area, finding considerable variation, with substantial differences in funding levels and in how the programme was interpreted and implemented. Another study, this time from Stoke on Trent, looks at options for cost effective delivery of the Health Checks programme, comparing drop in clinics with booked appointments and considering the merits of targeting particular age groups.

Friday 14 October 2011

It's going to get personal

The government has announced that it will implement personal health budgets for people receiving continuing care by April 2014. While the small print states that this is subject to evaluations of the current pilot programmes, these are due to report in October 2012, so this announcement looks slightly like jumping the gun. The NHS Confederation, which has been considering the matter for some time, has issued a paper summarising the results of its research.

Primary Colours Issue 45

Primary Colours Bulletin, Issue 45, a round up of all the blogs for the last month is available on the EPHRU website

Thursday 13 October 2011

Not quite the tooth fairy

Much commented on in the press is a systematic review of the benefits of sugar-free products for dental health. The researchers found something of a swings and roundabouts situation: while sugar-free products may help to prevent dental caries, they often also contain acidic flavourings and or preservatives that are damaging to dental enamel. The article goes on to discuss the status of health claims for food: one of the sweeteners singled out for analysis, xylitol, has been approved for marketing as "tooth friendly" and is a common ingredient in chewing gum. The study's authors warn that "the term sugar-free may generate false security because people may automatically believe that sugar-free products are safe on teeth." A recent review of non-fluoride preventive measures for dental caries from the American Dental Association (ADA) considered the evidence for using sugar-free chewing gum preventively was not overly strong. This did not, however, prevent an article in Dentisty.co.uk from suggesting that xylitol had been given the "thumbs up," while the ADA's study merely notes that in high risk patients these treatments may be useful adjuncts to usual care including changes in diet and use of fluoride.

Wednesday 12 October 2011

To strategically go

Strategic commissioning is being embraced by local authorities as the way forward for public service delivery, according to a report from local government think tank Localis (in partnership with Essex County Council and Mears). Commission Impossible draws on findings from a survey of council leaders and chief executives which shows that the practice of commissioning services from outside providers is widespread and "set to accelerate significantly." While various healthcare press reports focus on the make-up of newly formed clinical commissioning groups (CCGs), a paper from the NHS Confederation and Royal College of General Practitioners addresses the oft-raised question of conflicts of interest and offers some timely guidance. In an article for Pulse, the chair of the Tower Hamlets CCG summarises this group's approach to integrated commissioning, joining the dots between primary and secondary care and local authority provision. This month's expert on call from the NHS Institute features Mark Jennings, Senior Advisor to the Development for Commissioners Programme, focusing on integration and commissioning.

Tuesday 11 October 2011

Experience counts

A useful survey of the state of play on measuring patient experience in primary care is provided by King's College London's Policy+ newsletter. Research published in Quality and Safety in Healthcare looks at the reasons why patients from ethnic minorities and some other patient groups "consistently report lower scores on patient surveys." While a substantial element of the difference for BME patients "reflected concentration of ethnic minority patients in low-performing practices," this was not the case for younger patients and those with poor self-reported health. Telling patients when mistakes have been made is likely to be a contractual obligation, if government proposals are adopted. DH has issued a consultation paper on implementing a duty of candour for NHS providers, as part of its efforts to enhance accountability. Patient safety group Action Against Medical Accidents has expressed concern that this duty should be statutory rather than contractual, according to HSJ.

Friday 7 October 2011

Risk assessments are the key

Not a popular position to take, but this is exactly what a clinical review in the BMJ proposes, as regards falls prevention. Falls risk screening, as recommended by NICE and the American British Geriatric Society guidelines, really works. The review also includes some video footage of assessments. A study from King's College London's Institute of Gerontology considers the possibility of a community partnership with the fire and rescue services.

Thursday 6 October 2011

Known unknowns

There's no question that good quality evidence is needed for public health policy development and decision making. But some topics are better served than others. A study by a team from McMaster University in Ontario attempts to map usage, quantity and quality of review level evidence coverage in a range of public health topics. The researchers, who examined the contents of the Canadian health-evidence.ca site, found that social determinants of health and healthy communities were amongst those most lacking in review evidence.

Wednesday 5 October 2011

Integrate!

A quick summary of what integrated care could mean for the NHS has been published by the King's Fund. It summarises an earlier report by King's Fund Chief Executive Chris Ham. The Royal College of General Practitioners (RCGP) is seeking the collective wisdom of its membership on the matter of integration. In a consultation paper published last month, the College asks about system design, payment systems and effects on GP practice boundaries, amongst other issues. Responses are due in by 31 October 2011. Meanwhile a paper from the Nuffield Trust looks at the contribution commissioners can make in promoting integration.

Counting the cost

Prescribing analogue insulin, rather than human insulin, is an expensive option for the NHS. A recent study suggests that, between 2000 and 2009, this was something like £625 million. NICE guidelines recommend human insulin as the first choice of therapy, however. An interesting study in Social Science and Medicine looks at how NHS managers evaluate exceptional requests for high-cost drugs, based on the work of a Welsh individual patient commissioning panel.

Tuesday 4 October 2011

Cheap at half the price?

The lack of rigorous cost effectiveness data for public health interventions has often been noted. This, coupled with the rather colder funding climate has lead NICE (the National Institute of Health and Clinical Excellence) to offer a meta-analysis of cost effectiveness data produced in the development of NICE's own public health guidance. Unsurprisingly, NICE has found that the majority of interventions assessed "are highly cost effective."

Wednesday 28 September 2011

Read all about it

An interesting study from the US compares public health professionals’ and journalists’ understanding of what makes a good story. The study considers the role and meaning of health literacy, with particular focus on the health news agenda for local newspapers. An excellent example of the divergence between biomedical science and news agendas can be found in the splendid deconstruction on NHS Choices Behind the Headlines of the “laughter really is the best medicine” study coverage. Elsewhere, Rob Findlay, in a series on the HSJ blog, has been looking at how UK newspapers report healthcare stats and waiting times in particular.

Breathless

Around one in four people are “likely to be diagnosed and receive medical attention for COPD during their lifetime” according to a recent Canadian study published in the Lancet, which compares lifetime risk for COPD with that for other chronic diseases. Another study published in BMC Public Health takes an international perspective on assessing impact of COPD in the working age population. While there’s general agreement that this condition presents a huge challenge to health services, there’s less agreement on approaches. With the recent publication of an outcomes strategy (for COPD and asthma) and quality standards, DH has taken a stand. Current spending is mapped by Dr Foster for Pulse, revealing the inevitable variations. HSJ reports on GP-commissioned clinics for COPD in Norfolk, designed to promote self-management and reduce hospital admissions. NHS Improvement summarises what has been learned from National Improvement Projects on managing COPD as a long term condition, again focusing on self-management and reducing admissions.