The financial challenges facing general practice

Future-Focused Finance and the HFMA have worked together to produce this briefing on the current financial challenges facing general practice.

We asked general practitioners (GPs) and practice managers about the current financial challenges they are facing Their responses highlight a number of serious concerns about the issues facing general practice and in this briefing we make a number of recommendations to address some of the most pressing issues.

General practice is facing unprecedented pressures and, with GPs managing heavier and more complex workloads, uncertainty about a sustainable future in a rapidly changing landscape is understandable. In such a stretched environment general practice needs guidance and support to manage the status quo, let alone deliver the increasing expectations set out in Next steps on the NHS five year forward view.

Further information is available here.

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Never Events in UK General Practice: A Survey of the Views of General Practitioners on Their Frequency and Acceptability as a Safety Improvement Approach.

Background: Never events (NEs) are serious preventable patient safety incidents and are a component of formal quality and safety improvement (Q&SI) policies in the United Kingdom and elsewhere. A preliminary list of NEs for UK general practice has been developed, but the frequency of these events, or their acceptability to general practitioner (GPs) as a Q&SI approach, is currently unknown. The study aims to estimate (1) the frequency of 10 NEs occurring within GPs’ own practices and (2) the extent to which the NE approach is perceived as acceptable for use.

Methods: General practitioners were surveyed, and mixed-effects logistic regression models examined the relationship between GP opinions of NE, estimates of NE frequency, and the characteristics of the GPs and their practices.

Results: Responses from 556 GPs in 412 practices were analyzed. Most participants (70%-88%, depending on the NE) agreed that the described incident should be designated as a NE. Three NEs were estimated to have occurred in less than 4% of practices in the last year; however, two NEs were estimated to have occurred in 45% to 61% of the practices. General practitioners reporting that a NE had occurred in their practice in the last year were significantly less likely to agree with the designation as a NE compared with GPs not reporting a NE (odds ratio, 0.42; 95% CI = 0.36-0.49).

Conclusions: The NE approach may have Q&SI potential for general practice, but further work to adapt the concept and content is required.

Journal of Patient Safety: Post Author Corrections: April 27, 2017

Effectiveness of a 6-year multidomain vascular care intervention to prevent dementia (preDIVA): a cluster-randomised controlled trial

Background

Cardiovascular risk factors are associated with an increased risk of dementia. We assessed whether a multidomain intervention targeting these factors can prevent dementia in a population of community-dwelling older people.

Methods

In this open-label, cluster-randomised controlled trial, we recruited individuals aged 70–78 years through participating general practices in the Netherlands. General practices within each health-care centre were randomly assigned (1:1), via a computer-generated randomisation sequence, to either a 6-year nurse-led, multidomain cardiovascular intervention or control (usual care). The primary outcomes were cumulative incidence of dementia and disability score (Academic Medical Center Linear Disability Score [ALDS]) at 6 years of follow-up. The main secondary outcomes were incident cardiovascular disease and mortality. Outcome assessors were masked to group assignment. Analyses included all participants with available outcome data. This trial is registered with ISRCTN, number ISRCTN29711771.

Findings

Between June 7, 2006, and March 12, 2009, 116 general practices (3526 participants) within 26 health-care centres were recruited and randomly assigned: 63 (1890 participants) were assigned to the intervention group and 53 (1636 participants) to the control group. Primary outcome data were obtained for 3454 (98%) participants; median follow-up was 6·7 years (21 341 person-years). Dementia developed in 121 (7%) of 1853 participants in the intervention group and in 112 (7%) of 1601 participants in the control group (hazard ratio [HR] 0·92, 95% CI 0·71–1·19; p=0·54). Mean ALDS scores measured during follow-up did not differ between groups (85·7 [SD 6·8] in the intervention group and 85·7 [7·1] in the control group; adjusted mean difference −0·02, 95% CI −0·38 to 0·42; p=0·93). 309 (16%) of 1885 participants died in the intervention group, compared with 269 (16%) of 1634 participants in the control group (HR 0·98, 95% CI 0·80–1·18; p=0·81). Incident cardiovascular disease did not differ between groups (273 [19%] of 1469 participants in the intervention group and 228 [17%] of 1307 participants in the control group; HR 1·06, 95% CI 0·86–1·31; p=0·57).

Interpretation

A nurse-led, multidomain intervention did not result in a reduced incidence of all-cause dementia in an unselected population of older people. This absence of effect might have been caused by modest baseline cardiovascular risks and high standards of usual care. Future studies should assess the efficacy of such interventions in selected populations.

Funding

Dutch Ministry of Health, Welfare and Sport; Dutch Innovation Fund of Collaborative Health Insurances; and Netherlands Organisation for Health Research and Development.

The Lancet, Volume 388, No. 10046, p797–805, 20 August 2016

Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost

Importance  The value of integrated team delivery models is not firmly established.

Objective  To evaluate the association of receiving primary care in integrated team-based care (TBC) practices vs traditional practice management (TPM) practices (usual care) with patient outcomes, health care utilization, and costs.

Design  A retrospective, longitudinal, cohort study to assess the association of integrating physical and mental health over time in TBC practices with patient outcomes and costs.

Setting and Participants  Adult patients (aged ≥18 years) who received primary care at 113 unique Intermountain Healthcare Medical Group primary care practices from 2003 through 2005 and had yearly encounters with Intermountain Healthcare through 2013, including some patients who received care in both TBC and TPM practices.

Exposures  Receipt of primary care in TBC practices compared with TPM practices for patients treated in internal medicine, family practice, and geriatrics practices.

Main Outcomes and Measures  Outcomes included 7 quality measures, 6 health care utilization measures, payments to the delivery system, and program investment costs.

Results  During the study period (January 2010-December 2013), 113 452 unique patients (mean age, 56.1 years; women, 58.9%) accounted for 163 226 person-years of exposure in 27 TBC practices and 171 915 person-years in 75 TPM practices. Patients treated in TBC practices compared with those treated in TPM practices had higher rates of active depression screening (46.1% for TBC vs 24.1% for TPM; odds ratio [OR], 1.91 [95% CI, 1.75 to 2.08), adherence to a diabetes care bundle (24.6% for TBC vs 19.5% for TPM; OR, 1.26 [95% CI, 1.11 to 1.42]), and documentation of self-care plans (48.4% for TBC vs 8.7% for TPM; OR, 5.59 [95% CI, 4.27 to 7.33]), lower proportion of patients with controlled hypertension (<140/90 mm Hg) (85.0% for TBC vs 97.7% for TPM; OR, 0.87 [95% CI, 0.80 to 0.95]), and no significant differences in documentation of advanced directives (9.6% for TBC vs 9.9% for TPM; OR, 0.97 [95% CI, 0.91 to 1.03]). Per 100 person-years, rates of health care utilization were lower for TBC patients compared with TPM patients for emergency department visits (18.1 for TBC vs 23.5 for TPM; incidence rate ratio [IRR], 0.77 [95% CI, 0.74 to 0.80]), hospital admissions (9.5 for TBC vs 10.6 for TPM; IRR, 0.89 [95% CI, 0.85 to 0.94]), ambulatory care sensitive visits and admissions (3.3 for TBC vs 4.3 for TPM; IRR, 0.77 [95% CI, 0.70 to 0.85]), and primary care physician encounters (232.8 for TBC vs 250.4 for TPM; IRR, 0.93 [95% CI, 0.92 to 0.94]), with no significant difference in visits to urgent care facilities (55.7 for TBC vs 56.2 for TPM; IRR, 0.99 [95% CI, 0.97 to 1.02]) and visits to specialty care physicians (213.5 for TBC vs 217.9 for TPM; IRR, 0.98 [95% CI, 0.97 to 0.99], P > .008). Payments to the delivery system were lower in the TBC group vs the TPM group ($3400.62 for TBC vs $3515.71 for TPM; β, −$115.09 [95% CI, −$199.64 to −$30.54]) and were less than investment costs of the TBC program.

Conclusions and Relevance  Among adults enrolled in an integrated health care system, receipt of primary care at TBC practices compared with TPM practices was associated with higher rates of some measures of quality of care, lower rates for some measures of acute care utilization, and lower actual payments received by the delivery system.

JAMA. 2016;316(8):826-834

Improving the transition from primary care for people with neurological conditions

A report from the Neurological Alliance finds that GPs in England lack confidence in the care for people with neurological conditions.

GPs expressed doubts about the ability of local services and systems to manage neurology patients effectively and concern over unnecessary delays. The report sets out eight recommendations aimed at improving the primary care pathway for people with neurological conditions, including a call for the development of a “watch list” of the ten signs and symptoms GPs should be aware of during patient interactions in primary care settings.

Read the full report here

Calling the GP surgery: patient burden, patient satisfaction, and implications for training

Background Good communication is central to the effectiveness of GP service provision, as well as to patient satisfaction with surgeries, but very little is known about the actual communication that occurs between patients and surgeries.

Aim This study was carried out to examine, for the first time, how receptionists interact with patients on the telephone, to identify features of communication associated with efficacy and patient satisfaction.

Design and setting A qualitative conversation analysis of incoming patient telephone calls, recorded ‘for training purposes’, in three English GP surgeries.

Method Data were analysed qualitatively to identify effective communication, then coded to establish the relative prevalence of communication types across each surgery.

Results Analysis identified a burden on patients to drive calls forward and achieve service. ‘Patient burden’ occurred when receptionists failed to offer alternatives to patients whose initial requests could not be met, or to summarise relevant next actions (for example, appointment, call-back, or other query) at the end of calls. Coding revealed that ‘patient burden’ frequency differed across the services. Increased ‘patient burden’ was associated with decreased satisfaction on published satisfaction survey scores.

Conclusion Patients in some practices have to push for effective service when calling GP surgeries. Conversation analysis specifies what constitutes (in)effective communication. Findings can then underpin receptionist training and improve patient experience and satisfaction.

Stokoe, E et al. Calling the GP surgery: patient burden, patient satisfaction, and implications for training British Journal of General Practice. Published 16 August 2016

Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007–14

Background

Primary care is the main source of health care in many health systems, including the UK National Health Service (NHS), but few objective data exist for the volume and nature of primary care activity. With rising concerns that NHS primary care workload has increased substantially, we aimed to assess the direct clinical workload of general practitioners (GPs) and practice nurses in primary care in the UK.

Methods

We did a retrospective analysis of GP and nurse consultations of non-temporary patients registered at 398 English general practices between April, 2007, and March, 2014. We used data from electronic health records routinely entered in the Clinical Practice Research Datalink, and linked CPRD data to national datasets. Trends in age-standardised and sex-standardised consultation rates were modelled with joinpoint regression analysis.

Findings

The dataset comprised 101 818 352 consultations and 20 626 297 person-years of observation. The crude annual consultation rate per person increased by 10·51%, from 4·67 in 2007–08, to 5·16 in 2013–14. Consultation rates were highest in infants (age 0–4 years) and elderly people (≥85 years), and were higher for female patients than for male patients of all ages. The greatest increases in age-standardised and sex-standardised rates were in GPs, with a rise of 12·36% per 10 000 person-years, compared with 0·9% for practice nurses. GP telephone consultation rates doubled, compared with a 5·20% rise in surgery consultations, which accounted for 90% of all consultations. The mean duration of GP surgery consultations increased by 6·7%, from 8·65 min (95% CI 8·64–8·65) to 9·22 min (9·22–9·23), and overall workload increased by 16%.

Interpretation

Our findings show a substantial increase in practice consultation rates, average consultation duration, and total patient-facing clinical workload in English general practice. These results suggest that English primary care as currently delivered could be reaching saturation point. Notably, our data only explore direct clinical workload and not indirect activities and professional duties, which have probably also increased. This and additional research questions, including the outcomes of workload changes on other sectors of health care, need urgent answers for primary care provision internationally.

Funding

Department of Health Policy Research Programme.

The lancet, Volume 387, No. 10035, p2323–2330, 4 June 2016