Showing papers by "Mark Ashworth published in 2005"

Variations in antibiotic prescribing and consultation rates for acute respiratory infection in UK general practices 1995–2000

Abstract: Background Antibiotic prescribing by GPs in the UK has declined since 1995. Aim We investigated whether general practices that issue fewer antibiotic prescriptions to patients presenting with acute respiratory infections had lower consultation rates for these conditions. Design of study Retrospective data analysis. Setting UK general practice. Method We analysed data from the General Practice Research Database, including all registered patients from 108 practices between 1995 and 2000. For each practice, numbers of consultations for acute respiratory tract infections and the proportion of consultations resulting in an antibiotic prescription were obtained. An age- and sex-standardised consultation ratio (SCR) and standardised prescription ratio (SPR) were calculated for each practice. We evaluated whether SPR and SCR values were associated. Results For the mid-year data (1997), the crude consultation rate for all acute respiratory infections ranged from 125–1110 per 1000 registered patients at different practices; the proportion of consultations with antibiotics prescribed ranged from 45–98%. After standardising for varying age and sex structure of practice populations, practices with lower SPR values had lower SCR values ( r = 0.41; P <0.001). This association was observed in each study year. Moreover, practices that demonstrated reductions in SPR between 1995 and 2000 also showed reductions in SCR ( r = 0.27; P = 0.005). Conclusion Practices that prescribe antibiotics to a smaller proportion of patients presenting with acute respiratory infections have lower consultation rates for these conditions. Practices that succeed, over time, in reducing antibiotic prescribing also experience reductions in consultation rates for these conditions. Although our methodology cannot prove that these two findings are causally related, they imply that patients alter their illness behaviour and that this may be a response to previous consultation experience. In consequence, respiratory illness in the community may be undergoing a process of de-medicalisation.

Accuracy of the pressure scale of sphygmomanometers in clinical use within primary care

Abstract: BACKGROUND It is widely recommended that sphygmomanometers are maintained and calibrated regularly to ensure that the pressure scale remains accurate to within the European Standard specification of +/-3 mmHg. In primary care, however, such checks are reported to be only rarely performed. This paper describes a survey of the accuracy of the absolute static pressure scale of aneroid, mercury and automated sphygmomanometers in clinical use in primary care. METHODS On-site measurements of sphygmomanometer pressure scale accuracy were carried out in 45 general practices within Lambeth, Southwark and Lewisham. A total of 279 sphygmomanometers from these practices were included in the study. The device pressure scales were calibrated using an accurate electronic reference pressure sensor. RESULTS The key finding of this study is that 17.9% (50 out of 279) of all surveyed devices gave errors exceeding the +/-3 mmHg threshold. Of these, 53.2% (33 out of 62) of aneroid devices were found to be reading in error by more than +/-3 mmHg compared with 7.8% (16 out of 217) of the combined population of mercury and automated devices. The difference between these groups is statistically significant (P=0.002). Significant differences in the performance of specific models of aneroid, mercury and automated devices were also identified. CONCLUSION A service model for improving the accuracy of blood pressure monitoring in primary care needs to take into account the current proliferation of pressure scale errors in these devices, the lack of uptake of regular checks and the poor quality of some of the devices currently in use.

Which general practices have higher list inflation? An exploratory study.

Abstract: Results. 42 712 letters were sent. 33.5% of registered patients were eventually deducted from the GP list (deduction figures only available for 20‐24 year old group). Practice level deduction rates ranged from 7‐76%. Practices with higher deduction rates achieved lower vaccination rates for 2 year olds (Pearson’s r = � 0.25; P = 0.005) and cervical smear rates (Pearson’s r = � 0.18; P = 0.04); they also had cheaper prescribing costs per ASTRO-PU (Pearson’s r = � 0.20; P = 0.03). Conclusions. If these findings apply to the whole registered population, the national deghosting exercise is likely to result in large changes to the list size of some practices. Without correcting for list inflation, primary care research based on patient list size as the denominator may underestimate various measures of GP activity, particularly in deprived inner city areas. Resource allocation is also likely to be distorted by differences in list inflation.

The experiences of therapists using a new client-centred psychometric instrument, PSYCHLOPS (Psychological Outcome Profiles)

Abstract: PSYCHLOPS (‘Psychological Outcome Profiles’) is a newly developed client-generated psychometric instrument which can be used as an outcome measure. Uniquely, it asks clients to state their own problems, in their own words. As part of its validation, we used it alongside an existing measure, CORE-OM (‘Clinical Outcomes Routine Evaluation – Outcome Measure’). Based on a qualitative methodology, we report here on the first-hand experiences of four therapists using both instruments. The key themes that emerged from therapists’ responses were feasibility, validity and usefulness. Both questionnaires were perceived as complementing each other, the qualitative information from PSYCHLOPS balancing the quantitative information from CORE-OM and that both could contribute to the therapist-client interaction. The key features of PSYCHLOPS are likely to prove attractive to therapists and should increase acceptance and uptake of outcome measures.

What factors are associated with improvement after brief psychological interventions in primary care? Issues arising from using routine outcome measurement to inform clinical practice

Abstract: Study purpose: This descriptive study used a routine practice dataset to investigate whether demographic variables and intervention length were associated with outcome after brief psychological interventions in primary care. Brief description of the participants: The data are from 3687 adults with a wide range of presenting problems, from a culturally diverse inner London borough, referred to primary care psychologists and counsellors. Methodology: Demographic and service activity data were routinely collected using a local monitoring form and self-report outcome data using the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM). The paradigm of reliable and clinically significant change was used to explore individual as well as group change. The relationship between demographic variables, intervention length and outcome was investigated. Results, conclusions and implications: Sixty-six per cent of the group with complete outcome data (n = 458) showed reliable improvement and 45% al...

Performance for health.

Abstract: In November 2004 the UK Government published a White Paper about health in England.1 Behind it lies the notion that, in general, consumers wish to make their own choices for health but that they need help in coping with adverse factors—such as the relentless ploys of the food industry to fatten us up and the lack of affordable and safe ways to take regular exercise. Children in particular need protection from unscrupulous marketing and from the hazards posed by individuals who smoke in their presence. There is renewed emphasis on reducing obesity, sexual ill health, smoking and stress at work. Proposals that caught the headlines are for a new cadre of personal trainers accredited by the National Health Service, four hundred new sports academies and a ban by 2008 on smoking in premises that sell food. This White Paper differs from any previous document in purporting to give public health back to the public. However, there are limits to consumerism in health; 5.2 million people lack basic literacy skills and two-thirds of people from ethnic minorities live in the 88 most deprived areas of the country. The White Paper addresses these potential gaps by designating a group of spearhead communities, among the most deprived areas, which will receive special funding and attention to work in whatever public, private and voluntary partnerships are necessary to improve health and quality of life for their residents. The locations are already well known because they show remarkable consistency in their adverse health profiles. Our own area is an example. In the deprived populations of the inner city along the River Thames, people have triple the odds of dying earlier than those in middle-class suburbia. If they survive, they have double the odds of living with disability. There are eight stops between Westminster and Canning Town on the London Underground. By the end of the journey, life expectancy in the resident population has fallen by 6 years.2 On almost every other health indicator known, people in such areas fare poorly—despite the efforts of professionals and policy-makers to improve matters with targeted local programmes and catch-up campaigns for screening and immunization. For years Government has been funding initiatives across the public sector to draw in the wider contributors to health.3 What will it take for these populations to ‘choose health’, and for the NHS to perform as well on health as it has on healthcare? We might learn from what has been tried already. A population characterized by systematic deprivation, absorbed in day-to-day survival and unkeen on officialdom, is not easily engaged. A first step is to secure local political commitment to common objectives, and this itself is a time-consuming and complex task. The outcomes sought, such as improved life expectancy, educational achievement or crime reduction, are at least mid-term achievements. ‘Health action zones’, devised for this purpose, launched a multiplicity of initiatives but often failed to establish the necessary roots in these communities; a project-based, short-term mentality prevailed and even the corporate knowledge generated from these projects was dissipated in a wave of system reorganization. Despite the large sums spent on the programmes themselves and their evaluation we are not much the wiser about what makes a difference and why.4 More controversially, successive governments have moved to influence the behaviour of professionals towards the preventive services by setting targets—for instance, concerning smoking cessation. On this matter we have learnt a great deal, because of the close relation of smoking cessation programmes to the performance rating of primary care trusts; failure to achieve targets means loss of star ratings ando therefore attracts the attention of senior managers and politicians. The path to the desired prize is strewn with obstacles. The outcome depends on access to the service, the confidence of practitioners to intervene in the face of patient indifference or hostility, the organization of the service and the efficiency of data transfer, and the relationship with and back-up from the local NHS. Some fortunate places can get through all of these pinch points. Public health leaders in these areas talk of having begun relationships as long ago as ten years with the many practitioners and agencies who contribute to the complex business of health. Another key to success is the presence of highly effective individuals in critical enabling roles. The current emphasis on preventive targets raises strong emotions not only among clinicians but even among public health professionals. Many public health workers based in primary care trusts frankly object to putting intense pressure on the service for interventions that ultimately depend on behaviour changes in the lower income third of the population. Mobility of up to 30% annually, poor achievement in education and employment, chaos through crime and substance misuse and cultural indifference to the concept of health defy attempts to build community capacity and prevent individual ill-health. From early social marketing for health in south-east London, our impression is that substantial numbers do not identify with the concept of future risk. Moreover, the professionals who might exert leverage via primary health—the general practitioners and nurses—do not champion or even ‘own’ the targets, so that accountability and delivery are uncoupled. Some, indeed, have ethical objections to the linking of clinical practice with remuneration for hitting targets.5 Critical examination of ‘performance for health’, including achievement of targets, exposes some uncomfortable findings. Examples are the modest outputs achieved for apparently large amounts of effort and money and the variations in performance between populations with similar levels of deprivation.1 It is tempting to ascribe poor results to the nature of the populations, but to what degree do we have our own house in order within the public services? Traditionally we have addressed population health in the same manner as the control of epidemics. However, the analogy is false: we can compel people to change their activities in order to prevent the spread of infection but we cannot force them to change their behaviour and protect themselves against chronic disease.1,6 For success with the latter we need a good understanding of the values and aspirations (or lack of them) of the individuals and groups behind the epidemiology—and the know-how and ways into this may not reside within the National Health Service.7 We should work alongside people and not do things for or to them. Could we be offering services that are more in tune with people’s lives—for example, through workplaces, shopping centres, pharmacies, churches and clubs? Schools are obvious locations and ‘healthy schools’ programmes are widespread; yet experience in some parts of England has been discouraging. The relationship between education and health services is decidedly distant—education has different targets and no particular interest in ‘taking on’ health. The White Paper offers people a range of choices including personal help and health records in their own internet slot. With personal computer-linked records and an enhanced nurse practitioner cadre in the community, they might then have access to preventive, diagnostic and treatment services without necessarily going via a general practitioner. The White Paper opens up possibilities for different types of partnership with individuals, communities, providers of care and social marketers. One result might be the emergence of local champions for health who would engage the population and lead a demand for more responsive and accessible preventive services. What about chronic disease? The omens here are good. The new UK-wide contract for general practitioners, relating remuneration to quality of care, should be beneficial not only to vulnerable individuals but also to the public health. Early onset and high prevalence of severe chronic disease is closely linked to health inequalities. The information generated by this contract will offer strong incentives to good performance—not least by allowing comparisons. Performance for health, particularly from the NHS and local government, will need to sharpen. When the NHS announced an intention to modernize its accident and emergency and elective services there were cries from within that the ambitious targets were completely unrealistic. But the critics have been proved wrong. As with healthcare so, perhaps, with public health. By combined application of targets, performance development and culture changes, the preventive and health-promoting services could be nudged past a frontier that has long seemed impassable.

The relationship between income and performance indicators in general practice: a cross-sectional study

Abstract: Objective: To explore the relationship between the income of general practitioners (GPs) and the performance characteristics of their practices.Design: Cross-sectional survey.Setting: All practices (n = 166) in an inner city health authority, two years before the introduction of the new GP contract in April 2004 were studied.Main outcome measures: True income per GP was unavailable to us. Instead, the proxy measure - superannuable pay - was calculated (gross eligible income per GP minus the national average sum for GP expenses). Practice staff funding figures were also obtained. These two financial indicators were compared with practice characteristics and performance indicators.Results: Data were available from 151 out of 166 practices. Based on regression analysis, larger list sizes and higher practice staff budgets predicted 31% of the variation in GP income (standardized β = 0.66, P < 0.001; β = 0.19, P = 0.02; respectively). Higher staff budgets were independently associated with better cervical smea...