Brenda Leese

Representation of South Asian people in randomised clinical trials: analysis of trials' data

Excluding patients of ethnic minority groups from clinical trials is unethical,1 introduces substantial bias, and means that findings are based on unrepresentative populations.2 The National Institutes of Health Revitalization Act 1993 requires that all minority groups be represented in the sample in research projects supported by the National Institutes of Health, unless there is a clear and compelling justification not to do so. In the United Kingdom no such legislation exists. To determine the proportion of South Asian participants (the biggest minority ethnic group in Britain) included in clinical trials we investigated the ethnicity profile of six clinical trials recently conducted by the Northern and Yorkshire Clinical Trials and Research Unit, University of Leeds. All were phase III, multicentre, randomised, controlled trials and had recruited large numbers of participants and centres. Two were national breast cancer trials for which regional recruitment figures were available; two …

Paying doctors by salary: a controlled study of general practitioner behaviour in England

The study aim was to evaluate the impact of the experimental introduction of salaried contracts in England on general practitioner (GP) behaviour and the quality of care. A controlled before-and-after design was implemented involving ten practices of standard contract GPs, paid largely by capitation and fee-for-service, and ten salaried GP practices. Diaries and routinely available data were used to assess GP workload, and patient assessments of the quality of care were obtained by postal questionnaire. GPs in salaried practices spent less time on practice administration but more working out-of-hours and in direct patient care, allowing more patients to be seen. Total list sizes were smaller in salaried compared with standard contract practices, but lists per GP were higher because of staffing policies. Salaried GPs tended to provide shorter consultations compared with standard contract GPs, prescribe in fewer consultations, but referral rates were similar. Quality was rated as higher for seven out of thirteen aspects of care examined in salaried practices and two in standard contract practices. However, none of these differences were statistically significant. To conclude, salaried contracts did not adversely affect GP productivity and had little impact on other aspects of GP behaviour or the quality of care provided.

Change in general practice and its effects on service provision in areas with different socioeconomic characteristics

Abstract Objective: To investigate the changes in the structure and service provision of general practice in areas with different socioeconomic characteristics. Design: Interview survey; postal questionnaire. Setting: 260 group and 80 singlehanded general practices in six family health services authorities in England. Main outcome measures: Changes in computer-isation, premises, staffing, incomes, and service provision since the introduction of the 1990 contract, including comparison with data from a study in 1987. Results: In 1993, 94% (245) of group practices were computerised compared with 38% in 1987, and 35% (90) of practices had used the cost rent scheme since 1987. Practice managers were employed in 88% (228) of group practices, and practice nurses in 96% (249) (61% and 60% respectively in 1987). Diabetes and asthma programmes were generally more common in the more affluent areas than elsewhere. A minority of practices (27% (9/33)) in the London inner city area achieved the higher target level for cervical smear testing, compared with 88% (230) overall. A similar trend was apparent for childhood immunisation. Perceived workload increased sharply between 1987 and 1993. Differences in the mean net incomes of general practitioners between areas were much lower than in 1987. Singlehanded practices generally had more problems than group practices in improving service provision. Conclusions: Practices in all areas have shown a strong response to the new incentives. The evidence suggests, however, that generally the urban and inner city practices still lag behind practices in rural and suburban areas in terms of practice structure and service provision.

Retention of nurses in the primary and community care workforce after the age of 50 years:database analysis and literature review

AIM This paper is a report of a study conducted to explore strategies for retaining nurses and their implications for the primary and community care nursing workforce. BACKGROUND An ageing nursing workforce has forced the need for recruitment and retention of nurses to be an important feature of workforce planning in many countries. However, whilst there is a growing awareness of the factors that influence the retention of nurses within secondary care services, little is known about those that influence retention of nurses in primary and community care. Little is known about the age profile of such nurses or the impact of the ageing nursing workforce on individual nursing specialities in the England. METHODS Nursing databases were analysed to explore the impact of age on nursing specialities in primary and community care. The nurse retention literature was reviewed from 1995 to 2006. FINDINGS Workforce statistics reveal that primary and community care nurses have a higher age profile than the National Health Service nursing workforce as a whole. However, there are important gaps in the literature in relation to the factors influencing retention of older primary and community care nurses. Specific factors exist for older nurses within primary care that are unique. Implications for their retention are suggested. CONCLUSION Particular attention needs to be paid to factors influencing retention of older nurses in primary and community care. These factors need to be incorporated into local and national policy planning and development.

Uptake of immunisation in district health authorities in England

The uptakes of immunisation in the district health authorities in England were studied for the years 1983-5. Multiple regression analysis showed that the factors significantly associated with a low uptake of immunisation were mainly related to social conditions, particularly overcrowding of households and population density. Of the service factors, high proportions of elderly and singlehanded general practitioners and high average list sizes were also associated with a low uptake of immunisation in some of the analyses. The results suggest that the measures outlined in the governments white paper on improving primary health care services are likely to lead to improved uptakes of immunisation. If, however, the uptakes of immunisation are used as a measure of standards of the services provided they should first be adjusted to control for variations in social conditions, and the quality of vaccination data would have to be improved.

Retaining older nurses in primary care and the community

AIM This paper is a report of a study conducted to examine issues associated with the impact of age on the retention of female primary and community care nurses in the National Health Service in England. BACKGROUND Little is known about why older nurses in the primary and community care workforce leave and what might encourage them to stay. METHODS A cross-sectional survey using a semi-structured postal questionnaire was carried out during 2005. Responses were received from 485 (61%) district nurses, health visitors, school nurses and practice nurses in five primary care trusts in England. Data were analysed to test for associations. RESULTS Older nurses were more likely than younger ones to report that their role had lived up to expectations (P = 0.001). Issues important for older nurses were feeling valued and being consulted when change was implemented. Important factors encouraging nurses to stay were pension considerations, reduced working hours near retirement, and reduced workload. For those with degree-level qualifications, enhanced pay was a factor encouraging retention (P = 0.044). Nurses might leave in response to high administrative workloads, problems in combining work and family commitments (P < or = 0.001), and lack of workplace support (P = 0.029). Retirement and pensions advice was not widely available. CONCLUSION Since two-thirds of nurses were generally happy in their role, it is important that the conditions necessary to maintain this level of satisfaction are continued throughout a nurses working life. Nurses may all too easily consider leaving prematurely unless policy makers and managers ensure that their working environment reflects the issues nurses consider to be conducive to retention.

Imbalances in the GP Labour Market in the UK: Evidence from a Postal Survey and Interviews with GP Leavers

There is concern that the UK general practitioner (GP) workforce has declined relative to the expanding needs of a primary care-led NHS. Much of the debate about possible solutions within the profession and amongst medical workforce planners has focused on the need to raise medical school intakes and recruit more new GPs. However, other evidence shows that, as with medicine in general, a differential relationship exists in the GP labour market based upon socially ascribed characteristics. It follows that many already qualified GPs (e.g. women, ethnic minority and older doctors) are under-used in the context of generally accepted career structures. Hence, we would argue, part of the solution to workforce shortages lies in better retention and management of existing human resources. This paper first suggests a simple re-conceptualisation, which will help to frame a more sophisticated analysis than so far used for workforce planning of the nature of GP demand and supply. The framework is then used to explore the findings of the first ever national survey (n=621) and follow-up interviews (n=32) with a cohort of GP principal leavers. These showed that a variety of more flexible employment arrangements are needed in order to improve both GP recruitment and retention. In taking this approach, the paper also explores the potential implications of changing social trends for the structure of the GP profession.

Primary care groups: Modernising primary and community health services

This is the second in a series of five articles The governments plan for the NHS, published in July 2000, sets out an ambitious programme of investment, recognising that “the development of primary care services is key to the modernisation of the NHS.”1 Since the founding of the NHS primary care has been one of its greatest strengths but also its weakness. It has provided low cost, easily accessible care, but it has also been characterised by wide variability in quantity and quality, fragmentation, and a lack of coordination. The Labour governments 1997 white paper on the NHS proposed sweeping away the internal market and promoting a culture of collaboration and partnership.2 The establishment of primary care groups in England in 1999—which were charged with developing primary and community health services, commissioning hospital services, and improving the health of communities of around 100 000 people—represented a radical change in the organisation of primary and community health services. By 2004 all of these groups will become fully fledged primary care trusts, controlling most of the budget for providing health care to the populations that they serve. These organisations, led by local health professionals, will play a vital role in delivering the changes to primary and community services that the government sees as key to modernising the NHS. Within a framework of goals and performance standards set at the national level, the NHS plan asserts that the responsibility for decisions about services should be devolved to those who best understand local needs and circumstances.1 In this article, we focus on three key components of the governments strategy for modernising primary and community services: promoting a more efficient use of resources through collaboration and sharing, improving access to primary care, and enhancing the capacity of the workforce. #### Summary points Developing primary and …

Family doctors and innovation in general practice

Family doctors have been presented with changes in government policies and incentives in a recent white paper on primary care. Little work has been done, however, to find out how general practitioners respond to such measures. The response of general practitioners to professional and economic incentives was examined in relation to the location of the practice and the characteristics of the practitioners in seven different areas of England. The areas represented urban, rural, affluent, and deprived communities. The overall response rate was 74%, but the response varied among the areas, being poorest (64%) in an inner city area. Practices were subdivided as innovative, traditional, or intermediate, according to whether they employed a nurse and participated in the cost rent scheme and the vocational training scheme. Innovative practices were defined as fulfilling two of these criteria and traditional practices as fulfilling none; the remainder were classed as intermediate. The results showed that these three types of practice had distinct strategies that were related to financial constraints and the local population. Innovative practices had more partners and were often located in rural or affluent suburban areas; traditional practices had fewer partners and were more common in urban and working class areas. Innovative practices seemed to be in the best position to increase their services, and hence their incomes, in response to the recent proposals in the white paper. Practices in areas of developmental difficulty (predominantly urban but not necessarily inner city areas) had been less able to respond to existing incentives and had a smaller margin available for developing their services. In view of the effect of local constraints of economics and population on the strategy of practices, concentrating resources for primary care in local budgets for working class and urban areas may be preferable to extending the system of charging fees for services provided by family doctors.

Moving specialist care into the community: an initial evaluation

Objectives: To assess the likely impact on patients and local health economies of shifting specialist care from hospitals to the community in 30 demonstration sites in England. Methods: The evaluation comprised: interviews with service providers at 30 sites, supplemented by interviews with commissioners, GPs and hospital doctors at 12 sites; economic case studies in six sites; and patient surveys at 30 sites plus at nine conventional outpatient services. Outcomes comprised: staff views of service organization and development, impact on primary and secondary care, and benefits for patients; cost per consultation and cost per patient in new services compared to estimates of the price of services if undertaken by hospitals; patients’ views of waiting time, access, quality (technical and interpersonal), coordination and satisfaction. Results: New services required high initial investment in staff, premises and equipment, and the support of hospital consultants. Most new services were added to existing hospital services so expanded capacity. Patient reported waiting times (6.7 versus 10.1 weeks; p = 0.001); technical quality of care (96.2 versus 94.5; p < 0.001), overall satisfaction (88.2 versus 85.4; p = 0.04); and access (72.2 versus 65.8; p = 0.001) were significantly better for new compared to conventional services but there was no significant difference in coordination or interpersonal quality of care. Some service providers expressed concerns about service quality. New services dealt with less complex conditions and undercut the price tariff applied to hospitals thus providing a cost saving to commissioners. There was some concern that expansion of new services might destabilize hospitals. Conclusions: Moving specialist care into the community can improve patient access, particularly when new services are added to existing hospital services. Wider impacts on health care quality, capacity and cost merit closer scrutiny before rollout.