Darrin Baines

Selection bias in GP fundholding

This paper uses a logistic regression model based on 1993 data for general practices in a single Family Health Services Authority (Lincolnshire) to analyse the differences in characteristics between existing fundholding (up to and including wave three) and non-fundholding practices. A high degree of classification accuracy is obtained. Fundholders are revealed to be more likely than non-fundholders to meet a number of the various quality criteria laid down by central government following the 1990 National Health Services Act, for example, with respect to prescribing cost control, minor surgery and cervical screening uptake. The model is employed to forecast the fourth wave of fundholding and poor predictions suggest the existence of a structural break in the characteristics of fundholders between those in the first three waves and those of wave four. The evidence presented also supports the existence of selection bias in the first three waves of fundholding, although further logistic regression analysis reveals a form of such bias in the fourth wave also.

Income-based incentives in UK general practice.

Since 1990, income-based economic incentives have ostensibly become more important in the remuneration structure of UK general practitioners. For incentives to fulfil their role, however, GPs must possess discretion over income-generating activity and be assumed to be income maximisers. Evidence from one English health authority suggests that a very high proportion of GP income continues to be determined by patient characteristics and the scope for a discretionary response to income incentives is correspondingly small. Where discretion does exist, higher levels of GP incomes do not appear to militate against further discretionary income raising, except in the case where this income and budgetary discipline are in conflict.

A prescription for improvement? An observational study to identify how general practices vary in their growth in prescribing costs

Abstract Objective: To identify how some general practices have low growth in prescribing costs relative to other practices. Design: Observational study. Setting: Trent region of England. Participants: 162 general practices: 54 with low growth in prescribing costs, 54 with average increases in costs, and 54 with large increases in costs. Main outcome measures: Changes in prescribing costs in therapeutic categories in which it has been suggested that savings can be made. Results: There were significant differences between the three groups of practices in terms of their changes in prescribing costs for almost all the variables studied. For the group of practices with lowest growth in costs the most important factors were reducing numbers of prescription items and costs per item; relatively low growth in the costs of “new and expensive” drugs; increasing generic prescribing; and reducing costs for modified release products. This group of practices did not increase costs as much as the others for lipid lowering drugs (P=0.012) and hormone replacement therapy (P=0.007). The practices with the greatest increases in costs had particularly large increases for proton pump inhibitors, selective serotonin reuptake inhibitors, and modified release products. Compared with the other groups these practices had larger increases in costs for “expensive hospital initiated drugs” (P=0.009). Conclusion: General practices vary in their growth in prescribing costs in many ways, with growth in costs for “new and expensive” drugs being particularly important.

The costs of prescribing in dispensing practices

The existence of significant disparities between the prescribing costs of dispensing and non‐dispensing general practices has long been suspected, and received confirmation in a study of Lincolnshire, based on data for 1990–91. This study subsequently attracted much criticism. In this paper, we extend the analysis by considering annual cost and other prescribing data for Lincolnshire for the years between and including 1990–91 and 1993–94, in the light of the prescribing criteria developed by the Audit Commission. Our results show that dispensing practices had higher prescribing costs per patient for all the years analysed. In 1993–94, dispensing practices prescribed more items per patient (fewer of them generically) and were less capable of remaining within their prescribing budgets. The essential difference in prescribing costs lies in the area defined by the Audit Commission as ‘core prescribing’. Using the Audit Commissions criteria for ‘rational’ prescribing, dispensing practices could make a significantly higher level of savings than non‐dispensing practices. The findings lend support to the hypothesis advanced in the earlier analysis, namely, that the higher costs of prescribing in dispensing practices are accounted for primarily by management practice and the structure of incentives.

The dangers of the day of birth

To compare the risk of fetal death on the day of childbirth, with the risk of death at other ages, and with the risks of some hazardous activities, on a common scale of risk per day.

General practitioner fundholding and prescribing expenditure control. Evidence from a rural English health authority.

SummaryIn April 1991, the fundholding and indicative prescribing schemes introduced budgets for expenditure on prescribed drugs into UK general practice. Although both schemes were designed to be equally effective at containing prescribing-cost inflation, several studies suggest that expenditure growth has been lower in fundholding practices, compared with nonfundholding practices. This study attempts to ascertain how fundholding practices control their expenditure by examining data from a rural English health authority for the financial year 1993 to 1994.The fundholding practices sampled were found to control their expenditure through: (i) reduced overprescribing; (ii) using fewer drugs that have limited clinical value; (iii) substituting similar, but less expensive, drugs; (iv) more generic prescribing; and (v) appropriate use of expensive preparations.However, whether the cost differential between fundholding and nonfundholding practices is sustained in future years will depend upon: (i) the ability of fundholding practices to generate further savings; (ii) the characteristics of the practices that enter the fundholding scheme in subsequent waves; (iii) the way in which the scheme is organised; and (iv) the level at which budgets are set.

GP fundholding and prescribing in UK general practice: evidence from two rural, English Family Health Services Authorities.

BACKGROUND Two separate prescribing budget regimes (part of GP fundholding and the indicative prescribing scheme) were introduced into UK general practice in April 1991 in an attempt to contain the growth in NHS expenditure on prescribed drugs. OBJECTIVES The aims of this study are (i) to examine whether the fundholding scheme has been more effective at containing prescribing cost growth than the indicative prescribing scheme and (ii) to ascertain whether its implementation, at a practice level, has been affected by local circumstances and conditions. METHODS Prescribing cost data were collected from two rural, English Family Health Services Authorities for the financial years 1990/1991 to 1993/1994. Exploratory analysis was performed using regression analysis and nonparametric statistical techniques. RESULTS AND CONCLUSIONS Initially, the fundholding scheme has been the more effective at containing expenditure on prescribed drugs. However, the implementation of the schemes in rural areas has probably been affected by the existence of practices with permission to dispense drugs to their own patients, due to a lack of pharmacies in such areas.

The use of the ASTRO-PU and the ASTRO(97)-PU in the setting of prescribing budgets in English general practice

Objectives: To examine the variation in prescribing costs explained by the Age, Sex and Temporary Resident Originated Prescribing Unit (ASTRO‐PU) and its replacement, the ASTRO (97)‐PU, in order to determine the appropriateness of their use in the setting of prescribing budgets in English general practice. Methods: Linear regression analysis was used to analyse routinely collected patient and prescribing data from one English health authority (Lincolnshire Health) for the fiscal year 1995. Results: The goodness‐of‐fit of the regression models constructed varied according to whether practices had dispensing status (i.e. rural practices that have permission to dispense drugs to their own patients as a means of compensating for the lack of pharmacies in such areas), with the ASTRO‐PU and ASTROP(97)‐PU explaining a higher proportion of the variation in prescribing costs amongst practices with such status. Conclusions: This paper draws two main conclusions. First, the weights embodied in the ASTRO‐PU and the ASTRO(97)‐PU may have been biased by the number of dispensing practices sampled during their construction. Second, the denominators may be more applicable to dispensing practices, implying that primary care groups may need to follow the principle of ‘local flexibility’ during the budget‐setting process.

A cluster randomized controlled trial of the effectiveness and cost-effectiveness of Intermediate Care Clinics for Diabetes (ICCD): study protocol for a randomized controlled trial

AbstractBackgroundWorld-wide healthcare systems are faced with an epidemic of type 2 diabetes. In the United Kingdom, clinical care is primarily provided by general practitioners (GPs) rather than hospital specialists. Intermediate care clinics for diabetes (ICCD) potentially provide a model for supporting GPs in their care of people with poorly controlled type 2 diabetes and in their management of cardiovascular risk factors. This study aims to (1) compare patients with type 2 diabetes registered with practices that have access to an ICCD service with those that have access only to usual hospital care; (2) assess the cost-effectiveness of the intervention; and (3) explore the views and experiences of patients, health professionals and other stakeholders.Methods/DesignThis two-arm cluster randomized controlled trial (with integral economic evaluation and qualitative study) is set in general practices in three UK Primary Care Trusts. Practices are randomized to one of two groups with patients referred to either an ICCD (intervention) or to hospital care (control). Intervention group: GP practices in the intervention arm have the opportunity to refer patients to an ICCD - a multidisciplinary team led by a specialist nurse and a diabetologist. Patients are reviewed and managed in the ICCD for a short period with a goal of improving diabetes and cardiovascular risk factor control and are then referred back to practice.or Control group: Standard GP care, with referral to secondary care as required, but no access to ICCD.Participants are adults aged 18 years or older who have type 2 diabetes that is difficult for their GPs to control. The primary outcome is the proportion of participants reaching three risk factor targets: HbA1c (≤7.0%); blood pressure (<140/80); and cholesterol (<4 mmol/l), at the end of the 18-month intervention period. The main secondary outcomes are the proportion of participants reaching individual risk factor targets and the overall 10-year risks for coronary heart disease(CHD) and stroke assessed by the United Kingdom Prospective Diabetes Study (UKPDS) risk engine. Other secondary outcomes include body mass index and waist circumference, use of medication, reported smoking, emotional adjustment, patient satisfaction and views on continuity, costs and health related quality of life. We aimed to randomize 50 practices and recruit 2,555 patients.DiscussionForty-nine practices have been randomized, 1,997 patients have been recruited to the trial, and 20 patients have been recruited to the qualitative study. Results will be available late 2012.Trial registration[ClinicalTrials.gov: Identifier NCT00945204]

Assessing Efficiency in General Practice: An Application of Data Envelopment Analysis

As with any health care process, the efficiency with which outputs are produced in general practice is of considerable importance. Using data from Lincolnshire, this study utilizes data envelopment analysis to examine the relationships between practice costs and outputs, measured not only as the number of patients treated, but also on the basis of performance indicators. The technique permits the construction of an efficiency ranking, facilitating the accurate targeting of monitoring resources.