Mark Pickin

The Multiple Sclerosis Risk Sharing Scheme Monitoring Study--early results and lessons for the future.

BackgroundRisk sharing schemes represent an innovative and important approach to the problems of rationing and achieving cost-effectiveness in high cost or controversial health interventions. This study aimed to assess the feasibility of risk sharing schemes, looking at long term clinical outcomes, to determine the price at which high cost treatments would be acceptable to the NHS.MethodsThis case study of the first NHS risk sharing scheme, a long term prospective cohort study of beta interferon and glatiramer acetate in multiple sclerosis (MS) patients in 71 specialist MS centres in UK NHS hospitals, recruited adults with relapsing forms of MS, meeting Association of British Neurologists (ABN) criteria for disease modifying therapy. Outcome measures were: success of recruitment and follow up over the first three years, analysis of baseline and initial follow up data and the prospect of estimating the long term cost-effectiveness of these treatments.ResultsCentres consented 5560 patients. Of the 4240 patients who had been in the study for a least one year, annual review data were available for 3730 (88.0%). Of the patients who had been in the study for at least two years and three years, subsequent annual review data were available for 2055 (78.5%) and 265 (71.8%) patients respectively. Baseline characteristics and a small but statistically significant progression of disease were similar to those reported in previous pivotal studies.ConclusionSuccessful recruitment, follow up and early data analysis suggest that risk sharing schemes should be able to deliver their objectives. However, important issues of analysis, and political and commercial conflicts of interest still need to be addressed.

Cholesterol and coronary heart disease: screening and treatment.

Coronary heart disease (CHD) is a major cause of morbidity and mortality in the United Kingdom, accounting for just under one quarter of all deaths in 1995: 27% among men and 21% among women.1 Although many CHD deaths occur among elderly people, CHD accounts for 31% of male and 13% of female deaths within the 45–64 age group.

Quantifying patient preferences for out-of-hours primary care.

Objective: To quantify public preferences for different attributes of out-of-hours primary medical care. Methods This study applies a technique called conjoint analysis. A focus group was convened to identify the most important attributes for inclusion in the study, followed by a postal questionnaire asking people to choose between hypothetical services containing different mixes of these attributes. Multi-variate regression analysis estimated the relative importance of different attributes to respondents. The respondents were 436 adults who were among respondents to an earlier postal survey of 25 090 randomly selected Sheffield residents. Results: The doctors manner (whether the doctor takes time to listen), the type of consultation (whether the patient receives a home visit, telephone advice, sees an accident and emergency doctor or attends a primary care treatment centre) and waiting time for consultation best predicted the publics preferences for out-of-hours care. Another three attributes - ease of access; seeing a familiar doctor; and the doctors shift arrangements - were not statistically significant. Conclusions: By asking people to make simple choices between hypothetical services, it is possible to quantify their strength of preference for different aspects of a service. This has important implications for the planning of services. Specifically, for out-of-hours services, more consideration should be given to the doctors manner and waiting times rather than familiarity of doctor.

Commissioning processes in primary care trusts: a repeated cross-sectional survey of health care commissioners in England.

Objectives To determine the extent to which primary care trusts (PCTs) in England employed processes associated with quality commissioning and to assess whether changes occurred in these processes during a policy drive to improve commissioning. Methods Telephone surveys of PCT managers leading commissioning for diabetes, chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), and emergency and urgent care in all 152 PCTs in both 2009 and 2010. Results The response rate was 51% (77/152) of PCTs in 2009 and 60% (91/152) in 2010. Two-thirds of commissioners had commissioned initiatives starting in the previous financial year. Over half of initiatives starting in 2008/09 had been instigated by the PCT alone. This reduced to a third in 2010, showing a shift towards partnership working. Commissioners reported that a large proportion of initiatives had been developed and shaped with the involvement of general practitioners (GPs) with direct links to the PCT and of specialist clinicians (70%), but that a lower proportion of initiatives had involvement from other GPs (40%). Patients or the public were less likely to be involved in initiatives than clinicians, but there was evidence of increasing involvement over the two years from 35% (52/149) to 51% (67/132) of initiatives. There was no evidence of changes in whether needs assessment was undertaken, how evidence was used or how initiatives were led and performance managed. Conclusions PCT commissioners reported clinical engagement in the majority of commissioning initiatives, a shift towards partnership commissioning, and increased involvement of patients and public in the development of initiatives. The new model of commissioning in England through clinical commissioning groups will need to improve on these processes if it is to demonstrate a higher quality approach to commissioning.

The impact of Advanced Access on antibiotic prescribing: a controlled before and after study

Advanced Access practices provide quicker access to appointments and this may lead to patients being seen earlier in the course of acute self-limiting illnesses, and therefore increased antibiotic prescribing. We examined the impact of Advanced Access on antibiotic prescribing. We undertook a controlled before and after study in 24 Advanced Access and 24 control practices, examining monthly antibiotic prescribing data. We found no significant change in prescribing rates between Advanced Access and control practices. There was no evidence that Advanced Access alters antibiotic prescribing behaviour.

Do marginal investments made by NHS healthcare commissioners in the UK produce the outcomes they hope to achieve? Observational study

Objective To investigate the effect of targeted marginal annual investments by local healthcare commissioners on the outcomes they expected to achieve with these investments. Design Controlled before and after study. Setting: 152 commissioning organisations (primary care trusts) in England. Methods National surveys of commissioning managers in 2009 and 2010 to identify: the largest marginal investments made in four key conditions/services (diabetes, coronary heart disease, chronic pulmonary airways disease and emergency and urgent care) in 2008/2009 and 2009/2010; the outcomes commissioners expected to achieve with these investments; and the processes commissioners used to develop these investments. Collation of routinely available data on outcomes commissioners expected from these investments over the period 2007/2008 to 2010/2011. Results 51% (77/152) of commissioners agreed to participate in the survey in 2009 and 60% (91/152) in 2010. Around half reported targeted marginal investments in each condition/service each year. Routine data on many of the outcomes they expected to achieve through these investments were not available. Also, commissioners expected some outcomes to be achieved beyond the time scale of our study. Therefore, only a limited number of outcomes of investments were tested. Outcomes included directly standardised emergency admission rates for the four conditions/services, and the percentage of patients with diabetes with glycated haemoglobin <7. There was no evidence that targeted marginal investments reduced emergency admission rates. There was evidence of an improvement in blood glucose management for diabetes for commissioners investing to improve diabetes care but this was compromised by a change in how the outcome was measured in different years. This investment was unlikely to be cost-effective. Conclusions Commissioners made marginal investments in specific health conditions and services with the aim of improving a wide range of outcomes. There was little evidence of impact on the limited number of outcomes measured.