Stefanie Tan

Impact of initiatives to improve access to, and choice of, primary and urgent care in England: A systematic review.

BACKGROUND There were ten initiatives in the primary and urgent care system in the English NHS during the New Labour government, 1997-2010, aimed at delivering higher quality, more accessible and responsive care by expanding access, increasing convenience and introducing greater patient choice of provider. We examine their impact on demand, equity, patient satisfaction, referrals, and costs. METHODS Studies were systematically identified through electronic databases and reference lists of publications. Studies of all designs were included if published between 1997 and 2013, and with empirical data on the impacts above. RESULTS Nineteen studies of ten initiatives were included. Innovations often overlapped, complicating care. There was some demand for new provision on grounds of convenience, but little evidence of substitution between services. Patient satisfaction varied across schemes. There was little evidence on the costs and benefits of new versus existing provision. CONCLUSION New services generated a more complex system where new and existing providers delivered overlapping services. The new provision did not induce substitution and was likely to have increased overall demand. Initiatives to improve access to existing provision may have greater potential to improve access and convenience at lower marginal costs than developing new forms of provision.

Evaluating Labour's market reforms, 2002–10

Starting in 2002, the UK Labour government of 1997-2010 introduced a series of changes to the National Health Service (NHS) in England designed to increase individual NHS patient choice of place of elective hospital care and competition among public and private providers of elective hospital services for NHS-funded patients. In 2006, the Department of Health initiated the Health Reform Evaluation Programme (HREP) to assess the impact of the changes. The changes broadly had the effects that proponents had predicted but the effects were mostly modest. Most of the undesirable impacts feared by critics appeared not to have materialized to any discernible extent, at least by early in 2010. Labours market appeared to have generated stronger incentives for quality and efficiency than its 1990s predecessor with no obvious detriment to equity of access. However, this high level conclusion conceals a far more nuanced and complex picture of both the process of implementation and the impact of the changes, as the papers in this supplement drawn from the HREP show.

Potential impact of removing general practice boundaries in England: A policy analysis☆

In 2015, the UK government plans to widen patient choice of general practitioner (GP) to improve access through the voluntary removal of practice boundaries in the English NHS. This follows a 12-month pilot in four areas where volunteer GP practices accepted patients from outside their boundaries. Using evidence from the pilot evaluation, we discuss the likely impact of this policy change on patient experience, responsiveness and equity of access. Patients reported positive experiences but in a brief pilot in four areas, it was not possible to assess potential demand, the impact on quality of care or health outcomes. In the rollout, policymakers and commissioners will need to balance the access needs of local residents against the demands of those coming into the area. The rollout should include full information for prospective patients; monitoring and understanding patterns of patient movement between practices and impact on practice capacity; and ensuring the timely transfer of clinical information between providers. This policy has the potential to improve choice and convenience for a sub-group of the population at lower marginal costs than new provision. However, there are simpler, less costly, ways of improving convenience, such as extending opening hours or offering alternatives to face-to-face consultation.

Improving healthcare for people with dementia in England: good progress but more to do.

The announcement in late 2014 of a £55 payment to general practitioners in England for each patient they diagnose as having dementia was further evidence of the emphasis the government has been putting on this previously neglected condition. Increasing the diagnosis rate was only one aspect of a wide range of initiatives that have been pursued since 2009 when the National Dementia Strategy was published and given even greater prominence under the Prime Minister’s Challenge on Dementia inaugurated in 2012. In 2014, to inform the government’s work in drawing up its vision for further improvements from April 2015, a rapid review was conducted to consider what had been achieved and what future action should be considered. While people with dementia and their relatives clearly require integrated and coordinated health and social care, here we consider only healthcare, focusing on four key aspects: diagnosis; post-diagnostic healthcare; hospital care; and training of healthcare staff.

Black box audio/video recording in the operating room: time for anesthesiologists to get with the picture

To the Editor, I recently spent time at a hospital where the surgical department initiated research efforts to evaluate how audio/ video (A/V) recording in the operating room (OR) akin to black boxes in the aviation industry can be used to improve quality of care through review of critical incidents. However, this workplace surveillance may have ramifications that extend beyond the insights gained from the original objective to review A/V footage after critical incidents. Surgeons have generated most of the published evidence and opinions available on this topic with little participation or input from the anesthesiology community. Even so, anesthesiologists have a vested interest in the pursuit of this type of policy, both as experts in delivering perioperative care, and importantly, because they can become the subjects of A/V footage. In addition to the parallels in safety improvement drawn from the aviation industry’s use of black boxes, proponents of routine OR A/V recordings also draw comparisons to the wearable cameras employed by some police forces. However, police forces were motivated to install wearable cameras to improve accountability by influencing real-time behavioural improvements in light of critical lapses in professionalism with regard to racial profiling and abuse of force. As routine A/V recordings can motivate both positive and negative behavioural changes in real time, it is possible that workplace surveillance could increase the potential for litigation and non-allowances for normal practice variations as well as create a culture of overly cautious practice. There is a growing view that improving quality and safety should be a more dominant aspect of the medical culture. This is motivated not only by the increased recognition that medical error plays a large role in morbidity and mortality but also by a widely publicized catastrophic lapse in professionalism that incited a call for greater means to enforce accountability. A particularly striking incident occurred in Toronto, Ontario where an anesthesiologist was convicted of sexual abuse that took place inside the OR. In Ontario, events like this have sparked the development of a task force to review legislation to prevent sexual abuse of patients. It is clear that routine A/V recording could be an influential tool for proponents of such legislation. The use of A/V recording in the OR (and potentially in other locations in the hospital) raises many questions. For example, how will patients respond? Would patients or staff be able to limit the scope of information captured? Will recordings become part of the medical record? Would physicians be responsible for routinely reviewing the files? Will the recordings become a tool to generate punitive incentives? Will the routine use of the recordings make physicians less likely to proceed with higher-risk procedures or patients? The possibility of it becoming a perverse policy tool will require careful consideration before introduction into clinical practice. Black box recordings in the OR have the potential to improve but also to limit anesthesia practice. With careful implementation and strong regulatory measures, this technology could potentially improve care, but there are some major issues and motivations that need to be carefully D. Levin, MD (&) Department of Anesthesia, University of Toronto, Toronto, ON, Canada e-mail: david.levin@utoronto.ca

Patients’ experiences of the choice of GP practice pilot, 2012/2013: a mixed methods evaluation

Objectives To investigate patients’ experiences of the choice of general practitioner (GP) practice pilot. Design Mixed-method, cross-sectional study. Setting Patients in the UK National Health Service (NHS) register with a general practice responsible for their primary medical care and practices set geographic boundaries. In 2012/2013, 43 volunteer general practices in four English NHS primary care trusts (PCTs) piloted a scheme allowing patients living outside practice boundaries to register as an out of area patient or be seen as a day patient. Participants Analysis of routine data for 1108 out of area registered patients and 250 day patients; postal survey of out of area registered (315/886, 36%) and day (64/188, 34%) patients over 18 years of age, with a UK mailing address; comparison with General Practice Patient Survey (GPPS); semistructured interviews with 24 pilot patients. Results Pilot patients were younger and more likely to be working than non-pilot patients at the same practices and reported generally more or at least as positive experiences than patients registered at the same practices, practices in the same PCT and nationally, despite belonging to subgroups of the population who typically report poorer than average experiences. Out of area patients who joined a pilot practice did so: after moving house and not wanting to change practice (26.2%); for convenience (32.6%); as newcomers to an area who selected a practice although they lived outside its boundary (23.6%); because of dissatisfaction with their previous practice (13.9%). Day patients attended primarily on grounds of convenience (68.8%); 51.6% of the day patient visits were for acute infections, most commonly upper respiratory infections (20.4%). Sixty-six per cent of day patients received a prescription during their visit. Conclusions Though the 12-month pilot was too brief to identify all costs and benefits, the scheme provided a positive experience for participating patients and practices.

Evaluation of the Choice of GP Practice Pilot, 2012-13

The choice of general practice pilot began in April 2012 for 12 months and allowed patients to choose to seek care from any volunteer general practice in four volunteer Primary Care Trust (PCT) areas of the country (Westminster, Salford, Manchester and Nottingham City) without being restricted by practice boundaries. Patients could either register with a pilot practice as an out of area (OoA) patient, or be seen as a ‘day patient’, while remaining registered with their original practice. The aim of the evaluation was to describe the uptake of the pilot scheme, and give an early indication of its potential costs and benefits for participating practices and patients over a 12-month period, recognising that it would not be possible to quantify costs and benefits definitively over such a short time.