The organisation and delivery of health improvement in general practice and primary care: a scoping study

Background This project examines the organisation and delivery of health improvement activities by and within general practice and the primary health-care team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices, how individual practices and the primary health-care team organise such public health activities, and how these contribute to health improvement. Our focus was on health promotion and ill-health prevention activities. Aims The aim of this scoping exercise was to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary health-care team. The key objectives were to provide an overview of the range and type of health improvement activities, identify gaps in knowledge and areas for further empirical research. Our specific research objectives were to map the range and type of health improvement activity undertaken by general practice staff and the primary health-care team based within general practice; to scope the literature on health improvement in general practice or undertaken by health-care staff based in general practice and identify gaps in the evidence base; to synthesise the literature and identify effective approaches to the delivery and organisation of health improvement interventions in a general practice setting; and to identify the priority areas for research as defined by those working in general practice. Methods We undertook a comprehensive search of the literature. We followed a staged selection process involving reviews of titles and abstracts. This resulted in the identification of 1140 papers for data extraction, with 658 of these papers selected for inclusion in the review, of which 347 were included in the evidence synthesis. We also undertook 45 individual and two group interviews with primary health-care staff. Findings Many of the research studies reviewed had some details about the type, process or location, or who provided the intervention. Generally, however, little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches, with practices engaging in both primary and secondary prevention. The range of activities suggests that general practitioners do not take a population approach but focus on individual patients. However, it is clear that many general practitioners see health promotion as an integral part of practice, whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Our key conclusion is that there is currently insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care more widely. Future Research Future research on health improvement in general practice and by the primary health-care team needs to move beyond clinical research to include delivery systems and be conducted in a primary care setting. More research needs to examine areas where there are chronic disease burdens – cancer, dementia and other disabilities of old age. Reviews should be commissioned that examine the whole prevention pathway for health problems that are managed within primary care drawing together research from general practice, pharmacy, community engagement, etc

United We Ride National Dialogue

The Coordinating Council on Access and Mobility (CCAM) asked the National Academy of Public Administration and Easter Seals Project ACTION to develop and host the first United We Ride (UWR) National Dialogue. The goal of the Dialogue was to help shape future policy direction and provide input to the next CCAM strategic plan. The National Academy also assembled a small work group with representatives of the Federal Interagency Coordinating Council on Access and Mobility, Easter Seals Project ACTION, and the National Resource Center on Human Service Transportation to help guide the process of design and implementation.The CCAM includes 11 federal departments, nine of which are responsible for providing transportation for people with disabilities, older adults, and people with limited incomes. CCAM officially launched United We Ride in 2004 to (1) provide more rides for target populations while using the same or fewer assets, (2) simplify access, and (3) increase customer satisfaction.Key FindingsThe process used to create coordinated transportation plans needs improvement. Significant federal policy barriers still exist to strategies that would facilitate access to transportation services. Mobility management strategies are underutilized in communities across the country, and missed opportunities to bridge gaps between transportation and other community services still need to be addressed

Iowa Disaster Recovery Framework

This Iowa Disaster Recovery Framework (IDRF) is meant to detail a lasting, flexible structure and system to coordinate and manage disaster recovery in the long-term. The IDRF provides a structure to engage stakeholders such as individual Iowans, local and tribal governments, businesses, voluntary, faith-based and community organizations as well as state and federal agencies to identify and resolve recovery challenges both before and after disaster events. It applies to all disasters, recovery partners, and recovery activities

Contracting with General Dental Services: a mixed-methods study on factors influencing responses to contracts in English general dental practice

Background: Independent contractor status of NHS general dental practitioners (GDPs) and general medical practitioners (GMPs) has meant that both groups have commercial as well as professional identities. Their relationship with the state is governed by a NHS contract, the terms of which have been the focus of much negotiation and struggle in recent years. Previous study of dental contracting has taken a classical economics perspective, viewing practitioners’ behaviour as a fully rational search for contract loopholes. We apply institutional theory to this context for the first time, where individuals’ behaviour is understood as being influenced by wider institutional forces such as growing consumer demands, commercial pressures and challenges to medical professionalism. Practitioners hold values and beliefs, and carry out routines and practices which are consistent with the field’s institutional logics. By identifying institutional logics in the dental practice organisational field, we expose where tensions exist, helping to explain why contracting appears as a continual cycle of reform and resistance. Aims: To identify the factors which facilitate and hinder the use of contractual processes to manage and strategically develop General Dental Services, using a comparison with medical practice to highlight factors which are particular to NHS dental practice. Methods: Following a systematic review of health-care contracting theory and interviews with stakeholders, we undertook case studies of 16 dental and six medical practices. Case study data collection involved interviews, observation and documentary evidence; 120 interviews were undertaken in all. We tested and refined our findings using a questionnaire to GDPs and further interviews with commissioners. Results: We found that, for all three sets of actors (GDPs, GMPs, commissioners), multiple logics exist. These were interacting and sometimes in competition. We found an emergent logic of population health managerialism in dental practice, which is less compatible than the other dental practice logics of ownership responsibility, professional clinical values and entrepreneurialism. This was in contrast to medical practice, where we found a more ready acceptance of external accountability and notions of the delivery of ‘cost-effective’ care. Our quantitative work enabled us to refine and test our conceptualisations of dental practice logics. We identified that population health managerialism comprised both a logic of managerialism and a public goods logic, and that practitioners might be resistant to one and not the other. We also linked individual practitioners’ behaviour to wider institutional forces by showing that logics were predictive of responses to NHS dental contracts at the dental chair-side (the micro level), as well as predictive of approaches to wider contractual relationships with commissioners (the macro level) . Conclusions: Responses to contracts can be shaped by environmental forces and not just determined at the level of the individual. In NHS medical practice, goals are more closely aligned with commissioning goals than in general dental practice. The optimal contractual agreement between GDPs and commissioners, therefore, will be one which aims at the ‘satisfactory’ rather than the ‘ideal’; and a ‘successful’ NHS dental contract is likely to be one where neither party promotes its self-interest above the other. Future work on opportunism in health care should widen its focus beyond the self-interest of providers and look at the contribution of contextual factors such as the relationship between the government and professional bodies, the role of the media, and providers’ social and professional networks. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Toward Interagency Collaboration: The Role of Children's Cabinets

Today in our Commonwealth, children and families in need are served by multiple agencies -- Department of Children and Families, Department of Youth Services, Department of Mental Health - as well as by their local public schools. Yet, there is often little or no coordination among the agencies and public school systems.Social workers rarely talk with, or even know, the teacher of the child with whom they are working -- a teacher who may spend as many as six hours each day with the child. Too often the burden of navigating the labyrinth of social services falls on these already struggling families -- or, worse, on the children themselves.In an effort to better align state and local services for children, youth and their families, many states have begun establishing children or youth cabinets. Here in Massachusetts, in October 2008, Governor Patrick signed an executive order establishing the Child and Youth Readiness Cabinet -- a state leadership team focused on streamlining state efforts to improve services for children, youth and families. The Readiness Cabinet is jointly chaired by Paul Reville, Secretary of Education, and Dr. JudyAnn Bigby, Secretary of Health and Human Services, and includes the state secretaries of Administration and Finance, Housing and Economic Development, Labor and Workforce Development, Public Safety and the Child Advocate. The Rennie Center's new policy brief, Toward Interagency Collaboration: The Role of Children's Cabinets, is designed to inform the general public about the purpose of children's cabinets and to highlight the potential role that non-government stakeholders (such as parents, youth leaders, advocacy groups, and service providers) might play as the Governor's Child and Youth Readiness Cabinet begins their work in Massachusetts. It was also written to contribute to the policy dialogue about how to increase the level of collaboration among state departments and agencies that serve Massachusetts children, youth and families by putting forth examples of structures and strategies being used by other states' children's cabinets to carry out their work. The policy brief was the subject of discussion at a public event on June 10, 2009, co-hosted by the Full-service Schools Roundtable

Integration and continuity of primary care: polyclinics and alternatives - a patient-centred analysis of how organisation constrains care co-ordination

Background An ageing population, the increasing specialisation of clinical services and diverse health-care provider ownership make the co-ordination and continuity of complex care increasingly problematic. The way in which the provision of complex health care is co-ordinated produces – or fails to produce – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational and relational). Care co-ordination is accomplished by a combination of activities by patients themselves; provider organisations; care networks co-ordinating the separate provider organisations; and overall health-system governance. This research examines how far organisational integration might promote care co-ordination at the clinical level. Objectives To examine (1) what differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical co-ordination of care; (2) what difference provider ownership (corporate, partnership, public) makes; (3) how much scope either structure allows for managerial discretion and ‘performance’; (4) differences between networked and hierarchical governance regarding the continuity and integration of primary care; and (5) the implications of the above for managerial practice in primary care. Methods Multiple-methods design combining (1) the assembly of an analytic framework by non-systematic review; (2) a framework analysis of patients’ experiences of the continuities of care; (3) a systematic comparison of organisational case studies made in the same study sites; (4) a cross-country comparison of care co-ordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics; and (5) the analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute inpatient care. Results Starting from data about patients’ experiences of the co-ordination or under-co-ordination of care, we identified five care co-ordination mechanisms present in both the integrated organisations and the care networks; four main obstacles to care co-ordination within the integrated organisations, of which two were also present in the care networks; seven main obstacles to care co-ordination that were specific to the care networks; and nine care co-ordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than did care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and a larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care co-ordination because of their impact on general practitioner workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care co-ordination and, therefore, continuities of care than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings. Future research is therefore required, above all to evaluate comparatively the different techniques for coordinating patient discharge across the triple interface between hospitals, general practices and community health services; and to discover what effects increasing the scale and scope of general practice activities will have on continuity of care