Learning from contract change in primary care dentistry: a qualitative study of stakeholders in the north of England

The aim of this research was to explore and synthesise learning from stakeholders (NHS dentists, commissioners and patients) approximately five years on from the introduction of a new NHS dental contract in England. The case study involved a purposive sample of stakeholders associated with a former NHS Primary Care Trust (PCT) in the north of England. Semi-structured interviews were conducted with 8 commissioners of NHS dental services and 5 NHS general dental practitioners. Three focus group meetings were held with 14 NHS dental patients. All focus groups and interviews were audio recorded and transcribed verbatim. The data were analysed using a framework approach. Four themes were identified: ‘commissioners’ views of managing local NHS dental services’; ‘the risks of commissioning for patient access’; ‘costs, contract currency and commissioning constraints’; and ‘local decision-making and future priorities’. Commissioners reported that much of their time was spent managing existing contracts rather than commissioning services. Patients were unclear about the NHS dental charge bands and dentists strongly criticised the contract's target-driven approach which was centred upon them generating ‘units of dental activity’. NHS commissioners remained relatively constrained in their abilities to reallocate dental resources amongst contracts. The national focus upon practitioners achieving their units of dental activity appeared to outweigh interest in the quality of dental care provided

Provider diversity in the English NHS: a study of recent developments in four local health economies

Objectives: The overall objective of the research was to assess the impact of provider diversity on quality and innovation in the English NHS. The aims were to map the extent of diverse provider activity, identify the differences in performance between Third Sector Organisations (TSOs), for-profit private enterprises, and incumbent organisations within the NHS, and the factors that affect the entry and growth of new private and TSOs. Methods: Case studies of four Local Health Economies (LHEs). Data included: semi-structured interviews with 48 managerial and clinical staff from NHS organizations and providers from the private and Third Sector; some documentary evidence; a focus group with service users; and routine data from the Care Quality Commission and Companies House. Data collection was mainly between November 2008 and November 2009. Results: Involvement of diverse providers in the NHS is limited. Commissioners’ local strategies influence degrees of diversity. Barriers to the entry for TSOs include lack of economies of scale in the bidding process. Private providers have greater concern to improve patient pathways and patient experience, whereas TSOs deliver quality improvements by using a more holistic approach and a greater degree of community involvement. Entry of new providers drives NHS Trusts to respond by making improvements. Information sharing diminishes as competition intensifies. Conclusions: There is scope to increase the participation of diverse providers in the NHS, but care must be taken not to damage public accountability, overall productivity, equity and NHS providers (especially acute hospitals, which are likely to remain in the NHS) in the process

Assessing the impact of a new health sector pay system upon NHS staff in England

<p>Abstract</p> <p>Background</p> <p>Pay and pay systems are a critical element in any health sector human resource strategy. Changing a pay system can be one strategy to achieve or sustain organizational change. This paper reports on the design and implementation of a completely new pay system in the National Health Service (NHS) in England. 'Agenda for Change' constituted the largest-ever attempt to introduce a new pay system in the UK public services, covering more than one million staff. Its objectives were to improve the delivery of patient care as well as enhance staff recruitment, retention and motivation, and to facilitate new ways of working.</p> <p>Methods</p> <p>This study was the first independent assessment of the impact of Agenda for Change at a local and national level. The methods used in the research were a literature review; review of 'grey' unpublished documentation provided by key stakeholders in the process; analysis of available data; interviews with key national informants (representing government, employers and trade unions), and case studies conducted with senior human resource managers in ten NHS hospitals in England</p> <p>Results</p> <p>Most of the NHS trust managers interviewed were in favour of Agenda for Change, believing it would assist in delivering improvements in patient care and staff experience. The main benefits highlighted were: 'fairness', moving different staff groups on to harmonized conditions; equal pay claim 'protection'; and scope to introduce new roles and working practices.</p> <p>Conclusion</p> <p>Agenda for Change took several years to design, and has only recently been implemented. Its very scale and central importance to NHS costs and delivery of care argues for a full assessment at an early stage so that lessons can be learned and any necessary changes made. This paper highlights weaknesses in evaluation and limitations in progress. The absence of systematically derived and applied impact indicators makes it difficult to assess impact and impact variations. Similarly, the lack of any full and systematic evaluation constrained the overall potential for Agenda for Change to deliver improvements to the NHS.</p

Primary care capitation payments in the UK. An observational study

<p>Abstract</p> <p>Background</p> <p>In 2004 an allocation formula for primary care services was introduced in England and Wales so practices would receive equitable pay. Modifications were made to this formula to enable local health authorities to pay practices.</p> <p>Similar pay formulae were introduced in Scotland and Northern Ireland, but these are unique to the country and therefore could not be included in this study.</p> <p>Objective</p> <p>To examine the extent to which the Global Sum, and modifications to the original formula, determine practice funding.</p> <p>Methods</p> <p>The allocation formula determines basic practice income, the Global Sum. We compared practice Global Sum entitlements using the original and the modified allocation formula calculations.</p> <p>Practices receive an income supplement if Global Sum payments were below historic income in 2004. We examined current overall funding levels to estimate what the effect will be when the income supplements are removed.</p> <p>Results</p> <p>Virtually every Welsh and English practice (97%) received income supplements in 2004. Without the modifications to the formula only 72% of Welsh practices would have needed supplements. No appreciable change would have occurred in England.</p> <p>The formula modifications increased the Global Sum for 99.5% of English practices, while it reduced entitlement for every Welsh practice.</p> <p>In 2008 Welsh practices received approximately £6.15 (9%) less funding per patient per year than an identical English practice. This deficit will increase to 11.2% when the Minimum Practice Income Guarantee is abolished.</p> <p>Conclusions</p> <p>Identical practices in different UK countries do not receive equitable pay. The pay method disadvantages Wales where the population is older and has higher health needs.</p

The Control of Methicillin-Resistant Staphylococcus aureus Blood Stream infections in England

Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infection (BSI) is a major healthcare burden in some but not all healthcare settings, and it is associated with 10%–20% mortality. The introduction of mandatory reporting in England of MRSA BSI in 2001 was followed in 2004 by the setting of target reductions for all National Health Service hospitals. The original national target of a 50% reduction in MRSA BSI was considered by many experts to be unattainable, and yet this goal has been far exceeded (∼80% reduction with rates still declining). The transformation from endemic to sporadic MRSA BSI involved the implementation of serial national infection prevention directives, and the deployment of expert improvement teams in organizations failed to meet their improvement trajectory targets. We describe and appraise the components of the major public health infection prevention campaign that yielded major reductions in MRSA infection. There are important lessons and opportunities for other healthcare systems where MRSA infection remains endemic

Applying the Lessons of Tobacco and Alcohol Control to Cannabis

It is clear there is agreement on numerous issues. First, cannabis is associated with psychosis, although there is some divergence on the degree of certainty about direct causality, especially in chronic psychosis. Second, reliance on a single legal remedy has been ineffective. Third, education should play a greater role in strategies to tackle cannabis use