General practice views of managing childhood obesity in primary care: a qualitative analysis:managing childhood obesity in primary care

Objective: To explore general practice staff views of managing childhood obesity in primary care. Design: A qualitative study to elicit the views of clinical and non-clinical general practice staff on managing childhood obesity. Setting: Interviews were conducted at 30 general practices across England. These practices were interviewed as part of the Quality and Outcomes Framework (QOF) Pilot Study. Participants: A total of 52 staff from 30 practices took part in a semi structured interview. Main outcome measures: Key themes were identified through thematic analysis of transcripts using an inductive approach. Results: Three themes were identified: lack of contact with well children, sensitivity of the issue, and the potential impact of general practice. Identifying overweight children was challenging because well children rarely attended the practice. Interviewees felt ill equipped to solve the issue because they lacked influence over the environmental, economic and lifestyle factors underpinning obesity. They described little evidence to support general 4 practice intervention and seemed unaware of other services. Raising the issue was described as sensitive. Conclusion: General practice staff were unconvinced they could have a significant role in managing childhood obesity on a large scale. Participants believed schools have more contact with children and should coordinate the identification and management of overweight children. Future policy could recommend a minor role for general practice involving opportunistically identifying overweight children and signposting to obesity services

A protocol for the development and piloting of quality measures to support the Healthier You : The NHS Diabetes Prevention Programme

Background The increasing prevalence of type 2 diabetes in the UK creates an additional, potentially preventable burden on health care and service providers. The Healthier You: NHS Diabetes Prevention Programme aims to reduce the incidence of type 2 diabetes through identification of people at risk and the provision of intensive lifestyle change support. The provision of this care can be monitored through quality measurement at both the general practice and specialist service level. Aim To develop quality measures through piloting to assess the validity, credibility, acceptability, reliability and feasibility of any proposed measures. Design and setting The non-experimental mixed design piloting study consists of consensus testing and exploratory research with general practitioners (GPs), commissioners and patients from Herefordshire, England. Methods A mixed-method approach will be used to develop and validate measures for diabetes prevention care and evaluate their performance over a six month pilot period consisting of i) consensus testing using a modified RAND approach with GPs and commissioners, ii) four focus groups with 10-12 participants discussing experiences of non-diabetic hyperglycaemia, perceived ability to access care and prevent diabetes, and views on potential quality measures, iii) piloting final measures with at least 5 general practices for baseline and 6 month data. Results The findings will inform the implementation of the diabetes prevention quality measures on a national scale whilst addressing any issue with validity, credibility, feasibility, and cost-effectiveness. Conclusion Health care professionals and patients have the opportunity to evaluate the reliability, acceptability and validity of measure

From dental contract to system reform: why an incremental approach is needed.

Dental contracts are required to simultaneously satisfy three seemingly unreconcilable requirements: access based on need and not ability to pay (equity); minimisation of costs per unit output (efficiency); and paying for it all without breaking the bank (cost). In dentistry, further tensions exist, such as how to incentivise prevention while maintaining optimal efficiency and minimising opportunism, even though the dividing line between what is too much or too little treatment is often blurred. This is a classic type of policy problem which can be understood in terms of the properties of wicked (or stubborn) problems where stakeholders see the problem differently. There is no obvious solution and every attempt at a solution leaves a mark. This means that it is inappropriate to be talking about a new dental contract as the one perfect resolution to a problem which has eluded us since the 1990s, but rather we need to seek a 'better' arrangement achieving an acceptable equilibrium balancing various tensions. These types of policy problems also tend to be a 'cluster of interlocked problems with interdependent solutions'. We need to recognise that while dental contracts can shape system outputs, outputs are also determined by a range of wider system factors, such as culture and team-working, which determine how the system works, what is produced and for whom. Thus, we should be talking about the dental system, rather than dental contract reform. Further lessons from health policy are that the process of reform can be as complex as the content of reforms. Success in reform is dictated more by how the process is applied rather than purely on what contents are formulated, so implementation is key and a staged or incremental approach to reform is advised. This paper outlines the approach to dental system reform taken by NHS England since March 2021

Pay for performance and the management of hypertension

With the global epidemiological transition from communicable to non-communicable diseases, hypertension has become a major risk factor for burden of disease in many high, middle, and low income countries.[1] While no absolute cut point exists for high blood pressure, persistent systolic blood pressure readings of > 140 and/or diastolic blood pressure readings of > 90 are commonly defined as hypertension.[2] Hypertension is a risk factor for cardiovascular disease and its management is advocated to reduce burden to both individuals and health systems

Developing and testing quality indicators for the Thai Quality and Outcomes Framework

Background: Primary care serves as an entry point in the Thai health care system. While effective interventions are provided in the primary care setting, the quality of the services have not been measured or tracked. A number of initiatives were undertaken to improve primary healthcare quality including the use of financial incentives to reward adherence to performance indicators. However, there were concerns that the current quality indicators had not been developed in a systematic, participatory, and evidence-based manner. Therefore, this study aims to develop new quality indicators for use in subsequent iterations of the program. Methods: The development of indicators follows a well-designed approach. Reviews of existing documents as well as secondary data analyses were performed and presented to key stakeholders. Disease areas were then prioritised. Recommendations from the Thai clinical practice guidelines on the prioritised areas were then used to formulate statements and templates for each indicator. Finally, the indicators developed were piloted for 3 months in 28 primary care units across the country. Results: Indicators related to care for diabetes and hypertension, maternal and child health, and rational use of antibiotics received high acceptability, and information was available and collectable in the current administrative database. However, there were problems in implementing indicators for managing cardiovascular risk, care for bedridden patients, and asthma and COPD. Conclusions: The development of quality indicators using a guideline-based approach is a useful way of generating evidence to support the effective implementation of a program. Indicator piloting is recommended prior to introducing indicators in the health system

Implementation of pay for performance in primary care:a qualitative study 8 years after introduction

BACKGROUND: Pay for performance is now a widely adopted quality improvement initiative in health care. One of the largest schemes in primary care internationally is the English Quality and Outcomes Framework (QOF). AIM: To obtain a longer term perspective on the implementation of the QOF. DESIGN AND SETTING: Qualitative study with 47 health professionals in 23 practices across England. METHOD: Semi-structured interviews. RESULTS: Pay for performance is accepted as a routine part of primary care in England, with previous more individualistic and less structured ways of working seen as poor practice. The size of the QOF and the evidence-based nature of the indicators are regarded as key to its success. However, pay for performance may have had a negative impact on some aspects of medical professionalism, such as clinical autonomy, and led a significant minority of GPs to prioritise their own pay rather than patients’ best interests. A small minority of GPs tried to increase their clinical autonomy with further unintended consequences. CONCLUSION: Pay for performance indicators are now welcomed by primary healthcare teams and GPs across generations. Almost all interviewees wanted to see a greater emphasis on involving front line practice teams in developing indicators. However, almost all GPs and practice managers described a sense of decreased clinical autonomy and loss of professionalism. Calibrating the appropriate level of clinical autonomy is critical if pay for performance schemes are to have maximal impact on patient care