Clinical excellence: evidence on the assessment of senior doctors' applications to the UK Advisory Committee on Clinical Excellence Awards. Analysis of complete national data set.

Published onlineJournal ArticleOBJECTIVES: To inform the rational deployment of assessor resource in the evaluation of applications to the UK Advisory Committee on Clinical Excellence Awards (ACCEA). SETTING: ACCEA are responsible for a scheme to financially reward senior doctors in England and Wales who are assessed to be working over and above the standard expected of their role. PARTICIPANTS: Anonymised applications of consultants and senior academic GPs for awards were considered by members of 14 regional subcommittees and 2 national assessing committees during the 2014-2015 round of applications. DESIGN: It involved secondary analysis of complete anonymised national data set. PRIMARY AND SECONDARY OUTCOME MEASURES: We analysed scores for each of 1916 applications for a clinical excellence award across 4 levels of award. Scores were provided by members of 16 subcommittees. We assessed the reliability of assessments and described the variance in the assessment of scores. RESULTS: Members of regional subcommittees assessed 1529 new applications and 387 renewal applications. Average scores increased with the level of application being made. On average, applications were assessed by 9.5 assessors. The highest contributions to the variance in individual assessors' assessments of applications were attributable to assessors or to residual variance. The applicant accounted for around a quarter of the variance in scores for new bronze applications, with this proportion decreasing for higher award levels. Reliability in excess of 0.7 can be attained where 4 assessors score bronze applications, with twice as many assessors being required for higher levels of application. CONCLUSIONS: Assessment processes pertaining in the competitive allocation of public funds need to be credible and efficient. The present arrangements for assessing and scoring applications are defensible, depending on the level of reliability judged to be required in the assessment process. Some relatively minor reconfiguration in approaches to scoring might usefully be considered in future rounds of assessment.The study was supported by a research award from the UK National Institute for Health Research Policy Research Programme (Award: PR-ST-0915-10014). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health

Factors affecting patients' trust and confidence in GPs: evidence from the English national GP patient survey.

OBJECTIVES: Patients' trust in general practitioners (GPs) is fundamental to effective clinical encounters. Associations between patients' trust and their perceptions of communication within the consultation have been identified, but the influence of patients' demographic characteristics on these associations is unknown. We aimed to investigate the relative contribution of the patient's age, gender and ethnicity in any association between patients' ratings of interpersonal aspects of the consultation and their confidence and trust in the doctor. DESIGN: Secondary analysis of English national GP patient survey data (2009). SETTING: Primary Care, England, UK. PARTICIPANTS: Data from year 3 of the GP patient survey: 5 660 217 questionnaires sent to patients aged 18 and over, registered with a GP in England for at least 6 months; overall response rate was 42% after adjustment for sampling design. OUTCOME MEASURES: We used binary logistic regression analysis to investigate patients' reported confidence and trust in the GP, analysing ratings of 7 interpersonal aspects of the consultation, controlling for patients' sociodemographic characteristics. Further modelling examined moderating effects of age, gender and ethnicity on the relative importance of these 7 predictors. RESULTS: Among 1.5 million respondents (adjusted response rate 42%), the sense of 'being taken seriously' had the strongest association with confidence and trust. The relative importance of the 7 interpersonal aspects of care was similar for men and women. Non-white patients accorded higher priority to being given enough time than did white patients. Involvement in decisions regarding their care was more strongly associated with reports of confidence and trust for older patients than for younger patients. CONCLUSIONS: Associations between patients' ratings of interpersonal aspects of care and their confidence and trust in their GP are influenced by patients' demographic characteristics. Taking account of these findings could inform patient-centred service design and delivery and potentially enhance patients' confidence and trust in their doctor

Why do patients with multimorbidity in England report worse experiences in primary care? Evidence from the General Practice Patient Survey.

OBJECTIVES: To describe and explain the primary care experiences of people with multiple long-term conditions in England. DESIGN AND METHODS: Using questionnaire data from 906,578 responders to the English 2012 General Practice Patient Survey, we describe the primary care experiences of patients with long-term conditions, including 583,143 patients who reported one or more long-term conditions. We employed mixed effect logistic regressions to analyse data on six items covering three care domains (access, continuity and communication) and a single item on overall primary care experience. We controlled for sociodemographic characteristics, and for general practice using a random effect, and further, controlled for, and explored the importance of, health-related quality of life measured using the EuroQoL (EQ-5D) scale. RESULTS: Most patients with long-term conditions report a positive experience of care at their general practice (after adjusting for sociodemographic characteristics and general practice, range 74.0-93.1% reporting positive experience of care across seven questions) with only modest variation by type of condition. For all three domains of patient experience, an increasing number of comorbid conditions is associated with a reducing percentage of patients reporting a positive experience of care. For example, compared with respondents with no long-term condition, the OR for reporting a positive experience is 0.83 (95% CI 0.80 to 0.87) for respondents with four or more long-term conditions. However, this relationship is no longer observed after adjusting for health-related quality of life (OR (95% CI) single condition=1.23 (1.21 to 1.26); four or more conditions=1.31 (1.25 to 1.37)), with pain making the greatest difference among five quality of life variables included in the analysis. CONCLUSIONS: Patients with multiple long-term conditions more frequently report worse experiences in primary care. However, patient-centred measures of health-related quality of life, especially pain, are more important than the number of conditions in explaining why patients with multiple long-term conditions report worse experiences of care

Drivers of overall satisfaction with primary care: Evidence from the English General Practice Patient Survey

This is the final version. Available from Wiley via the DOI in this record.Background/objectives: To determine which aspects of primary care matter most to patients, we aim to identify those aspects of patient experience that show the strongest relationship with overall satisfaction and examine the extent to which these relationships vary by socio-demographic and health characteristics. Design/setting: Data from the 2009/10 English General Practice Patient Survey including 2 169 718 respondents registered with 8362 primary care practices. Measures/analyses: Linear mixed-effects regression models (fixed effects adjusting for age, gender, ethnicity, deprivation, self-reported health, self-reported mental health condition and random practice effect) predicting overall satisfaction from six items covering four domains of care: access, helpfulness of receptionists, doctor communication and nurse communication. Additional models using interactions tested whether associations between patient experience and satisfaction varied by socio-demographic group. Results: Doctor communication showed the strongest relationship with overall satisfaction (standardized coefficient 0.48, 95% CI = 0.48, 0.48), followed by the helpfulness of reception staff (standardized coefficient 0.22, 95% CI = 0.22, 0.22). Among six measures of patient experience, obtaining appointments in advance showed the weakest relationship with overall satisfaction (standardized coefficient 0.06, 95% CI = 0.05, 0.06). Interactions showed statistically significant but small variation in the importance of drivers across different patient groups. Conclusions: For all patient groups, communication with the doctor is the most important driver of overall satisfaction with primary care in England, along with the helpfulness of receptionists. In contrast, and despite being a policy priority for government, measures of access, including the ability to obtain appointments, were poorly related to overall satisfaction.UK Department of HealthNational Institute for Health Research (NIHR

The underlying structure of the English Cancer Patient Experience Survey: Factor analysis to support survey reporting and design

BACKGROUND: The English Cancer Patient Experience Survey (CPES) is a regularly conducted survey measuring the experience of cancer patients. We studied the survey's underlying structure using factor analysis to identify potential for improvements in reporting or questionnaire design. METHODS: Cancer Patient Experience Survey 2015 respondents (n = 71,186, response rate 66%) were split into two random subgroups. Using exploratory factor analysis (EFA) on the first subgroup, we identified the survey's latent structure. EFA was then applied to 12 sets of items. A first ("core") set was formed by questions that applied to all participants. The subsequent sets contained the "core set" plus questions corresponding to specific care pathways/patient groups. We used confirmatory factor analysis (CFA) on the second data subgroup for cross-validation. RESULTS: The EFA suggested that five latent factors underlie the survey's core questions. Analysis on the remaining 11 care pathway/patient group items also indicated the same five latent factors, although additional factors were present for questions applicable to patients with an overnight stay or those accessing specialist nursing. The five factors models had an excellent fit (comparative fit index = 0.95, root mean square error of approximation = 0.045 for core set of questions). Items loading on each factor generally corresponded to a specific section or subsection of the questionnaire. CFA findings were concordant with the EFA patterns. CONCLUSION: The findings suggest five coherent underlying sub-constructs relating to different aspects of cancer health care. The findings support the construction of evidence-based composite indicators for different domains of experience and provide options for survey re-design

Quitting patient care and career break intentions among general practitioners in South West England: findings of a census survey of general practitioners

Objective: Given recent concerns regarding general practitioner (GP) workforce capacity, we aimed to describe GPs’ career intentions, especially those which might impact on GP workforce availability over the next 5 years. Design: Census survey, conducted between April and June 2016 using postal and online responses , of all GPs on the National Health Service performers list and eligible to practise in primary care. Two reminders were used as necessary. Setting: South West England (population 3.5  million), a region with low overall socioeconomic deprivation. Participants: Eligible GPs were 2248 out of 3370 (67 % response rate). Main outcome measures: Reported likelihood of permanently leaving or reducing hours spent in direct patient care or of taking a career break within the next 5 years and present morale weighted for non-response. Results: Responders included 217 7 GPs engaged in patient care. Of these, 863 (37% weighted, 95%  CI 35 % to 39 %) reported a high likelihood of quitting direct patient care within the next 5 years. Overall, 1535 (70% weighted, 95%  CI 68 % to 72 %) respondents reported a career intention that would negatively impact GP workforce capacity over the next 5 years, through permanently leaving or reducing hours spent in direct patient care, or through taking a career break. GP age was an important predictor of career intentions; sharp increases in the proportion of GPs intending to quit patient care were evident from 52 years. Only 305 (14% weighted, 95%  CI 13 % to 16 %) reported high morale, while 1195 ( 54 % weighted, 95%  CI 52 % to 56 %) reported low morale. Low morale was particularly common among GP partners. Current morale strongly predicted GPs’ career intentions; those with very low morale were particularly likely to report intentions to quit patient care or to take a career break. Conclusions: A substantial majority of GPs in South West England report low morale. Many are considering career intentions which, if implemented, would adversely impact GP workforce capacity within a short time period. Study registration: NIHR HS&DR - 14/196/02, UKCRN ID 20700

A survey of physicians knowledge regarding awareness of maternal alcohol use and the diagnosis of FAS.

BACKGROUND: Alcohol is the most widely used drug in the world that is a human teratogen whose use among women of childbearing age has been steadily increasing. It is also probable that Fetal Alcohol Syndrome is under diagnosed by physicians. The objectives of this study were twofold: 1) to evaluate the experience, knowledge and confidence of family physicians with respect to the diagnosis of FAS and 2) to evaluate physicians awareness of maternal drinking patterns. METHODS AND PARTICIPANTS: A multiple choice anonymous questionnaire was sent to a randomly selected group of family physicians in the Metropolitan Toronto area. RESULTS: There was a 73% (75/103) total response rate; Overall, 6/75 (8%) of family physicians reported that they had actually diagnosed a child with FAS. 17.9% had suspicions but did not make a diagnosis and 12.7% reported making a referral to confirm the diagnosis. Physician rated confidence in the ability to diagnosis FAS was low, with 49% feeling they had very little confidence. 75% reported counselling pregnant women and 60.8% reported counselling childbearing women in general on the use of alcohol. When asked what screening test they used to detect the use of alcohol, 75% described frequency/quantity. Not a single respondent identified using the current accepted screening method for alcohol use (TWEAK) which is recommended by The Centre for Addiction and Mental Health. CONCLUSIONS: Family physicians do not feel confident about diagnosing FAS. None of the physicians were aware of the current screening methods to accurately gage alcohol use in pregnant and childbearing wome

General Gauge Mediation at the Weak Scale

We completely characterize General Gauge Mediation (GGM) at the weak scale by solving all IR constraints over the full parameter space. This is made possible through a combination of numerical and analytical methods, based on a set of algebraic relations among the IR soft masses derived from the GGM boundary conditions in the UV. We show how tensions between just a few constraints determine the boundaries of the parameter space: electroweak symmetry breaking (EWSB), the Higgs mass, slepton tachyons, and left-handed stop/sbottom tachyons. While these constraints allow the left-handed squarks to be arbitrarily light, they place strong lower bounds on all of the right-handed squarks. Meanwhile, light EW superpartners are generic throughout much of the parameter space. This is especially the case at lower messenger scales, where a positive threshold correction to $m_h$ coming from light Higgsinos and winos is essential in order to satisfy the Higgs mass constraint.Comment: 43 pages, 20 figures, mathematica package included in the sourc

Revealing the footprints of squark gluino production through Higgs search experiments at the Large Hadron Collider at 7 TeV and 14 TeV

The invariant mass distribution of the di-photons from the decay of the lighter scalar Higgs boson(h) to be carefully measured by dedicated h search experiments at the LHC may be distorted by the di-photons associated with the squark-gluino events with much larger cross sections in Gauge Mediated Supersymmetry Breaking (GMSB) models. This distortion if observed by the experiments at the Large Hadron Collider at 7 TeV or 14 TeV, would disfavour not only the standard model but various two Higgs doublet models with comparable h - masses and couplings but without a sector consisting of new heavy particles decaying into photons. The minimal GMSB (mGMSB) model constrained by the mass bound on h from LEP and that on the lightest neutralino from the Tevatron, produce negligible effects. But in the currently popular general GMSB(GGMSB) models the tail of the above distribution may show statistically significant excess of events even in the early stages of the LHC experiments with integrated luminosity insufficient for the discovery of h. We illustrate the above points by introducing several benchmark points in various GMSB models - minimal as well as non-minimal. The same conclusion follows from a detailed parameter scan in a simplified GGMSB model recently employed by the CMS collaboration to interpret their searches in the di-photon + \etslash channel. Other observables like the effective mass distribution of the di-photon + X events may also reveal the presence of new heavy particles beyond the Higgs sector. The contamination of the h mass peak and simple remedies are also discussed.Comment: 23 pages, 7 figures, title and organization of the paper is changed, detailed parameter scan in a simplified GGMSB model is added, conclusions and old numerical results remain unchange

The rural dispensing practice – better medication adherence and clinical outcomes compared to non-dispensing practices? A cross-sectional analysis of routine data

This is the author accepted manuscript. The final version is available on open access from the Royal College of General Practitioners via the DOI in this record.Background Most patients obtain medications from pharmacies by prescription, but rural general practices can dispense medications. Clinical implications of this difference in drug delivery are unknown. We hypothesised that dispensing status may be associated with better medication adherence. This could impact intermediate clinical outcomes dependent on medication adherence in, for example, hypertension or diabetes. Aim We investigated whether dispensing status is associated with differences in achievement of Quality and Outcome Framework (QOF) indicators that rely on medication adherence. Design and Setting Cross-sectional analysis of QOF data for 7,392 general practices in England. Method We analysed QOF data from 2016/17 linked to dispensing status for general practices with list sizes ≥1000 in England. QOF indicators were categorised according to whether their achievement depended on a record of prescribing only, medication adherence, or neither. We estimated differences between dispensing and non-dispensing practices using mixed-effects logistic regression adjusting for practice population age, sex, deprivation, list size, single-handed status and rurality. Results Data existed for 7,392 practices; 1,014 (13.7%) could dispense. Achievement was better in dispensing practices than in non-dispensing practices for seven of nine QOF indicators dependant on adherence, including blood pressure targets. Only one of ten indicators dependent on prescribing but not adherence displayed evidence of a difference; indicators unrelated to prescribing showed a trend towards higher achievement by dispensing practices. Conclusion Dispensing practices may achieve better clinical outcomes than prescribing practices. Further work is required to explore underlying mechanisms for these observations, and to directly study medication adherence rates.South West General Practice Trus