Foundation Trusts: A Retrospective Review

There is limited research evidence on foundation trusts (FTs) and much of the available material is in the form of commentary or the regular reports from Monitor. Comparative research is made difficult through lack of a counter-factual and robust methods are required to overcome bias. Summary points from the literature and from some initial analysis of Monitor reports that we have undertaken for this review are given below. Future policy and research issues are highlighted in the main report.

National survey of job satisfaction and retirement intentions among general practitioners in England

Objectives To measure general practitioners' intentions to quit direct patient care, to assess changes between 1998 and 2000, and to investigate associated factors, notably job satisfaction. Design Analysis of national postal surveys conducted in 1998 and 2001. Setting England. Participants 1949 general practitioner principals, of whom 790 were surveyed in 1998 and 1159 in 2001. Main outcome measures Overall job satisfaction and likelihood of leaving direct patient care in the next five years. Results The proportion of doctors intending to quit direct patient care in the next five years rose from 14% in 1998 to 22% in 2001. In both years, the main factors associated with an increased likelihood of quitting were older age and ethnic minority status. Higher job satisfaction and having children younger than 18 years were associated with a reduced likelihood of quitting. There were no significant differences in regression coefficients between 1998 and 2001, suggesting that the effect of factors influencing intentions to quit remained stable over time. The rise in intentions to quit was due mainly to a reduction in job satisfaction (1998 mean 4.64, 2001 mean 3.96) together with a slight increase in the proportion of doctors from ethnic minorities and in the mean age of doctors. Doctors' personal and practice characteristics explained little of the variation in job satisfaction within or between years. Conclusions Job satisfaction is an important factor underlying intention to quit, and attention to this aspect of doctors' working lives may help to increase the supply of general practitioners

Defining and characterising structural uncertainty in decision analytic models

An inappropriate structure for a decision analytic model can potentially invalidate estimates of cost-effectiveness and estimates of the value of further research. However, there are often a number of alternative and credible structural assumptions which can be made. Although it is common practice to acknowledge potential limitations in model structure, there is a lack of clarity about methods to characterize the uncertainty surrounding alternative structural assumptions and their contribution to decision uncertainty. A review of decision models commissioned by the NHS Health Technology Programme was undertaken to identify the types of model uncertainties described in the literature. A second review was undertaken to identify approaches to characterise these uncertainties. The assessment of structural uncertainty has received little attention in the health economics literature. A common method to characterise structural uncertainty is to compute results for each alternative model specification, and to present alternative results as scenario analyses. It is then left to decision maker to assess the credibility of the alternative structures in interpreting the range of results. The review of methods to explicitly characterise structural uncertainty identified two methods: 1) model averaging, where alternative models, with different specifications, are built, and their results averaged, using explicit prior distributions often based on expert opinion and 2) Model selection on the basis of prediction performance or goodness of fit. For a number of reasons these methods are neither appropriate nor desirable methods to characterize structural uncertainty in decision analytic models. When faced with a choice between multiple models, another method can be employed which allows structural uncertainty to be explicitly considered and does not ignore potentially relevant model structures. Uncertainty can be directly characterised (or parameterised) in the model itself. This method is analogous to model averaging on individual or sets of model inputs, but also allows the value of information associated with structural uncertainties to be resolved.

Priority setting for research in health care: An application of value of information analysis to glycoprotein IIb/IIIa antagonists in non-ST elevation acute coronary syndrome

The purpose of this study is to explain the rationale for the value of information approach to priority setting for research and to describe the methods intuitively for those familiar with basic decision analytical modeling. A policy-relevant case study is used to show the feasibility of the method and to illustrate the type of output that is generated and how these might be used to frame research recommendations. The case study relates to the use of glycoprotein IIb/IIIa antagonists for the treatment of patients with non-ST elevation acute coronary syndrome. This is an area that recently has been appraised by the National Institute for Health and Clinical Excellence

Bridging the gap between methods research and the needs of policy makers: A review of the research priorities of the National Institute for Health and Clinical Excellence

Objectives: The aim of this study was to establish a list of priority topics for methods research to support decision making at the National Institute for Health and Clinical Excellence (NICE). Methods: Potential priorities for methods research topics were identified through a focused literature review, interviews, an email survey, a workshop and a Web-based feedback exercise. Participants were members of the NICE secretariat and its advisory bodies, representatives from academia, industry, and other organizations working closely with NICE. The Web exercise was open to anyone to complete but publicized among the above groups. Results: A list of potential topics was collated. Priorities for further research differed according to the type of respondent and the extent to which they work directly with NICE. Priorities emerging from the group closest to NICE included: methodology for indirect and mixed treatment comparisons; synthesis of qualitative evidence; research relating to the use of quality-adjusted life-years (QALYs) in decision making; methods and empirical research for establishing the cost-effectiveness threshold; and determining how data on the uncertainty of effectiveness and cost-effectiveness data should be taken into account in the decision-making process. Priorities emerging from the broadest group of respondents (through the Web exercise) included: methods for extrapolating beyond evidence observed in trials, methods for capturing benefits not included in the QALY and methods to assess when technologies should be recommended in the context of further evidence gathering. Conclusions: Consideration needs to be given to the needs of those who use the outputs of research for decision making when determining priorities for future methods research.NIHR Medical Research Council

Regional variation in the productivity of the English National Health Service

At a time when there are severe pressures on reducing public spending there is increasing emphasis on determining which parts of the country secure best value for money in the NHS. By linking together large scale and routinely collected datasets we produce and compare productivity estimates across the ten Strategic Health Authorities in England in 2007/08.

Laparoscopic fundoplication compared with medical management for gastro-oesophageal reflux disease : cost effectiveness study

Peer reviewedPublisher PD