International Implementation Research Network in Primary Health Care

This paper outlines the importance of Implementation Research in primary health care and the context in which it operates. The first section gives background to the vital role of implementation research in developing and supporting health care delivery, systems and services, and the importance of closely linking implementation research to primary health care to achieve this. The second section outlines the background, purpose and role of the IIRNPC and to discuss network activities in 2014

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

Heroin Treatment - New Alternative : proceedings of a seminar held on 1 November 1991, Ian Wark Theatre, Backer House, Canberra

The meeting today grows out of a study conducted jointly by the National Centre for Epidemiology and Population Health and the Australian Institute of Criminology in the early part of this year. That study was prompted by an invitation from the Chairman of the ACT Legislative Assembly’s Select Committee on HIV, Illegal Drugs and Prostitution - Mr Michael Moore - who invited us to examine the feasibility of a trial of the controlled availability of opioids in the ACT. Dr Gabriele Bammer, who directed that investigation, will be setting the scene for us by describing its conclusions at the outset of the day’s discussions. We hope that from that baseline we can move forward in the course of the day to explore the implications of those conclusions and to discuss whether or not it is appropriate to extend the feasibility study to the next stage. So our objective today is to explore the medical, health, social and law enforcement implications of evaluating, in the ACT, new approaches to the treatment of heroin dependent individuals. Drug policy is a highly political issue, any action to change the way we manage drug dependent people in the ACT has political implications for the ACT and for other parts of Australia as well. So I am delighted that we have representatives from drug and law enforcement agencies from most states of Australia here today and that many of the people who will frame attitudes to the proposed ACT trial will have an opportunity to discuss these issues in an open and uninhibited way.The meeting has been assisted by a grant from the ACT Government

APHCRI Dialogue

Through this bulletin, published between 2005 and 2010, APHCRI debated issues applicable to national policy formulation. Issues emerged through national and international media watches, systematic reviews of research, government documents and discussion at workshops and conferences attended by APHCRI staff. They were within one of eight identified areas of interest for APHCRI addressed in the primary health care setting - namely: 1. Chronic disease management; 2. Integration, co-ordination and multidisciplinary care; 3. Prevention and early intervention; 4. Innovative models for comprehensive primary health care delivery; 5. Innovative models for the management of mental health in primary health care settings; 6. Older Australians and health promotion, prevention and post-acute care; 7. Children and young Australians, health promotion and prevention; and 8. Workforce. A topic area was selected for each issue of the publication and was discussed in the bulletin, with room for responses from readers in future issues. It was recognised that issues addressed in the APHCRI Dialogue would at times be controversial. In putting forward the evidence and raising the questions the aim was to facilitate informed debate – not to take a particular ‘partisan’ line. APHCRI Dialogue had regular features examining how issues discussed in the bulletin have been explored in the media, as well as an update on the activities of the APHCRI team during the quarter, including their policy development work, new research grants, the latest research results and policy and information seminars.The Australian Primary Health Care Research Institute is supported by a grant from the Australian Government Department of Health and Ageing under the Primary Health Care Research Evaluation and Development Strategy

Is brief advice in primary care a cost-effective way to promote physical activity?

This article is made available through the Brunel Open Access Publishing Fund. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial.Aim: This study models the cost-effectiveness of brief advice (BA) in primary care for physical activity (PA) addressing the limitations in the current limited economic literature through the use of a time-based modelling approach. Methods: A Markov model was used to compare the lifetime costs and outcomes of a cohort of 100 000 people exposed to BA versus usual care. Health outcomes were expressed in terms of quality-adjusted life years (QALYs). Costs were assessed from a health provider perspective (£2010/11 prices). Data to populate the model were derived from systematic literature reviews and the literature searches of economic evaluations that were conducted for national guidelines. Deterministic and probability sensitivity analyses explored the uncertainty in parameter estimates including short-term mental health gains associated with PA. Results: Compared with usual care, BA is more expensive, incurring additional costs of £806 809 but it is more effective leading to 466 QALYs gained in the total cohort, a QALY gain of 0.0047/person. The incremental cost per QALY of BA is £1730 (including mental health gains) and thus can be considered cost-effective at a threshold of £20 000/QALY. Most changes in assumptions resulted in the incremental cost-effectiveness ratio (ICER) falling at or below £12 000/QALY gained. However, when short-term mental health gains were excluded the ICER was £27 000/QALY gained. The probabilistic sensitivity analysis showed that, at a threshold of £20 000/QALY, there was a 99.9% chance that BA would be cost-effective. Conclusions: BA is a cost-effective way to improve PA among adults, provided short-term mental health gains are considered. Further research is required to provide more accurate evidence on factors contributing to the cost-effectiveness of BA.NICE Centre for Public Health Excellenc

Children of Migrants: The Cumulative Impact of Parental Migration on their Children\u27s Education and Health Outcomes

In the past 15 years, around 160 million Chinese rural workers migrated to cities for work. Because of restrictions on migrant access to local health and education system, many migrant children are left-behind in rural villages and growing up without parental care. This paper examines how parental migration affects children\u27s health and education outcomes in the long run. Using the Rural-Urban Migration Survey in China (RUMiC) data, we measure the share of children\u27s lifetime during which parents were away from home. We instrument this measure of parental absence with weather changes in their home villages when parents were aged 16-25, or when they were most likely to initiate migration. Results show a sizable adverse impact of exposure to parental migration on the health and education outcomes of children, in particular boys. We also find that what the literature has always done (using contemporaneous measure for parental migration) is likely to underestimate the effect of exposure to parental migration on children\u27s outcomes.JEL Classification Codes: J38, I28http://www.grips.ac.jp/list/jp/facultyinfo/yamauchi_chikako