822 research outputs found

    Can Primary Care Networks contribute to the national goal of reducing health inequalities? A mixed method study.

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    BACKGROUND: Significant health inequalities exist in England. Primary care networks (PCNs), comprised of GP practices, were introduced in England in 2019 with funding linked to membership. PCNs are tasked with tackling health inequalities.AIM: We consider how the design and introduction of PCNs might influence their ability to tackle health inequalities.DESIGN AND SETTING: A sequential mixed methods study of Primary Care Networks in England.METHODS: Linear regression of annual PCN allocated funding per workload-weighted patient on income deprivation score from 2019-2023. Qualitative interviews and observations of PCNs and PCN staff were undertaken across seven PCN sites in England (July 2020-March 2022).RESULTS: Across 1,243 networks in 2019-20, a 10% higher level of income deprivation resulted in £0.31 (£0.25, £0.37), 4.50%, less funding per weighted patient. In 2022-23, the same difference in deprivation resulted in £0.16 (£0.11, £0.21), 0.60%, more funding. Qualitative interviews highlighted that although there were requirements for PCNs to tackle health inequalities, the policy design and PCN internal relationships and maturity shaped and sometimes restricted how PCNs approached this locally.CONCLUSION: Allocated PCN funding has become more pro-poor over time, suggesting that the need to account for deprivation within funding models is understood by policy makers. We highlight additional approaches which could support PCNs to tackle inequalities: better management support; encouragement and support to redistribute funding internally to support practices serving more deprived populations; and greater specificity in service requirements.</p

    Processes supporting effective skill-mix implementation in general practice: a qualitative study.

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    Objectives Health policy and funding initiatives have addressed increasing workloads in general practice through the deployment of clinicians from different disciplinary backgrounds. This study examines how general practices in England operate with increasingly diverse groups of practitioners. Methods Five general practices were selected for maximum variation of the duration and diversity of skill-mix in their workforce. Individual interviews were recorded with management and administrative staff and different types of practitioner. Patient surveys and focus groups gathered patients’ perspectives of consulting with different practitioners. Researchers collaborated during coding and thematic analysis of transcripts of audio recordings. Results The introduction of a wide range of practitioners required significant changes in how practices dealt with patients requesting treatment, and these changes were not necessarily straightforward. The matching of patients with practitioners required effective categorization of health care patients’ reported problem(s) and an understanding of practitioners’ capabilities. We identified individual and organizational responses that could minimize the impact on patients, practitioners and practices of imperfections in the matching process. Conclusions The processes underpinning the redistribution of tasks from GPs to non-GP practitioners are complex. As practitioner employment under the Primary Care Network contracts continues to increase, it is not clear how the necessarily fine-grained adjustments will be made for practitioners working across multiple practices

    General practice managers’ motivations for skill mix change in primary care: results from a cross-sectional survey in England

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    Objectives: To determine the factors that motivated GP practice managers in England to employ non-medical roles, and to identify an ideal hypothetical GP practice workforce. Methods: Cross sectional survey of GP practice managers in England (n=1,205). The survey focused on six non-medical roles: advanced nurse practitioner, specialist nurse, health care assistant, physician associate, paramedic and pharmacist. Results: The three most commonly selected motivating factors were: (i) to achieve a better match between what patients need and what the practitioner team can deliver; (ii) to increase overall appointment availability; and (iii) to release GP time. Employment of pharmacists and physician associates was most commonly supported by additional funding. Practice managers’ preferred accessing new non-medical roles through a primary care network or similar, while there was a clear preference for direct employment of additional GPs, advanced nurse practitioners or practice nurses. The ideal practice workforce would comprise over 70% of GPs and nurses, containing, on average, fewer GPs than the current GP practice workforce. Conclusion: This study confirms that more diverse teams of practitioners are playing an increasing role in providing primary care in England. Managers prefer not to employ all new roles directly within the practice. A more detailed investigation of future workforce requirements is necessary to ensure that health policy supports the funding (whether practice or population based), recruitment, training, deployment and workloads associated with the mix of roles needed in an effective primary care workforce

    Scale, scope and impact of skill mix change in primary care in England: a mixed-methods study

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    Background General practices have had difficulty recruiting and retaining enough general practitioners to keep up with increasing demand for primary health care in recent years. Proposals to increase workforce capacity include a policy-driven strategy to employ additional numbers and a wider range of health professionals. Objectives Our objective was to conduct a comprehensive study of the scale, scope and impact of changing patterns of practitioner employment in general practice in England. This included an analysis of employment trends, motivations behind employment decisions, staff and patient experiences, and how skill mix changes are associated with outcome measures and costs. Design NHS Digital workforce data (2015‚Äď19) were used to analyse employment changes and to look at their association with outcomes data, such as the General Practitioner Patient Survey, General Practitioner Worklife Survey, prescribing data, Hospital Episode Statistics, Quality and Outcomes Framework and NHS payments to practices. A practice manager survey (August‚ÄďDecember 2019) explored factors motivating general practices‚Äô employment decisions. An in-depth case study of five general practices in England (August‚ÄďDecember 2019) examined how a broader range of practitioners is experienced by practice staff and patients. Results We found a 2.84% increase in reported full-time equivalent per 1000 patients across all practitioners during the study period. The full-time equivalent of general practitioner partners decreased, while the full-time equivalent of salaried general practitioners, advanced nurse practitioners, clinical pharmacists, physiotherapists, physician associates and paramedics increased. General practitioners and practice managers reported different motivating factors regarding skill mix employment. General practitioners saw skill mix employment as a strategy to cope with a general practitioner shortage, whereas managers prioritised potential cost-efficiencies. Case studies demonstrated the importance of matching patients‚Äô problems with practitioners‚Äô competencies and ensuring flexibility for practitioners to obtain advice when perfect matching was not achieved. Senior clinicians provided additional support and had supervisory and other responsibilities, and analysis of the General Practitioner Worklife Survey data suggested that general practitioners‚Äô job satisfaction may not increase with skill mix changes. Patients lacked information about newer practitioners, but felt reassured by the accessibility of expert advice. However, General Practitioner Patient Survey data indicated that higher patient satisfaction was associated with a higher general practitioner full-time equivalent. Quality and Outcomes Framework achievement was higher when more practitioners were employed (i.e. full-time equivalent per 1000 patients). Higher clinical pharmacist full-time equivalents per 1000 patients were associated with higher quality and lower cost prescribing. Associations between skill mix and hospital activity were mixed. Our analysis of payments to practices and prescribing costs suggested that NHS expenditure may not decrease with increasing skill mix employment. Limitations These findings may reflect turbulence during a period of rapid skill mix change in general practice. The current policy of employing staff through primary care networks is likely to accelerate workforce change and generate additional challenges. Conclusions Skill mix implementation is challenging because of the inherent complexity of general practice caseloads; it is associated with a mix of positive and negative outcome measures. Future work Findings from this study will inform future funding applications for projects that seek to examine the nature and impact of evolving multiprofessional teams in primary care. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 9. See the NIHR Journals Library website for further project information

    Dimensions of corruption in Pakistan: A systems thinking approach and qualitative analysis

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    Over the past few decades, many studies of corruption have been carried out. These studies have mainly focused on specific aspects of corruption such as economic issues, legal issues, social propositions, national development and economic policy. This study builds a systems thinking model of corruption, which helps in the understanding of corruption and acts as an input into future policymaking on corruption. Data for the qualitative analysis come from 198 interviews (including 43 in‚Äźdepth interviews) conducted in Pakistan. The main contribution of the study is the increased understanding and insights about issues of values, social aspects, inflation, government size and political norms when considering perceptions of corruption in Pakistan. Some of our key findings, such as the effect of inflation, government size, transparency in international negotiations and the juxtaposition of religious values with corruption, have not been widely discussed in the literature

    Comparison of the impact of two national health and social care integration programmes on emergency hospital admissions

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    Background: Policy-makers expect that integration of health and social care will improve user and carer experience and reduce avoidable hospital use. [We] evaluate the impact on emergency hospital admissions of two large nationally-initiated service integration programmes in England: the Pioneer (November 2013 to March 2018) and Vanguard (January 2015 to March 2018) programmes. The latter had far greater financial and expert support from central agencies. Methods: Of the 206 Clinical Commissioning Groups (CCGs) in England, 51(25%) were involved in the Pioneer programme only, 22(11%) were involved in the Vanguard programme only and 13(6%) were involved in both programmes. We used quasi-experimental methods to compare monthly counts of emergency admissions between four groups of CCGs, before and after the introduction of the two programmes. Results: CCGs involved in the programmes had higher monthly hospital emergency admission rates than non-participants prior to their introduction [7.9 (95% CI:7.8‚Äď8.1) versus 7.5 (CI: 7.4‚Äď7.6) per 1000 population]. From 2013 to 2018, there was a 12% (95% CI:9.5‚Äď13.6%) increase in emergency admissions in CCGs not involved in either programme while emergency admissions in CCGs in the Pioneer and Vanguard programmes increased by 6.4% (95% CI: 3.8‚Äď9.0%) and 8.8% (95% CI:4.5‚Äď13.1%), respectively. CCGs involved in both initiatives experienced a smaller increase of 3.5% (95% CI:-0.3‚Äď7.2%). The slowdown largely occurred in the final year of both programmes. Conclusions: Health and social care integration programmes can mitigate but not prevent rises in emergency admissions over the longer-term. Greater financial and expert support from national agencies and involvement in multiple integration initiatives can have cumulative effects

    Charity Fundraising Project:A Team-Based Project for Developing Problem-Structuring Skills

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    Increasingly, graduates of business schools will face business and organizational situations with a high degree of complexity and ambiguity. In this context, teaching and learning strategies need to develop students’ abilities in problem structuring and complex problem solving. This article describes a team-based project set to teams of four or five students, who are required to design and deliver a fundraising event for their chosen charity. The goal of the fundraising activity is to raise as much money as they can in a 24-hour period. Using ideas from problem-based learning (PBL), students learn frameworks and tools to increase their confidence in these situations. This article describes this activity and will be of interest to teachers of final-year undergraduate and master’s programs looking for a fun and inspiring activity to do with students.Increasingly, graduates of business schools will face business and organizational situations with a high degree of complexity and ambiguity. In this context, teaching and learning strategies need to develop students’ abilities in problem structuring and complex problem solving. This article describes a team-based project set to teams of four or five students, who are required to design and deliver a fundraising event for their chosen charity. The goal of the fundraising activity is to raise as much money as they can in a 24-hour period. Using ideas from problem-based learning (PBL), students learn frameworks and tools to increase their confidence in these situations. This article describes this activity and will be of interest to teachers of final-year undergraduate and master’s programs looking for a fun and inspiring activity to do with students

    Using the AMAN-DA method to generate security requirements: a case study in the maritime domain

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    Security requirements are known to be ‚Äúthe most difficult of requirements types‚ÄĚ and potentially the ones causing the greatest risk if they are not correct. One approach to requirements elicitation is based on the reuse of explicit knowledge. AMAN-DA is a requirement elicitation method that reuses encapsulated knowledge in security and domain ontologies to produce security requirements specifications. The main research question addressed in this paper is to what extent is AMAN-DA able to generate domain-specific security requirements? Following a well-documented process, a case study related to the maritime domain was undertaken with the goal to demonstrate the utility and effectiveness of AMAN-DA for the elicitation and analysis of domain-specific security requirements. The usefulness of the method was also evaluated with a group of 12 experts. The paper demonstrates the elicitation of domain-specific security requirements by presenting the AMAN-DA method and its application. It describes the evaluation and reports some significant results and their implications for practice and future research, especially for the field of knowledge reuse in requirements engineering. ¬© 2017, Springer-Verlag London Ltd

    Beyond partnerships: embracing complexity to understand and improve research collaboration for global development

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    While there is a burgeoning literature on the benefits of research collaboration for development, it tends to promote the idea of the ‚Äėpartnership‚Äô as a bounded site in which interventions to improve collaborative practice can be made. This article draws on complexity theory and systems thinking to argue that such an assumption is problematic, divorcing collaboration from wider systems of research and practice. Instead, a systemic framework for understanding and evaluating collaboration is proposed. This framework is used to reflect on a set of principles for fair and equitable research collaboration that emerged from a programme of strategic research and capacity strengthening conducted by the Rethinking Research Collaborative (RRC) for the United Kingdom (UK)‚Äôs primary research funder: UK Research and Innovation (UKRI). The article concludes that a systemic conceptualisation of collaboration is more responsive than a ‚Äėpartnership‚Äô approach, both to the principles of fairness and equity and also to uncertain futures

    Out of the Panopticon and into Exile:Visibility and Control in Distributed New Culture Organizations

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    This paper builds a theoretical argument for exile as an alternative metaphor to the panopticon, for conceptualizing visibility and control in the context of distributed ‚Äúnew culture‚ÄĚ organizations. Such organizations emphasize team relationships between employees who use digital technologies to stay connected with each other and the organization. I propose that in this context, a fear of exile ‚Äď that is a fear of being left out, overlooked, ignored or banished ‚Äď can act as a regulating force that inverts the radial spatial dynamic of the panopticon and shifts the responsibility for visibility, understood both in terms of competitive exposure and existential recognition, onto workers. As a consequence these workers enlist digital technologies to become visible at the real or imagined organizational centre. A conceptual appreciation of exile, as discussed in existential philosophy and postcolonial theory, is shown to offer productive grounds for future research on how a need for visibility in distributed, digitised, and increasingly precarious work environments regulates employee subjectivity, in a manner that is not captured under traditional theories of ICT-enabled surveillance in organizations
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