BackgroundHealth services across the world increasingly face pressures on the use of expensive hospital services. Better organisation and delivery of primary care has the potential to manage demand and reduce costs for hospital services, but routine primary care services are not open during evenings and weekends.Extended access (evening and weekend opening) is hypothesized to reduce pressure on hospital services from emergency department visits. However, the existing evidence-base is weak, largely focused on emergency out-of-hours services, and analysed using a before-and after-methodology without effective comparators.Methods and FindingsThroughout 2014, 56 primary care practices (346,024 patients) in Greater Manchester, England, offered 7-day extended access, compared with 469 primary care practices (2,596,330 patients) providing routine access. Extended access included evening and weekend opening and served both urgent and routine appointments. To assess the effects of extended primary care access on hospital services, we apply a difference-in-differences analysis using hospital administrative data from 2011 to 2014. Propensity score matching techniques were used to match practices without extended access to practices with extended access. Differences in the change in “minor” patient-initiated emergency department visits per 1,000 population were compared between practices with and without extended access.Populations registered to primary care practices with extended access demonstrated a 26.4% relative reduction (compared to practices without extended access) in patient-initiated emergency department visits for “minor” problems (95% CI -38.6% to -14.2%, absolute difference: -10,933 per year, 95% CI -15,995 to -5,866), and a 26.6% (95% CI -39.2% to -14.1%) relative reduction in costs of patient-initiated visits to emergency departments for minor problems (absolute difference: -£767,976, -£1,130,767 to -£405,184). There was an insignificant relative reduction of 3.1% in total emergency department visits (95% CI -6.4% to 0.2%). Our results were robust to several sensitivity checks. A lack of detailed cost reporting of the running costs of extended access and an inability to capture health outcomes and other health service impacts constrain the study from assessing the full cost-effectiveness of extended access to primary care.ConclusionsThe study found that extending access was associated with a reduction in emergency department visits in the first 12 months. The results of the research have already informed the decision by National Health Service England to extend primary care access across Greater Manchester from 2016. However, further evidence is needed to understand whether extending primary care access is cost-effective and sustainable.

BackgroundThe Salford Integrated Care Programme (SICP) was a large-scale transformation project to improve care for older people with long-term conditions and social care needs. We report an evaluation of the ability of the SICP to deliver an enhanced experience of care, improved quality of life, reduced costs of care and improved cost-effectiveness.ObjectivesTo explore the process of implementation of the SICP and the impact on patient outcomes and costs.DesignQualitative methods (interviews and observations) to explore implementation, a cohort multiple randomised controlled trial to assess patient outcomes through quasi-experiments and a formal trial, and an analysis of routine data sets and appropriate comparators using non-randomised methodologies.SettingSalford in the north-west of England.ParticipantsOlder people aged ≥ 65 years, carers, and health and social care professionals.InterventionsA large-scale integrated care project with three core mechanisms of integration (community assets, multidisciplinary groups and an ‘integrated contact centre’).Main outcome measuresPatient self-management, care experience and quality of life, and health-care utilisation and costs.Data sourcesProfessional and patient interviews, patient self-report measures, and routine quantitative data on service utilisation.ResultsThe SICP and subsequent developments have been sustained by strong partnerships between organisations. The SICP achieved ‘functional integration’ through the pooling of health and social care budgets, the development of the Alliance Agreement between four organisations and the development of the shared care record. ‘Service-level’ integration was slow and engagement with general practice was a challenge. We saw only minor changes in patient experience measures over the period of the evaluation (both improvements and reductions), with some increase in the use of community assets and care plans. Compared with other sites, the difference in the rates of admissions showed an increase in emergency admissions. Patient experience of health coaching was largely positive, although the effects of health coaching on activation and depression were not statistically significant. Economic analyses suggested that coaching was likely to be cost-effective, generating improvements in quality of life [mean incremental quality-adjusted life-year gain of 0.019, 95% confidence interval (CI) –0.006 to 0.043] at increased cost (mean incremental total cost increase of £150.58, 95% CI –£470.611 to £711.776).LimitationsThe Comprehensive Longitudinal Assessment of Salford Integrated Care study represents a single site evaluation, with consequent limits on external validity. Patient response rates to the cohort survey were < 40%.ConclusionsThe SICP has been implemented in a way that is consistent with the original vision. However, there has been more rapid success in establishing new integrated structures (such as a formal integrated care organisation), rather than in delivering mechanisms of integration at sufficient scale to have a large impact on patient outcomes.Future workFurther research could focus on each of the mechanisms of integration. The multidisciplinary groups may require improved targeting of patients or disease subgroups to demonstrate effectiveness. Development of a proven model of health coaching that can be implemented at scale is required, especially one that would provide cost savings for commissioners or providers. Similarly, further exploration is required to assess the longer-term benefits of community assets and whether or not health impacts translate to reductions in care use.Trial registrationCurrent Controlled Trials ISRCTN12286422.FundingThis project was funded by the NIHR Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 31. See the NIHR Journals Library website for further project information.

BackgroundGeneral practices in England have been encouraged by national policy to work together on a larger scale by creating primary care networks (PCNs). Policy guidance recommended that they should serve populations of 30 000–50 000 people to perform effectively.AimTo describe variation in the size and characteristics of PCNs and their populations.Design and settingCross-sectional analysis in England.MethodUsing published information from January 2020, PCNs were identified that contained <30 000, between 30 000–50 000, and >50 000 people. Percentiles were calculated to describe variation in size and population characteristics. PCN composition within each commissioning region was also examined.ResultsIn total, 6758 practices had formed 1250 PCNs. Seven hundred and twenty-six (58%) PCNs had the recommended population of 30 000–50 000 people. Eighty-four (7%) PCNs contained <30 000 people. Four hundred and forty (35%) PCNs contained >50 000 people. Thirty-four (3%) PCNs comprised just one practice and 77 (6%) PCNs contained >10 practices. Some PCNs contained more than double the proportions of older people and people with chronic conditions compared to other PCNs. More than half of the population were from very socioeconomically deprived areas in 172 (14%) PCNs. Only six (4%) of the 135 commissioning regions ensured all PCNs were in the recommended population range. All practices had joined a single PCN in three (2%) commissioning regions.ConclusionMore than 40% of the PCNs were not of the recommended size, and there was substantial variation in their composition and characteristics. This high variability between PCNs is a risk to their future performance.

ObjectiveTo quantify general practitioners’ (GPs’) turnover in England between 2007 and 2019, describe trends over time, regional differences and associations with social deprivation or other practice characteristics.DesignA retrospective study of annual cross-sectional data.SettingAll general practices in England (8085 in 2007, 6598 in 2019).MethodsWe calculated turnover rates, defined as the proportion of GPs leaving a practice. Rates and their median, 25th and 75th percentiles were calculated by year and region. The proportion of practices with persistent high turnover (>10%) over consecutive years were also calculated. A negative binomial regression model assessed the association between turnover and social deprivation or other practice characteristics.ResultsTurnover rates increased over time. The 75th percentile in 2009 was 11%, but increased to 14% in 2019. The highest turnover rate was observed in 2013–2014, corresponding to the 75th percentile of 18.2%. Over time, regions experienced increases in turnover rates, although it varied across English regions. The proportion of practices with high (10% to 40%) turnover within a year almost doubled from 14% in 2009 to 27% in 2019. A rise in the number of practices with persistent high turnover (>10%) for at least three consecutive years was also observed, from 2.7% (2.3%–3.1%) in 2007 to 6.3% (5.7%–6.9%) in 2017. The statistical analyses revealed that practice-area deprivation was moderately associated with turnover rate, with practices in the most deprived area having higher turnover rates compared with practices in the least deprived areas (incidence rate ratios 1.09; 95% CI 1.06 to 1.13).ConclusionsGP turnover has increased in the last decade nationally, with regional variability. Greater attention to GP turnover is needed, in the most deprived areas in particular, where GPs often need to deal with more complex health needs. There is a large cost associated with GP turnover and practices with very high persistent turnover need to be further researched, and the causes behind this identified, to allow support strategies and policies to be developed.

BackgroundAdvancing Quality (AQ) is a voluntary programme providing financial incentives for improvement in the quality of care provided to NHS patients in the north-west of England.Objectives(1) To identify the impact of AQ on key stakeholders and clinical practice; (2) to assess its cost-effectiveness; (3) to identify key factors that assist or impede its successful implementation; and (4) to provide lessons for the wider implementation of pay-for-performance schemes across the NHS.DesignWe tested whether or not the financial incentives of AQ had an impact on mortality using two methods: a between-region difference-in-differences analysis comparing the North West region and the rest of England for the incentivised and non-incentivised conditions and a triple-difference analysis comparing performance on the incentivised conditions, as well as the non-incentivised conditions, in the North West region and the rest of England. A cost-effectiveness analysis of AQ based on the first 18 months of the programme was also undertaken. We used interviews and observation to explore how and why changes occurred.ResultsRisk-adjusted mortality rates for all three of the conditions we studied (pneumonia, heart failure and myocardial infarction) decreased in both the North West region and the rest of England during the first 18 months of the scheme. The reduction in mortality for incentivised conditions was greater in the North West region than in the rest of England. Compared with non-incentivised conditions within the North West region, there was a significant reduction in overall mortality for incentivised conditions, comprising a statistically significant reduction in pneumonia and non-significant reductions in the other two conditions. Comparing mortality for the incentivised conditions with mortality for these conditions in other regions, there was a significant reduction in overall mortality in the North West region, again made up of individually significant reductions in pneumonia and non-significant reductions in the other two conditions. The reduction in mortality over the 18-month period studied for non-incentivised conditions was not significantly different between the North West region and the rest of England. The between-region difference-in-differences analysis after 42 months showed that risk-adjusted mortality for the incentivised conditions fell in the rest of England and the North West region. This reduction in the rest of England was significantly larger than in the North West region and was concentrated in pneumonia. However, the reductions in mortality were larger for the non-incentivised conditions in the North West region than in the rest of England between these periods. For incentivised conditions, the triple-difference analysis shows a larger reduction in mortality for the rest of England than in the North West region between the short- and long-term periods.ConclusionsBased on the first 18 months, the AQ programme was a relatively effective and cost-effective intervention. However, findings at 42 months are open to interpretation. One interpretation is that the short-term improvements were not sustained and that the observed improvements in mortality in the non-incentivised conditions within hospitals participating in AQ were unrelated to the programme. An alternative interpretation is that these improvements are related to the positive spillover effect of AQ. Further research should be undertaken to determine the explanation for the findings.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Background The BNT162b2 mRNA vaccine has been shown to be effective at preventing serious COVID-19 events in clinical trials. There is less evidence on effectiveness in real-world settings, especially for older people. Here, we aimed to estimate vaccine effectiveness in the context of the rapid NHS mass-vaccination programme in England, exploiting age-based vaccination eligibility thresholds to minimise and correct for selection bias. Methods We studied 170,226 individuals between the ages of 80 and 83 years from community settings outside care homes who received one dose of BNT162b2 mRNA between the 15 and 20 December 2020 and were scheduled a second dose 21 days later. We matched these vaccine recipients to slightly younger (aged 76–79 years) persons not yet eligible to receive the vaccine on gender, area of residence, area deprivation, health status, living arrangements, acute illness, and history of seasonal flu vaccination. We compared their rates of COVID-19 positivity and hospitalisation in the subsequent 45 days. We adjusted for the increasing concentration of COVID-19 positivity in the control population caused by the requirement to have no COVID-19 symptoms prior to vaccination. Results Emergency hospital admissions were 51.0% (95% confidence interval 19.9 to 69.5%) lower and positive COVID-19 tests were 55.2% (40.8 to 66.8%) lower for vaccinated individuals compared to matched controls 21 to 27 days after first vaccination. Emergency admissions were 75.6% (52.8 to 87.6%) lower, and positive COVID-19 tests were 70.1% (55.1 to 80.1%) lower 35 to 41 days after first vaccination when 79% of participants had received a second dose within 26 days of their first dose. Conclusions Receipt of the BNT162b2 mRNA vaccine is effective at reducing COVID-19 hospitalisations and infections. The nationwide vaccination of older adults in England with the BNT162b2 mRNA vaccine reduced the burden of COVID-19.

BackgroundStroke often results in chronic disability, with partners and family members taking on the role of informal caregiver. There is considerable uncertainty regarding how best to identify and address carers’ needs. The Carer Support Needs Assessment Tool (CSNAT) is a carer-led approach to individualised assessment and support for caregiving that may be beneficial in palliative care contexts. CSNAT includes an implementation toolkit. Through collaboration, including with service users, we adapted CSNAT for stroke and for use in a UK stroke specialist organisation providing long-term support. The main aims of OSCARSS are to investigate the clinical and cost-effectiveness of CSNAT-Stroke relative to current practice. This paper focuses on the trial protocol, with the embedded process evaluation reported separately.MethodsLongitudinal, multi-site, pragmatic, cluster randomised controlled trial with a health economic analysis. Clusters are UK services randomised to CSNAT-Stroke intervention or usual care, stratified by size of service. Eligible carer participants are: adults aged > 18 years; able to communicate in English; referred to participating clusters; and seen face-to-face at least once by the provider, for support. The ‘date seen’ for initial support denotes the start of intervention (or control) and carers are referred to the research team after this for study recruitment. Primary outcome is caregiver strain (FACQ - Strain) at three months after ‘date seen’. Secondary outcomes include: caregiver distress; positive caregiving appraisals (both FACQ subscales); Pound Carer Satisfaction with Services; mood (HADs); and health (EQ-5D5L) at three months. All outcomes are followed up at six months. Health economic analyses will use additional data on caregiver health service utilisation and informal care provision.DiscussionOSCARSS is open to recruitment at the time of article submission. Study findings will allow us to evaluate the clinical and cost-effectiveness of the CSNAT-Stroke intervention, directed at improving outcomes for informal carers of stroke survivors. Trial findings will be interpreted in the context of our embedded process evaluation including qualitative interviews with those who received and provided services as well as data on treatment fidelity. OSCARSS will contribute to knowledge of the unmet needs of informal stroke caregivers and inform future stroke service development.Trial registrationISRCTN Registry, ISRCTN58414120. Registered on 26 July 2016.Electronic supplementary materialThe online version of this article (10.1186/s13063-018-3104-7) contains supplementary material, which is available to authorized users.

ObjectiveEnglish primary care faces significant challenges, including ‘persistent high turnover’ of general practitioners (GPs) in some partnerships. It is unknown whether there are specific predictors of persistent high turnover and whether it is associated with poorer population health outcomes.DesignA retrospective observational study.MethodsWe linked workforce data on individual GPs to practice-level data from Hospital Episode Statistics and the GP Patient Survey (2007–2019). We classified practices as experiencing persistent high turnover if more than 10% of GPs changed in at least 3 consecutive years. We used multivariable logistic or linear regression models for panel data with random effects to identify practice characteristics that predicted persistent high turnover and associations of practice outcomes (higher emergency hospital use and patient experience of continuity of care, access to care and overall patient satisfaction) with persistent high turnover.ResultsEach year, 6% of English practices experienced persistent high turnover, with a maximum of 9% (688/7619) in 2014. Larger practices, in more deprived areas and with a higher morbidity burden were more likely to experience persistent high turnover. Persistent high turnover was associated with 1.8 (95% CI 1.5 to 2.1) more emergency hospital attendances per 100 patients, 0.1 (95% CI 0.1 to 0.2) more admissions per 100 patients, 5.2% (95% CI −5.6% to −4.9%) fewer people seeing their preferred doctor, 10.6% (95% CI−11.4% to −9.8%) fewer people reporting obtaining an appointment on the same day and 1.3% (95% CI −1.6% to −1.1%) lower overall satisfaction with the practice.ConclusionsPersistent high turnover is independently linked to indicators of poorer service and health outcomes. Although causality needs to be further investigated, strategies and policies may be needed to both reduce high turnover and support practices facing challenges with high GP turnover when it occurs.