Voluntary Health Insurance expenditure in low- and middle-income countries: Exploring trends during 1995-2012 and policy implications for progress towards universal health coverage.

BACKGROUND: Most low- and middle-income countries (LMIC) rely significantly on private health expenditure in the form of out-of-pocket payments (OOP) and voluntary health insurance (VHI). This paper assesses VHI expenditure trends in LMIC and explores possible explanations. This illuminates challenges deriving from changes in VHI expenditure as countries aim to progress equitably towards universal health coverage (UHC). METHODS: Health expenditure data was retrieved from the WHO Global Health Expenditure Database to calculate VHI, OOP and general government health (GGHE) expenditure as a share of total health expenditure (THE) for the period of 1995-2012. A literature analysis offered potential reasons for trends in countries and regions. RESULTS: In 2012, VHI as a percentage of THE (abbreviated as VHI%) was below 1 % in 49 out of 138 LMIC. Twenty-seven countries had no or more than five years of data missing. VHI% ranged from 1 to 5 % in 39 LMIC and was above 5 % in 23 LMIC. There is an upwards average trend in VHI% across all regions. However, increases in VHI% cannot be consistently linked with OOP falling or being redirected into private prepayment. There are various countries which exhibit rising VHI alongside a rise in OOP and fall in GGHE, which is a less desirable path in order to equitably progress towards UHC. DISCUSSION AND CONCLUSION: Reasons for the VHI expenditure trends across LMIC include: external influences; government policies on the role of VHI and its regulation; and willingness and ability of the population to enrol in VHI schemes. Many countries have paid insufficient attention to the potentially risky role of VHI for equitable progress towards UHC. Expanding VHI markets bear the risk of increasing fragmentation and inequities. To avoid this, health financing strategies need to be clear regarding the role given to VHI on the path towards UHC.

Electronic health record-based behaviour change interventions aimed at general practitioners in the UK: a mixed methods systematic review using behaviour change theory.

OBJECTIVES: Electronic health record (EHR) systems are used extensively in healthcare; their design can influence clinicians' behaviour. We conducted a systematic review of EHR-based interventions aimed at changing the clinical practice of general practitioners in the UK, assessed their effectiveness and applied behaviour change theory to identify lessons for other settings. DESIGN: Mixed methods systematic review. DATA SOURCES: MEDLINE, EMBASE, CENTRAL and APA PsycINFO were searched up to March 2023. ELIGIBILITY CRITERIA: Quantitative and qualitative findings from randomised controlled trials (RCTs) controlled before-and-after studies and interrupted time series of EHR-based interventions in UK general practice were included. DATA EXTRACTION AND SYNTHESIS: Quantitative synthesis was based on Cochrane's Synthesis without Meta-analysis. Interventions were categorised using the Behaviour Change Wheel and MINDSPACE frameworks and effectiveness determined by vote-counting using direction of effect. Inductive thematic synthesis was used for qualitative studies. RESULTS: Database searching identified 3824 unique articles; 10 were included (from 2002 to 2021), comprising eight RCTs and two associated qualitative studies. Four of seven quantitative studies showed a positive effect on clinician behaviour and three on patient-level outcomes. Behaviour change techniques that may trigger emotions and required less cognitive engagement appeared to have positive effects. Qualitative findings indicated that interventions reassured clinicians of their decisions but were sometimes ignored. CONCLUSION: Despite widespread use, there is little high quality, up-to-date experimental evidence evaluating the effectiveness of EHR-based interventions in UK general practice. The evidence suggested EHR-based interventions may be effective at changing behaviour. Persistent, simple action-oriented prompts appeared more effective than complex interventions requiring greater cognitive engagement. However, studies lacked detail in intervention design and theory behind design choices. Future research should seek to optimise EHR-based behaviour change intervention design and delineate limitations, providing theory-based justification for interventions. This will be of increasing importance with the growing use of EHRs to influence clinicians' decisions. PROSPERO REGISTRATION NUMBER: CRD42022341009.

The changing shape of English general practice: a retrospective longitudinal study using national datasets describing trends in organisational structure, workforce and recorded appointments.

OBJECTIVE: To describe trends in the organisational structure, workforce and recorded appointments by role in English general practice. DESIGN: Retrospective longitudinal study. SETTING: English general practice. DATA SOURCES AND PARTICIPANTS: NHS England, Office for Health Improvement and Disparities and Care Quality Commission national administrative datasets covering between 5 to 10 years from 2013 to 2023. RESULTS: Between 2013 and 2023, the number of general practices fell by 20% from 8044 to 6419; the average practice list size increase by 40% from 6967 to 9724 patients. The total population covered by providers with over 100 000 registered patients reached 2.3 million in 2023 compared to 0.5 million in 2017. The proportion of practices under individual ownership decreased from 13% to 11% between 2018 and 2023; there was little change in the proportion owned by partnerships, incorporated companies or NHS bodies, which respectively averaged around 80.3%, 6.9% and 0.7%. Between 2015 and 2022, there was a 20% rise in the total full-time equivalent (FTE) general practice workforce, including Primary Care Network staff, from 1.97 to 2.37 per 1000 patients because of an increase in multidisciplinary other 'Direct Patient Care' (DPC) and administrative roles. The number of nurses remained stable, and the number of qualified general practitioners (GPs) decreased by 15%. In September 2022, there were 0.45 FTE qualified GPs per 1000 patients; GPs and other DPC roles, excluding nurses, each represented 19% of the FTE per 1000 patients workforce; administrative roles represented 51%. The general practice workforce is predominantly female. A quarter of GPs qualified overseas. Between 2018 and 2023, there was no clear upward or downward trend in total appointments per 1000 patients with, on average, half provided by GPs. CONCLUSIONS: Since 2013, there has been a shift in general practice towards larger practices with more multidisciplinary teams, alongside a reduction in the number of FTE qualified GPs per 1000 patients. We recommend that the impacts of these changes on access, quality and costs are closely monitored.

Workplace-based knowledge exchange programmes between academics, policy-makers and providers of healthcare: a qualitative study.

BACKGROUND: Workplace-based knowledge exchange programmes (WKEPs), such as job shadowing or secondments, offer potential for health and care providers, academics, and policy-makers to foster partnerships, develop local solutions and overcome key differences in practices. Yet opportunities for exchange can be hard to find and are poorly reported in the literature. OBJECTIVES: To understand the views of providers, academics and policy-makers regarding WKEPs, in particular, their motivations to participate in such exchanges and the perceived barriers and facilitators to participation. METHODS: A qualitative study involving semistructured interviews with 20 healthcare providers, academics and policy-makers in England. Rapid data collection and analysis techniques were employed. Interviews formed part of a wider scoping study that mapped the characteristics and existing literature related to WKEPs. RESULTS: Interviewees reported being motivated to develop, sponsor and/or participate in WKEPs with a clear purpose and defined outcomes that could demonstrate the value of the time out of work to their organisations. Perceived barriers included competitive application processes for national fellowships, a lack of knowing how to identify with whom to undertake an exchange (varying 'tribes'), and the burdens of time, costs and administration regarding arranging exchanges. WKEPs were reported to work best where there was a perceived sense of shared purpose, long-standing relationship and trust between organisations. Facilitators included existing confidentiality agreements and/or shared professional standards, as well as funding. CONCLUSION: WKEPs were reported to be valuable experiences but required significant organisational buy-in and cooperation to arrange and sustain. To benefit emerging partnerships, such as the new integrated care systems in England, more outcomes evaluations of existing WKEPs are needed, and research focused on overcoming barriers to participation, such as time and costs.

Barriers and facilitators to clinical behaviour change by primary care practitioners: a theory-informed systematic review of reviews using the Theoretical Domains Framework and Behaviour Change Wheel.

BACKGROUND: Understanding the barriers and facilitators to behaviour change by primary care practitioners (PCPs) is vital to inform the design and implementation of successful Behaviour Change Interventions (BCIs), embed evidence-based medicine into routine clinical practice, and improve quality of care and population health outcomes. METHODS: A theory-led systematic review of reviews examining barriers and facilitators to clinical behaviour change by PCPs in high-income primary care contexts using PRISMA. Embase, MEDLINE, PsychInfo, HMIC and Cochrane Library were searched. Content and framework analysis was used to map reported barriers and facilitators to the Theoretical Domains Framework (TDF) and describe emergent themes. Intervention functions and policy categories to change behaviour associated with these domains were identified using the COM-B Model and Behaviour Change Wheel (BCW). RESULTS: Four thousand three hundred eighty-eight reviews were identified. Nineteen were included. The average quality score was 7.5/11. Reviews infrequently used theory to structure their methods or interpret their findings. Barriers and facilitators most frequently identified as important were principally related to 'Knowledge', 'Environmental context and resources' and 'Social influences' TDF domains. These fall under the 'Capability' and 'Opportunity' domains of COM-B, and are linked with interventions related to education, training, restriction, environmental restructuring and enablement. From this, three key areas for policy change include guidelines, regulation and legislation. Factors least frequently identified as important were related to 'Motivation' and other psychological aspects of 'Capability' of COM-B. Based on this, BCW intervention functions of persuasion, incentivisation, coercion and modelling may be perceived as less relevant by PCPs to change behaviour. CONCLUSIONS: PCPs commonly perceive barriers and facilitators to behaviour change related to the 'Capability' and 'Opportunity' domains of COM-B. PCPs may lack insight into the role that 'Motivation' and aspects of psychological 'Capability' have in behaviour change and/or that research methods have been inadequate to capture their function. Future research should apply theory-based frameworks and appropriate design methods to explore these factors. With no 'one size fits all' intervention, these findings provide general, transferable insights into how to approach changing clinical behaviour by PCPs, based on their own views on the barriers and facilitators to behaviour change. SYSTEMATIC REVIEW REGISTRATION: A protocol was submitted to the London School of Hygiene and Tropical Medicine via the Ethics and CARE form submission on 16.4.2020, ref number 21478 (available on request). The project was not registered on PROSPERO.

Lessons for 'large-scale' general practice provider organisations in England from other inter-organisational healthcare collaborations.

Policymakers in England are increasingly encouraging the formation of 'large-scale' general practice provider collaborations with the expectation that this will help deliver better quality services and generate economies of scale. However, solid evidence that these expectations will be met is limited. This paper reviews evidence from other inter-organisational healthcare collaborations with similarities in their development or anticipated impact to identify lessons. Medline. SSCI, Embase and HMIC database searches identified a range of initiatives which could provide transferable evidence. Iterative searching was undertaken to identify further relevant evidence. Thematic analysis was used to identify areas to consider in the development of large-scale general practice providers. Framework analysis was used to identify challenges which may affect the ability of such providers to achieve their anticipated impact. A narrative approach was used to synthesise the evidence. Trade-offs exist in 'scaling-up' between mandated and voluntary collaboration; networks versus single organisations; small versus large collaborations; and different types of governance structures in terms of sustainability and performance. While positive impact seems plausible, evidence suggests that it is not a given that clinical outcomes or patient experience will improve, nor that cost savings will be achieved as a result of increasing organisational size. Since the impact and potential unintended consequences are not yet clear, it would be advisable for policymakers to move with caution, and be informed by ongoing evaluation.

Exploring the training and scope of practice of GPs in England, Germany and Spain.

OBJECTIVE: To explore general practitioner (GP) training, continuing professional development, scope of practice, ethical issues and challenges in the working environment in three European countries. METHOD: Qualitative study of 35 GPs from England, Germany and Spain working in urban primary care practices. Participants were recruited using convenience and snowball sampling techniques. Semi-structured interviews were recorded, transcribed and analysed by four independent researchers adopting a thematic approach. RESULTS: Entrance to and length of GP training differ between the three countries, while continuing professional development is required in all three, although with different characteristics. Key variations in the scope of practice include whether there is a gatekeeping role, whether GPs work in multidisciplinary teams or singlehandedly, the existence of appraisal processes, and the balance between administrative and clinical tasks. However, similar challenges, including the need to adapt to an ageing population, end-of-life care, ethical dilemmas, the impact of austerity measures, limited time for patients and gaps in coordination between primary and secondary care are experienced by GPs in all three countries. CONCLUSION: Primary health care variations have strong historical roots, derived from the different national experiences and the range of clinical services delivered by GPs. There is a need for an accessible source of information for GPs themselves and those responsible for safety and quality standards of the healthcare workforce. This paper maps out the current situation before Brexit is being implemented in the UK which could see many of the current EU arrangements and legislation to assure professional mobility between the UK and the rest of Europe dismantled.

The impact of new forms of large-scale general practice provider collaborations on England's NHS: a systematic review.

BACKGROUND: Over the past decade, collaboration between general practices in England to form new provider networks and large-scale organisations has been driven largely by grassroots action among GPs. However, it is now being increasingly advocated for by national policymakers. Expectations of what scaling up general practice in England will achieve are significant. AIM: To review the evidence of the impact of new forms of large-scale general practice provider collaborations in England. DESIGN AND SETTING: Systematic review. METHOD: Embase, MEDLINE, Health Management Information Consortium, and Social Sciences Citation Index were searched for studies reporting the impact on clinical processes and outcomes, patient experience, workforce satisfaction, or costs of new forms of provider collaborations between general practices in England. RESULTS: A total of 1782 publications were screened. Five studies met the inclusion criteria and four examined the same general practice networks, limiting generalisability. Substantial financial investment was required to establish the networks and the associated interventions that were targeted at four clinical areas. Quality improvements were achieved through standardised processes, incentives at network level, information technology-enabled performance dashboards, and local network management. The fifth study of a large-scale multisite general practice organisation showed that it may be better placed to implement safety and quality processes than conventional practices. However, unintended consequences may arise, such as perceptions of disenfranchisement among staff and reductions in continuity of care. CONCLUSION: Good-quality evidence of the impacts of scaling up general practice provider organisations in England is scarce. As more general practice collaborations emerge, evaluation of their impacts will be important to understand which work, in which settings, how, and why.

Time to go global: a consultation on global health competencies for postgraduate doctors.

BACKGROUND: Globalisation is having profound impacts on health and healthcare. We solicited the views of a wide range of stakeholders in order to develop core global health competencies for postgraduate doctors. METHODS: Published literature and existing curricula informed writing of seven global health competencies for consultation. A modified policy Delphi involved an online survey and face-to-face and telephone interviews over three rounds. RESULTS: Over 250 stakeholders participated, including doctors, other health professionals, policymakers and members of the public from all continents of the world. Participants indicated that global health competence is essential for postgraduate doctors and other health professionals. Concerns were expressed about overburdening curricula and identifying what is 'essential' for whom. Conflicting perspectives emerged about the importance and relevance of different global health topics. Five core competencies were developed: (1) diversity, human rights and ethics; (2) environmental, social and economic determinants of health; (3) global epidemiology; (4) global health governance; and (5) health systems and health professionals. CONCLUSIONS: Global health can bring important perspectives to postgraduate curricula, enhancing the ability of doctors to provide quality care. These global health competencies require tailoring to meet different trainees' needs and facilitate their incorporation into curricula. Healthcare and global health are ever-changing; therefore, the competencies will need to be regularly reviewed and updated.

Improving primary care through information. A Wonca keynote paper.

Information from health care encounters across the entire health care spectrum, when consistently collected, analysed and applied can provide a clearer picture of patients' history as well as current and future needs through a better understanding of their morbidity burden and health care experiences. It can facilitate clinical activity to target limited resources to those patients most in need through risk adjustment mechanisms that consider the morbidity burden of populations, and it can help target quality improvement and cost saving activities in the right places. It can also open the door to a new chapter of evidence-based medicine around multi-morbidity. In summary, it can support a better integrated health system where primary care can provide continuous, coordinated, and comprehensive person-centred care to those who could benefit most. This paper explores the potential uses of information collected in electronic health records (EHRs) to inform case-mix and predictive modelling, as well as the associated challenges, with a particular focus on their application to primary care.

Exploring the training and scope of practice of GPs in England, Germany and Spain / Análisis de la formación y el ámbito de práctica de los médicos de atención primaria en Inglaterra, Alemania y España

Objective: To explore general practitioner (GP) training, continuing professional development, scope of practice, ethical issues and challenges in the working environment in three European countries. Method: Qualitative study of 35 GPs from England, Germany and Spain working in urban primary care practices. Participants were recruited using convenience and snowball sampling techniques. Semi-structured interviews were recorded, transcribed and analysed by four independent researchers adopting a thematic approach. Results: Entrance to and length of GP training differ between the three countries, while continuing professional development is required in all three, although with different characteristics. Key variations in the scope of practice include whether there is a gatekeeping role, whether GPs work in multidisciplinary teams or singlehandedly, the existence of appraisal processes, and the balance between administrative and clinical tasks. However, similar challenges, including the need to adapt to an ageing population, end-of-life care, ethical dilemmas, the impact of austerity measures, limited time for patients and gaps in coordination between primary and secondary care are experienced by GPs in all three countries. Conclusion: Primary health care variations have strong historical roots, derived from the different national experiences and the range of clinical services delivered by GPs. There is a need for an accessible source of information for GPs themselves and those responsible for safety and quality standards of the healthcare workforce. This paper maps out the current situation before Brexit is being implemented in the UK which could see many of the current EU arrangements and legislation to assure professional mobility between the UK and the rest of Europe dismantled

Objetivo: Analizar la formación, el desarrollo profesional continuado, el ámbito de práctica, las cuestiones éticas y los retos en el entorno laboral de los médicos de atención primaria en tres países europeos. Método: Estudio cualitativo de 35 médicos de atención primaria de Inglaterra, Alemania y España que trabajan en centros urbanos de atención primaria. Se reclutó a los participantes utilizando técnicas de muestreo de oportunidad y con efecto multiplicador. Se registraron, transcribieron y analizaron entrevistas semiestructuradas realizadas por cuatro investigadores independientes, quienes adoptaron un enfoque temático. Resultados: El acceso y la duración de la formación del médico de atención primaria difieren entre los tres países, mientras que se requiere desarrollo profesional continuado en los tres, aunque con características diferentes. Las variaciones clave en el ámbito de la práctica incluyen la existencia de un papel curativo, si el trabajo de médico de atención primaria se realiza en equipos multidisciplinarios o de manera individual, la existencia de procesos de valoración, y el equilibrio entre las tareas administrativas y clínicas. Sin embargo, los médicos de atención primaria en los tres países se enfrentan a retos similares, que incluyen la necesidad de adaptarse al envejecimiento de la población, la atención al final de la vida, el impacto de las medidas de austeridad, la limitación del tiempo de dedicación al paciente, y las brechas en cuanto a coordinación entre la atención primaria y secundaria. Conclusión: Las variaciones de la atención primaria tienen fuertes raíces históricas, que se derivan de las diferentes experiencias nacionales y el rango de los servicios clínicos proporcionados por los médicos de atención primaria. Existe una necesidad de fuentes de información accesibles para dichos médicos, y aquellos responsables de los estándares de seguridad y calidad del personal sanitario. Este trabajo esboza la situación actual que está siendo implementada en el Reino Unido con anterioridad al Brexit, que podría vislumbrar muchos de los acuerdos y legislaciones actuales de la UE para garantizar la movilidad profesional entre el Reino Unido y el resto de la Europa desmantelada

Qualitative study of motivators and outcomes of Sri Lankan doctors achieving MRCGPInternational.

BACKGROUND: The UK's Royal College of General Practitioners accredits overseas examinations in family medicine through MRCGP[INT] rather than exporting MRCGP UK. There is limited research on the motivating factors and outcomes of this practice on candidates. AIM: To explore factors motivating Sri Lankan doctors to pursue the South Asian MRCGP[INT] and their perceived benefits and barriers to sitting the examination. METHODS: Qualitative semi-structured 1:1 interviews with 14 successful past MRCGP[INT]SA candidates were undertaken in Sri Lanka. Findings were analysed with N-Vivo software. A phenomenological approach was used. Interpretive dimensions were applied drawing on information from interviews, informal conversations and observations. RESULTS: Motivators to sit the examination included a desire to improve patient care and seeking recognition as a family doctor. Younger doctors had hopes of increased future income and there was some expectation that the examination may improve overseas employment prospects. The examination conferred greater confidence, new patient-centred communication skills, introduced the use of evidence-based guidelines and increased awareness of the UK health system to most participants. There were examples of diffusion of knowledge through different teaching channels. Relative to Sri Lankan examinations, formal training opportunities were limited and value for money of annual membership fees were questioned. Financial and geographical barriers to the examination were noted. CONCLUSION: Currently MRCGP[INT]SA offers additional value for successful candidates in Sri Lanka who perceive accreditation by a UK college favourably. Improvement of pre- and post-exam support linked to MRCGP[INT]SA in Sri Lanka is needed. Further research into the long-term impact is necessary, in particular regarding equity of access, migration and local training development.