Governing Integrated Health and Social Care: An Analysis of Experiences in Three European Countries.

Purpose: Achieving greater health and social care integration is a policy priority in many countries, but challenges remain. We focused on governance and accountability for integrated care and explored arrangements that shape more integrated delivery models or systems in Italy, the Netherlands and Scotland. We also examined how the COVID-19 pandemic affected existing governance arrangements. Design/methodology/approach: A case study approach involving document review and semi-structured interviews with 35 stakeholders in 10 study sites between February 2021 and April 2022. We used the Transparency, Accountability, Participation, Integrity and Capability (TAPIC) framework to guide our analytical enquiry. Findings: Study sites ranged from bottom-up voluntary agreements in the Netherlands to top-down mandated integration in Scotland. Interviews identified seven themes that were seen to have helped or hindered integration efforts locally. Participants described a disconnect between what national or regional governments aspire to achieve and their own efforts to implement this vision. This resulted in blurred, and sometimes contradictory, lines of accountability between the centre and local sites. Flexibility and time to allow for national policies to be adapted to local contexts, and engaged local leaders, were seen to be key to delivering the integration agenda. Health care, and in particular acute hospital care, was reported to dominate social care in terms of policies, resource allocation and national monitoring systems, thereby undermining better collaboration locally. The pandemic highlighted and exacerbated existing strengths and weaknesses but was not seen as a major disruptor to the overall vision for the health and social care system. Research limitations: We included a relatively small number of interviews per study site, limiting our ability to explore complexities within sites. Originality: This study highlights that governance is relatively neglected as a focus of attention in this context but addressing governance challenges is key for successful collaboration.

Public trust in the Government to control the spread of COVID-19 in England after the first wave-a longitudinal analysis.

BACKGROUND: To control the spread of coronavirus disease 2019 (COVID-19), governments are increasingly relying on the public to voluntarily manage risk. Effectiveness is likely to rely in part on how much the public trusts the Government's response. We examined the English public's trust in the Conservative Government to control the spread of COVID-19 after the initial 'crisis' period. METHODS: We analyzed eight rounds of a longitudinal survey of 1899 smartphone users aged 18-79 in England between October 2020 and December 2021. We fitted a random-effects logit model to identify personal characteristics and opinions associated with trust in the Conservative Government to control the spread of COVID-19. RESULTS: Trust was lowest in January 2021 (28%) and highest in March 2021 (44%). Being older, having lower educational attainment and aligning with the Conservative Party were predictors of higher levels of trust. Conversely, being less deprived, reporting that Government communications were not clear and considering that the measures taken by the Government went too far or not far enough were predictors of being less likely to report a great deal or a fair amount of trust in the Government to control the pandemic. CONCLUSION: Trust in the Government's response was found to be low throughout the study. Our findings suggest that there may be scope to avoid losing trust by aligning Government actions more closely with scientific advice and public opinion, and through clearer public health messaging. However, it remains unclear whether and how higher trust in the Government's response would increase compliance with Government advice.

The sociocultural framing of public attitudes to sharing the costs of social care for older people in England.

Twelve synchronous online focus groups were conducted, each involving four to six members of the general public who had expressed in-principle support for sharing the costs of social care for older people between service users and government. These explored participants' reasons for preferring a shared approach and their views on how costs should be shared, with particular attention given to the sociocultural frames employed. Four main sociocultural frames were identified, reflecting dominant discourses concerning (i) the financial burden of meeting social care need ('scarcity' frame) (ii) the core purpose of social care ('medicalised conception of care' frame) (iii) the role and perceived limitations of the private market ('consumer' frame), and (iv) fundamental concerns about safety, security and belonging ('loss and abandonment' frame). Of these four frames, the 'scarcity' frame was dominant, with views about how costs should be shared overwhelmingly formulated upon assumptions of insufficient resources. This was reflected in concerns about affordability and the consequent need for the financial burden to be shared between individuals and government, and resulted in a residual vision for care and anxieties about care quality, cliff-edge costs and abandonment. The concept of shared funding was also employed rhetorically to suggest an equitable approach to managing financial burden, reflected in phrases such as 'splitting the difference'. Whilst out-of-pocket payments were sometimes seen as useful or necessary in the context of scarce public resources, the idea of shared funding was sometimes interpreted more flexibly to include individual contributions made in a range of ways, including tax, social insurance payments and wider social and economic contributions to society. Despite the dominance of the 'scarcity' frame, participants favoured greater government contribution than currently. These four frames and their associated discourses provide insight into how the public 'hear' and make sense of the debate about social care funding and, specifically, how apparent support for shared public-private funding is structured. Government and those hoping to influence the future of social care funding need to promote a vision of funding reform and win support for it by actively engaging with the sociocultural frames that the public recognise and engage with, with all of their apparent inconsistencies and contradictions.

Improving maternal and newborn health services in Northeast Nigeria through a government-led partnership of stakeholders: a quasi-experimental study.

OBJECTIVES: This study aimed to quantify change in the coverage, quality and equity of essential maternal and newborn healthcare interventions in Gombe state, Northeast Nigeria, following a four year, government-led, maternal and newborn health intervention. DESIGN: Quasi-experimental plausibility study. Repeat cross-sectional household and linked health facility surveys were implemented in intervention and comparison areas. SETTING: Gombe state, Northeast Nigeria. PARTICIPANTS: Each household survey included a sample of 1000 women aged 13-49 years with a live birth in the previous 12 months. Health facility surveys comprised a readiness assessment and birth attendant interview. INTERVENTIONS: Between 2016-2019 a complex package of evidence-based interventions was implemented to increase access, use and quality of maternal and newborn healthcare, spanning the six WHO health system building blocks. OUTCOME MEASURES: Eighteen indicators of maternal and newborn healthcare. RESULTS: Between 2016 and 2019, the coverage of all indicators improved in intervention areas, with the exception of postnatal and postpartum contacts, which remained below 15%. Greater improvements were observed in intervention than comparison areas for eight indicators, including coverage of at least one antenatal visit (71% (95% CI 62 to 68) to 88% (95% CI 82 to 93)), at least four antenatal visits (46% (95% CI 39 to 53) to 69% (95% CI 60 to 75)), facility birth (48% (95% CI 37 to 59) to 64% (95% CI 54 to 73)), administration of uterotonics (44% (95% CI 34 to 54) to 59% (95% CI 50 to 67)), delayed newborn bathing (44% (95% CI 36 to 52) to 62% (95% CI 52 to 71)) and clean cord care (42% (95% CI 34 to 49) to 73% (95% CI 66 to 79)). Wide-spread inequities persisted however; only at least one antenatal visit saw pro-poor improvement. CONCLUSIONS: This intervention achieved improvements in life-saving behaviours for mothers and newborns, demonstrating that multipartner action, coordinated through government leadership, can shift the needle in the right direction, even in resource-constrained settings.

A rapid systematic review and evidence synthesis of effective coverage measures and cascades for childbirth, newborn and child health in low- and middle-income countries.

BACKGROUND: Effective coverage measures aim to estimate the proportion of a population in need of a service that received a positive health outcome. In 2020, the Effective Coverage Think Tank Group recommended using a 'coverage cascade' for maternal, newborn, child and adolescent health and nutrition (MNCAHN), which organises components of effective coverage in a stepwise fashion, with each step accounting for different aspects of quality of care (QoC), applied at the population level. The cascade outlines six steps that increase the likelihood that the population in need experience the intended health benefit: 1) the population in need (target population) who contact a health service; 2) that has the inputs available to deliver the service; 3) who receive the health service; 4) according to quality standards; 5) and adhere to prescribed medication(s) or health workers instructions; and 6) experience the expected health outcome. We examined how effective coverage of life-saving interventions from childbirth to children aged nine has been defined and assessed which steps of the cascade are captured by existing measures. METHODS: We undertook a rapid systematic review. Seven scientific literature databases were searched covering the period from May 1, 2017 to July, 8 2021. Reference lists from reviews published in 2018 and 2019 were examined to identify studies published prior to May 2017. Eligible studies reported population-level contact coverage measures adjusted for at least one dimension of QoC. RESULTS: Based on these two search approaches this review includes literature published from 2010 to 2021. From 16 662 records reviewed, 33 studies were included, reporting 64 effective coverage measures. The most frequently examined measures were for childbirth and immediate newborn care (n = 24). No studies examined measures among children aged five to nine years. Definitions of effective coverage varied across studies. Key sources of variability included (i) whether a single effective coverage measure was reported for a package of interventions or separate measures were calculated for each intervention; (ii) the number and type of coverage cascade steps applied to adjust for QoC; and (iii) the individual items included in the effective coverage definition and the methods used to generate a composite quality measure. CONCLUSION: In the MNCAHN literature there is substantial heterogeneity in both definitions and construction of effective coverage, limiting the comparability of measures over time and place. Current measurement approaches are not closely aligned with the proposed cascade. For widespread adoption, there is a need for greater standardisation of indicator definitions and transparency in reporting, so governments can use these measures to improve investments in MNACHN and implement life-saving health policies and programs.

Operationalising effective coverage measurement of facility based childbirth in Gombe State; a comparison of data sources.

Estimating effective coverage of childbirth care requires linking population based data sources to health facility data. For effective coverage to gain widespread adoption there is a need to focus on the feasibility of constructing these measures using data typically available to decision makers in low resource settings. We estimated effective coverage of childbirth care in Gombe State, northeast Nigeria, using two different combinations of facility data sources and examined their strengths and limitations for decision makers. Effective coverage captures information on four steps: access, facility inputs, receipt of interventions and process quality. We linked data from the 2018 Nigerian Demographic and Health Survey (NDHS) to two sources of health facility data: (1) comprehensive health facility survey data generated by a research project; and (2) District Health Information Software 2 (DHIS2). For each combination of data sources, we examined which steps were feasible to calculate, the size of the drop in coverage between steps and the resulting estimate of effective coverage. Analysis included 822 women with a recent live birth, 30% of whom attended a facility for childbirth. Effective coverage was low: 2% based on the project data and less than 1% using the DHIS2. Linking project data with NDHS, it was feasible to measure all four steps; using DHIS2 it was possible to estimate three steps: no data was available to measure process quality. The provision of high quality care is suboptimal in this high mortality setting where access and facility readiness to provide care, crucial foundations to the provision of high quality of care, have not yet been met. This study demonstrates that partial effective coverage measures can be constructed from routine data combined with nationally representative surveys. Advocacy to include process of care indicators in facility summary reports could optimise this data source for decision making.

Public attitudes to, and behaviours taken during, hot weather by vulnerable groups: results from a national survey in England.

BACKGROUND: Hot weather leads to increased illness and deaths. The Heatwave Plan for England (HWP) aims to protect the population by raising awareness of the dangers of hot weather, especially for those most vulnerable. Individuals at increased risk to the effects of heat include older adults, particularly 75+, and those with specific chronic conditions, such as diabetes, respiratory and heart conditions. The HWP recommends specific protective actions which relate to five heat-health alert levels (levels 0-4). This study examines the attitudes to hot weather of adults in England, and the protective measures taken during a heatwave. METHODS: As part of a wider evaluation of the implementation and effects of the HWP, a survey (n = 3153) and focus groups, a form of group interview facilitated by a researcher, were carried out after the June 2017 level 3 heat-health alert. Survey respondents were categorised into three groups based on their age and health status: 'vulnerable' (aged 75+), 'potentially vulnerable' (aged 18-74 in poor health) and 'not vulnerable' (rest of the adult population) to hot weather. Multivariable logistic regression models identified factors associated with these groups taking protective measures. In-person group discussion, focused on heat-health, were carried out with 25 people, mostly aged 75 + . RESULTS: Most vulnerable and potentially vulnerable adults do not consider themselves at risk of hot weather and are unaware of the effectiveness of important protective behaviours. Only one-quarter of (potentially) vulnerable adults reported changing their behaviour as a result of hearing hot weather-related health advice during the level 3 alert period. Focus group findings showed many vulnerable adults were more concerned about the effects of the sun's ultra-violet radiation on the skin than on the effects of hot temperatures on health. CONCLUSIONS: Current public health messages appear to be insufficient, given the low level of (potentially) vulnerable adults changing their behaviour during hot weather. In the context of increasingly warmer summers in England due to climate change, public health messaging needs to convince (potentially) vulnerable adults of all the risks of hot weather (not just effects of sunlight on the skin) and of the importance of heat protective measures.

Quality improvement in general practice: what do GPs and practice managers think? Results from a nationally representative survey of UK GPs and practice managers.

BACKGROUND: This paper presents the results of the first UK-wide survey of National Health Service (NHS) general practitioners (GPs) and practice managers (PMs) designed to explore the service improvement activities being undertaken in practices, and the factors that facilitated or obstructed that work. The research was prompted by growing policy and professional interest in the quality of general practice and its improvement. The analysis compares GP and PM involvement in, and experience of, quality improvement activities. METHODS: This was a mixed-method study comprising 26 semistructured interviews, a focus group and two surveys. The qualitative data supported the design of the surveys, which were sent to all 46 238 GPs on the Royal College of General Practitioners (RCGP) database and the PM at every practice across the UK (n=9153) in July 2017. RESULTS: Responses from 2377 GPs and 1424 PMs were received and were broadly representative of each group. Ninety-nine per cent reported having planned or undertaken improvement activities in the previous 12 months. The most frequent related to prescribing and access. Key facilitators of improvement included 'good clinical leadership'. The two main barriers were 'too many demands from external stakeholders' and a lack of protected time. Audit and significant event audit were the most common improvement tools used, but respondents were interested in training on other quality improvement tools. CONCLUSION: GPs and PMs are interested in improving service quality. As such, the new quality improvement domain in the Quality and Outcomes Framework used in the payment of practices is likely to be relatively easily accepted by GPs in England. However, if improving quality is to become routine work for practices, it will be important for the NHS in the four UK countries to work with practices to mitigate some of the barriers that they face, in particular the lack of protected time.

Provision of essential evidence-based interventions during facility-based childbirth: cross-sectional observations of births in northeast Nigeria.

OBJECTIVES: To measure the provision of evidence-based preventive and promotive interventions to women, and subsequently their newborns, during childbirth in a high-mortality setting. DESIGN AND PARTICIPANTS: Cross-sectional observations of care provided to women, and their newborns during the intrapartum and immediate postpartum period using a standardised checklist capturing healthcare worker behaviours regarding lifesaving and respectful care. SETTING: Ten primary healthcare facilities in Gombe state, northeast Nigeria. The northeast region of Nigeria has some of the highest maternal and newborn death rates globally. MAIN OUTCOME MEASURES: Data on 50 measures of internationally recommended evidence-based interventions and good practice. RESULTS: 1875 women were admitted to a health facility during the observation period; of these, 1804 gave birth in the facility and did not experience an adverse event or death. Many clinical interventions around the time of birth were routinely implemented, including provision of uterotonic (96% (95% CI 93% to 98%)), whereas risk-assessment measures, such as history-taking or checking vital signs were rarely completed: just 2% (95% CI 2% to 7%) of women had their temperature taken and 12% (95% CI 9% to 16%) were asked about complications during the pregnancy. CONCLUSIONS: The majority of women did not receive the recommended routine processes of childbirth care they and their newborns needed to benefit from their choice to deliver in a health facility. In particular, few benefited from even basic risk assessments, leading to missed opportunities to identify risks. To continue with the recommendation of childbirth care in primary healthcare facilities in high mortality settings like Gombe, it is crucial that birth attendant capacity, capability and prioritisation processes are addressed.

Toward improving respectful maternity care: a discrete choice experiment with rural women in northeast Nigeria.

Introduction: There is a limited understanding of the importance of respectful maternity care on utilisation of maternal and newborn health services. This study aimed to determine how specific hypothetical facility birth experience of care attributes influenced rural Nigerian women's stated preferences for hypothetical place of delivery. Methods: Attributes were identified through a comprehensive review of the literature. These attributes and their respective levels were further investigated in a qualitative study. We then developed and implemented a cross-sectional discrete choice experiment with a random sample of 426 women who had facility-based childbirth to elicit their stated preferences for facility birth experience of care attributes. Women were asked to choose between two hypothetical health facilities or home birth for future delivery. Choice data were analysed using multinomial logit and mixed multinomial logit models. Results: Complete data for the discrete choice experiment were available for 425 of 426 women. The majority belonged to Fulani ethnic group (60%) and were married (95%). Almost half (45%) had no formal education. Parameter estimates were all of expected signs suggesting internal validity. The most important influence on choice of place of delivery was good health system condition, followed by absence of sexual abuse, then absence of physical and verbal abuse. Poor facility culture, including an unclean birth environment with no privacy and unclear user fee, was associated with the most disutility and had the most negative impact on preferences for facility-based childbirth. Conclusion: The likelihood of poor facility birth experiences had a significant impact on stated preferences for place of delivery among rural women in northeast Nigeria. The study findings further underline the important relationship between facility birth experience and utilisation. Achieving universal health coverage would require efforts toward addressing poor facility birth experiences and promoting respectful maternity care, to ensure women want to access the services available.

GPs' and practice staff's views of a telephone first approach to demand management: a qualitative study in primary care.

BACKGROUND: To better manage patient demand, some general practices have implemented a 'telephone first' approach in which all patients seeking a face-to-face appointment first have to speak to a GP on the telephone. Previous studies have suggested that there is considerable scope for this new approach, but there remain significant concerns. AIM: To understand the views of GPs and practice staff of the telephone first approach, and to identify enablers and barriers to successful adoption of the approach. DESIGN AND SETTING: A qualitative study of the telephone first approach in 12 general practices that have adopted it, and two general practices that have tried the approach but reverted to their previous system. METHOD: A total of 53 qualitative interviews with GPs and practice staff were conducted. Transcriptions of the interviews were systematically analysed. RESULTS: Staff in the majority of practices reported that the approach was an improvement on their previous system, but all practices experienced challenges; for example, where practices did not have the capacity to meet the increase in demand for telephone consultations. Staff were also aware that the new system suited some patients better than others. Adoption of the telephone first approach could be very stressful, with a negative impact on morale, especially reported in interviews with the two practices that had tried but stopped the approach. Interviewees identified enablers and barriers to the successful adoption of a telephone first approach in primary care. Enablers to successful adoption were: understanding demand, practice staff as pivotal, making modifications to the approach, and educating patients. CONCLUSION: Practices considering adopting or clinical commissioning groups considering funding a telephone first approach should consider carefully a practice's capacity and capability before launching.

Impact of the Southwark and Lambeth Integrated Care Older People's Programme on hospital utilisation and costs: controlled time series and cost-consequence analysis.

OBJECTIVES: To estimate the impact on hospital utilisation and costs of a multi-faceted primary care intervention for older people identified as being at risk of avoidable hospitalisation. DESIGN: Observational study: controlled time series analysis and estimation of costs and cost consequences of the Programme. General practitioner (GP)'s practice level data were analysed from 2009 to 2016 (intervention operated from 2012 to 2016). Mixed-effect Poisson regression models of hospital utilisation included comparisons with control practices and background trends in addition to within-practice comparisons. Cost estimation used standard tariff values. SETTING: 94 practices in Southwark and Lambeth and 263 control practices from other parts of England. MAIN OUTCOME MEASURES: Hospital utilisation: emergency department attendance, emergency admissions, emergency admissions for ambulatory sensitive conditions, outpatient attendance, elective admission and length of stay. RESULTS: By the fourth year of the Programme, there were reductions in accident and emergency (A&E) attendance (rate ratio 0.944, 95% CI 0.913 to 0.976), outpatient attendances (rate ratio 0.938, 95% CI 0.902 to 0.975) and elective admissions (rate ratio 0.921, 95% CI 0.908 to 0.935) but there was no evidence of reduced emergency admissions. The costs of the Programme were £149 per resident aged 65 and above but savings in hospital costs were only £86 per resident aged 65 and above, equivalent to a net increase in health service expenditure of £64 per resident though the Programme was nearly cost neutral if set-up costs were excluded. Holistic assessments carried out by GPs and consequent Integrated Care Management (ICM) plans were associated with increases in elective activity and costs; £126 increase in outpatient attendance and £936 in elective admission costs per holistic assessment carried out, and £576 increase in outpatient and £5858 in elective admission costs per patient receiving ICM. CONCLUSIONS: The Older People's Programme was not cost saving. Some aspects of the Programme were associated with increased costs of elective care, possibly through the identification of unmet need.

Newborn resuscitation in Gombe State, northeastern Nigeria.

BACKGROUND: Basic newborn resuscitation for babies not breathing at birth is a highly effective intervention and its scale-up identified as a top research priority. However, tracking progress on the scale-up and coverage of this intervention is compromised by limitations in measuring both the number of newborns receiving the intervention and the number of newborns requiring the intervention. Using data from a facility and birth attendant survey in Gombe State, Nigeria, we aimed to advance the measurement agenda by developing a proxy indicator defined as the "percent of newborns born in a facility with the potential to provide newborn resuscitation". METHODS: The indicator's denominator was defined as: the total number of births in facilities during a defined time period (facility records). The numerator was constructed from the number of those births that occurred in appropriately equipped facilities (facility inventory), where a birth attendant demonstrated basic resuscitation competence (assessed by a simulation exercise). The proportion of facility-births that took place in a setting with the potential to provide newborn resuscitation was then calculated. RESULTS: The analysis included 17 383 births that occurred during May-October 2015 in 117 primary and referral facilities surveyed in November 2015. Overall 81% of the facilities did not have all items of essential equipment required for resuscitation; the items of equipment least frequently present included a timing device and resuscitation bag with two sizes of neonatal face mask. Only 3% of 117 birth attendants interviewed demonstrated competence to undertake resuscitation, all of whom were classified as skilled attendants and worked in referral facilities. We found that 20% of the 17 383 births took place in a facility with the potential to provide lifesaving resuscitation care. CONCLUSIONS: The indicator definition of neonatal resuscitation presented here responds to the need to advance the measurement agenda for newborn care and importantly adjusts for the volume of births occurring in different facilities. Its application in this setting revealed substantial missed opportunities to providing lifesaving care and highlights the need for a greater focus on input as well as process quality in all levels of health facilities.

Impact of issuing longer- versus shorter-duration prescriptions: a systematic review.

BACKGROUND: Long-term conditions place a substantial burden on primary care services, with drug therapy being a core aspect of clinical management. However, the ideal frequency for issuing repeat prescriptions for these medications is unknown. AIM: To examine the impact of longer-duration (2-4 months) versus shorter-duration (28-day) prescriptions. DESIGN AND SETTING: Systematic review of primary care studies. METHOD: Scientific and grey literature databases were searched from inception until 21 October 2015. Eligible studies were randomised controlled trials and observational studies that examined longer prescriptions (2-4 months) compared with shorter prescriptions (28 days) in patients with stable, chronic conditions being treated in primary care. Outcomes of interest were: health outcomes, adverse events, medication adherence, medication wastage, professional administration time, pharmacists' time and/or costs, patient experience, and patient out-of-pocket costs. RESULTS: From a search total of 24 876 records across all databases, 13 studies were eligible for review. Evidence of moderate quality from nine studies suggested that longer prescriptions are associated with increased medication adherence. Evidence from six studies suggested that longer prescriptions may increase medication waste, but results were not always statistically significant and were of very low quality. No eligible studies were identified that measured any of the other outcomes of interest, including health outcomes and adverse events. CONCLUSION: There is insufficient evidence relating to the overall impact of differing prescription lengths on clinical and health service outcomes, although studies do suggest medication adherence may improve with longer prescriptions. UK recommendations to provide shorter prescriptions are not substantiated by the current evidence base.

A SYSTEMATIC REVIEW OF GROUP WALKING IN PHYSICALLY HEALTHY PEOPLE TO PROMOTE PHYSICAL ACTIVITY.

BACKGROUND: Walking is a good way to meet physical activity guidelines. We examined the effectiveness of walking in groups compared with walking alone or inactive controls in physically healthy adults on physical activity and quality of life. (PROSPERO CRD42016033752). METHODS: We searched Medline, Embase, Cinahl, Web of Knowledge Science Citation Index, and Cochrane CENTRAL until March 2016, for any comparative studies, in physically healthy adults, of walking in groups compared with inactive controls or walking alone, reporting any measure of physical activity. We searched references from recent relevant systematic reviews. Two reviewers checked study eligibility and independently extracted data. Disagreements were resolved through discussion. Quality was assessed using likelihood of selection, performance, attrition, and detection biases. Meta-analysis was conducted using Review Manager 5.3. RESULTS: From 1,404 citations, 18 studies were included in qualitative synthesis and 10 in meta-analyses. Fourteen compared group walking to inactive controls and four to walking alone. Eight reported more than one measure of physical activity, none reported according to current guidelines. Group walking compared with inactive controls increased follow-up physical activity (9 randomized controlled trials, standardized mean difference [SMD] 0.58 [95 percent confidence interval {CI}, 0.34-0.82] to SMD 0.43 [95 percent CI, 0.20-0.66]). Compared with walking alone, studies were too few and too heterogeneous to conduct meta-analysis, but the trend was improved physical activity at follow-up for group walking participants. Seven (all inactive control) reported quality-of-life: five showed statistically significantly improved scores. DISCUSSION: Better evidence may encourage government policy to promote walking in groups. Standardized physical activity outcomes need to be reported in research.

Qualitative study of patient views on a 'telephone-first' approach in general practice in England: speaking to the GP by telephone before making face-to-face appointments.

OBJECTIVE: To understand patients' views on a 'telephone-first' approach, in which all appointment requests in general practice are followed by a telephone call from the general practitioner (GP). DESIGN: Qualitative interviews with patients and carers. SETTING: Twelve general practices in England. PARTICIPANTS: 43 patients, including 30 women, nine aged over 75 years, four parents of young children, five carers, five patients with hearing impairment and two whose first language was not English. RESULTS: Patients expressed varied views, often strongly held, ranging from enthusiasm for to hostility towards the 'telephone-first' approach. The new system suited some patients, avoiding the need to come into the surgery but was problematic for others, for example, when it was difficult for someone working in an open plan office to take a call-back. A substantial proportion of negative comments were about the operation of the scheme itself rather than the principles behind it, for example, difficulty getting through on the phone or being unable to schedule when the GP would phone back. Some practices were able to operate the scheme in a way that met their patients' needs better than others and practices varied significantly in how they had implemented the approach. CONCLUSIONS: The 'telephone-first' approach appears to work well for some patients, but others find it much less acceptable. Some of the reported problems related to how the approach had been implemented rather than the 'telephone-first' approach in principle and suggests there may be potential for some of the challenges experienced by patients to be overcome.

Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling.

BACKGROUND: To reduce expenditure on, and wastage of, drugs, some commissioners have encouraged general practitioners to issue shorter prescriptions, typically 28 days in length; however, the evidence base for this recommendation is uncertain. OBJECTIVE: To evaluate the evidence of the clinical effectiveness and cost-effectiveness of shorter versus longer prescriptions for people with stable chronic conditions treated in primary care. DESIGN/DATA SOURCES: The design of the study comprised three elements. First, a systematic review comparing 28-day prescriptions with longer prescriptions in patients with chronic conditions treated in primary care, evaluating any relevant clinical outcomes, adherence to treatment, costs and cost-effectiveness. Databases searched included MEDLINE (PubMed), EMBASE, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Cochrane Central Register of Controlled Trials. Searches were from database inception to October 2015 (updated search to June 2016 in PubMed). Second, a cost analysis of medication wastage associated with < 60-day and ≥ 60-day prescriptions for five patient cohorts over an 11-year period from the Clinical Practice Research Datalink. Third, a decision model adapting three existing models to predict costs and effects of differing adherence levels associated with 28-day versus 3-month prescriptions in three clinical scenarios. REVIEW METHODS: In the systematic review, from 15,257 unique citations, 54 full-text papers were reviewed and 16 studies were included, five of which were abstracts and one of which was an extended conference abstract. None was a randomised controlled trial: 11 were retrospective cohort studies, three were cross-sectional surveys and two were cost studies. No information on health outcomes was available. RESULTS: An exploratory meta-analysis based on six retrospective cohort studies suggested that lower adherence was associated with 28-day prescriptions (standardised mean difference -0.45, 95% confidence interval -0.65 to -0.26). The cost analysis showed that a statistically significant increase in medication waste was associated with longer prescription lengths. However, when accounting for dispensing fees and prescriber time, longer prescriptions were found to be cost saving compared with shorter prescriptions. Prescriber time was the largest component of the calculated cost savings to the NHS. The decision modelling suggested that, in all three clinical scenarios, longer prescription lengths were associated with lower costs and higher quality-adjusted life-years. LIMITATIONS: The available evidence was found to be at a moderate to serious risk of bias. All of the studies were conducted in the USA, which was a cause for concern in terms of generalisability to the UK. No evidence of the direct impact of prescription length on health outcomes was found. The cost study could investigate prescriptions issued only; it could not assess patient adherence to those prescriptions. Additionally, the cost study was based on products issued only and did not account for underlying patient diagnoses. A lack of good-quality evidence affected our decision modelling strategy. CONCLUSIONS: Although the quality of the evidence was poor, this study found that longer prescriptions may be less costly overall, and may be associated with better adherence than 28-day prescriptions in patients with chronic conditions being treated in primary care. FUTURE WORK: There is a need to more reliably evaluate the impact of differing prescription lengths on adherence, on patient health outcomes and on total costs to the NHS. The priority should be to identify patients with particular conditions or characteristics who should receive shorter or longer prescriptions. To determine the need for any further research, an expected value of perfect information analysis should be performed. STUDY REGISTRATION: This study is registered as PROSPERO CRD42015027042. FUNDING: The National Institute for Health Research Health Technology Assessment programme.