Current and future cardiovascular disease risk assessment in the European Union: an international comparative study.

Background: Risk assessment is central to primary prevention of cardiovascular disease (CVD), but there remains a need to better understand the use of evidence-based interventions in practice. This study examines: (i) the policies and guidelines for risk assessment in Europe, (ii) the use of risk assessment tools in clinical practice and (iii) the barriers to, and facilitators of, risk assessment. Methods: Data were collected from academics, clinicians and policymakers in an online questionnaire targeted at experts from all European Union member states, and in 8 in-depth country case studies that were developed from a targeted literature review and 36 interviews. Results: The European Society of Cardiology (ESC) produces European guidelines for CVD risk assessment and recommends the Systematic COronary Risk Evaluation tool, which is the most widely used risk assessment tool in Europe. The use of risk assessment tools is variable. Lack of time and resources are important barriers. Integrating risk assessment tools into clinical systems and providing financial incentives to carry out risk assessments could increase implementation. Novel biomarkers would need to be supported by evidence of their clinical effectiveness and cost-effectiveness to be introduced in clinical practice. These findings were consistent across Europe. Conclusions: Efforts to improve the assessment of CVD risk in clinical practice should be carried out by or in collaboration with, the ESC. Increasing the use of existing risk assessment tools is likely to offer greater gains in primary prevention than the development of novel biomarkers.

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.

Future of Health: Findings from a survey of stakeholders on the future of health and healthcare in England.

This article presents findings from a survey conducted by RAND Europe at the request of the National Institute for Health Research (NIHR) to gather and synthesise stakeholder views on the future of health and healthcare in England in 20 to 30 years' time. The aim of the research was to generate an evidenced-based picture of the future health and healthcare needs, and how it might differ from today, in order to inform strategic discussions about the future priorities of the NIHR and the health and social care research communities more broadly. The survey provided a rich and varied dataset based on responses from 300 stakeholders in total. A wide range of fields were represented, including public health, social care, primary care, cancer, genomics, mental health, geriatrics, child health, patient advocacy and health policy. The respondent group also included a number of professional and private stakeholder categories, such as clinicians, policy experts, academics and patient and public representatives. The study findings validate a number of prominent health research priorities currently visible in England, such as antimicrobial resistance, the burden of dementia and age-related multi-morbidity, digital health and genomics. Interest in these areas and other themes, such as mental health, health inequalities and transforming health service models, cut across multiple disciplinary boundaries. However, it is clear that there are a variety of views among stakeholders on the relative importance of these areas of focus, and the best approach to manage their emergence in the coming decades. The full dataset of survey responses, for which permission to share was given, is a useful resource for those seeking to engage with a particular issue in more depth. The dataset can be found on NIHR's website at: http://nihr.ac.uk/news-and-events/documents/quotes.xls.

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.

Innovation as a Driver of Quality and Productivity in UK Healthcare: Creating and Connecting Receptive Places-Emerging Insights.

The demand for health services in England is both growing and changing in nature, yet resources are limited in their ability to respond to the scale and scope of need. As a result, the NHS is under increasing pressures to realise productivity gains, while continuing to deliver high quality care. RAND Europe and the University of Manchester have been commissioned to conduct a study to examine the potential of innovation to respond to the challenges the NHS faces, and to help deliver value for money, efficient and effective services. "Innovation" in this study refers to any product, technology or service that is new to the NHS, or applied in a new way, aimed at delivering affordable and improved care. The learning we have gained adds considerable depth to the practical discussions presented regarding how innovation can be first nurtured and then made meaningful and actionable in a variety of settings. This is important given the complexity of health innovation systems and the diversity of elements that need to interact and work together for the overall system to function effectively. We share insights related to skills, capabilities and leadership; motivations and accountabilities; information and evidence; relationships and networks; patient and public engagement; and funding and commissioning. We will develop these detailed learning points into a more systematic analysis as the research evolves. The research is funded by the Department of Health Policy Research Programme, in close collaboration with NHS England and the Office of Life Sciences.

Evaluation of telephone first approach to demand management in English general practice: observational study.

Objective To evaluate a "telephone first" approach, in which all patients wanting to see a general practitioner (GP) are asked to speak to a GP on the phone before being given an appointment for a face to face consultation.Design Time series and cross sectional analysis of routine healthcare data, data from national surveys, and primary survey data.Participants 147 general practices adopting the telephone first approach compared with a 10% random sample of other practices in England.Intervention Management support for workload planning and introduction of the telephone first approach provided by two commercial companies.Main outcome measures Number of consultations, total time consulting (59 telephone first practices, no controls). Patient experience (GP Patient Survey, telephone first practices plus controls). Use and costs of secondary care (hospital episode statistics, telephone first practices plus controls). The main analysis was intention to treat, with sensitivity analyses restricted to practices thought to be closely following the companies' protocols.Results After the introduction of the telephone first approach, face to face consultations decreased considerably (adjusted change within practices -38%, 95% confidence interval -45% to -29%; P<0.001). An average practice experienced a 12-fold increase in telephone consultations (1204%, 633% to 2290%; P<0.001). The average duration of both telephone and face to face consultations decreased, but there was an overall increase of 8% in the mean time spent consulting by GPs, albeit with large uncertainty on this estimate (95% confidence interval -1% to 17%; P=0.088). These average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase. Compared with other English practices in the national GP Patient Survey, in practices using the telephone first approach there was a large (20.0 percentage points, 95% confidence interval 18.2 to 21.9; P<0.001) improvement in length of time to be seen. In contrast, other scores on the GP Patient Survey were slightly more negative. Introduction of the telephone first approach was followed by a small (2.0%) increase in hospital admissions (95% confidence interval 1% to 3%; P=0.006), no initial change in emergency department attendance, but a small (2% per year) decrease in the subsequent rate of rise of emergency department attendance (1% to 3%; P=0.005). There was a small net increase in secondary care costs.Conclusions The telephone first approach shows that many problems in general practice can be dealt with over the phone. The approach does not suit all patients or practices and is not a panacea for meeting demand. There was no evidence to support claims that the approach would, on average, save costs or reduce use of secondary care.

Community Hospitals in Selected High Income Countries: A Scoping Review of Approaches and Models.

BACKGROUND: There is no single definition of a community hospital in the UK, despite its long history. We sought to understand the nature and scope of service provision in community hospitals, within the UK and other high-income countries. METHODS: We undertook a scoping review of literature on community hospitals published from 2005 to 2014. Data were extracted on features of the hospital model and the services provided, with results presented as a narrative synthesis. RESULTS: 75 studies were included from ten countries. Community hospitals provide a wide range of services, with wide diversity of provision appearing to reflect local needs. Community hospitals are staffed by a mixture of general practitioners (GPs), nurses, allied health professionals and healthcare assistants. We found many examples of collaborative working arrangements between community hospitals and other health care organisations, including colocation of services, shared workforce with primary care and close collaboration with acute specialists. CONCLUSIONS: Community hospitals are able to provide a diverse range of services, responding to geographical and health system contexts. Their collaborative nature may be particularly important in the design of future models of care delivery, where emphasis is placed on integration of care with a key focus on patient-centred care.

International Variation in Drug Usage: An Exploratory Analysis of the "Causes" of Variation.

This article explores the range of possible causes that might explain observed international variations in the usage of medicines for selected disease areas: dementia, osteoporosis, cancer, diabetes and hepatitis C. Commissioned by the UK Department of Health, through its Policy Research Programme, it complements a quantitative analysis of medicines uptake carried out by the Office for Health Economics (OHE) of medicines uptake across 16 classes of medicines in 13 high-income countries in 2012/13. Both studies build on an earlier study led by Professor Sir Mike Richards (UK) into the extent and causes of international variations in drug usage, published in 2010. Drawing on a rapid evidence assessment, we explore, for each of the five disease areas, epidemiological factors such as the disease burden and aspects of health system and service organisation that were shown to have a direct or indirect impact on drug usage, such as reimbursement mechanisms, access to diagnosis and treatment more broadly. We also provide a summary overview of key features of the health systems and of the principles of drug assessment or approval processes across the countries included in the OHE analysis. We find that a range of factors are likely to play a role in explaining international variation in medicines use, but their relative importance will vary depending on the disease area in question and the system context. Any given level of use of a given medicine in one country is likely determined by a set of factors the combination and the relative weight of which will be different in another country.