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Background: The COronaVIrus Disease 2019 (COVID-19) pandemic has led to significant re-organisation of general practice in the United Kingdom and around the world. The general practice workforce has led changes to their services, often dealing with high levels of uncertainty. The way in which many practitioners consult has shifted significantly, and there has been an increase in the number of phone and online consultations. We know very little about how those working in general practice experienced the service reorganisation introduced in the first year of the COVID-19 pandemic. Aim: The aim of this project was to describe the changes in the delivery of general practice in the United Kingdom in the first year of the COVID-19 pandemic. Furthermore, to explore primary care practitioners' and managers' experiences of change within general practice during this time and investigate shifts in perceptions of professional identities. Method: We conducted a longitudinal qualitative study that captured narrative accounts from 17 primary care practitioners and managers across England and Scotland. Each participant submitted narrative accounts in the first year of the COVID-19 pandemic using self-recorded or written contributions, or via an interview if preferred. These were analysed using a grounded theory approach, with thematic coding used to construct common themes. Findings: Participants' narratives describe the challenges COVID-19 presented to general practice. Responses mirror the shifts in the pandemic and its management – from an initial sense of autonomy but uncertainty, to a period of stability and patients' increasing frustration. The re-organisation of general practice has affected practitioners' views of their work and their role as clinicians. Participants' narratives were framed profoundly by the importance of their relationships with patients. This analysis of practitioners' and managers' narratives highlights the need for further exploration of how to support the general practice workforce's well-being longer term in a context of increased demand and significant change. [ABSTRACT FROM AUTHOR]

Introduction: For more than a decade the English NHS has pursued integrated care through three national pilot programmes. The independent evaluators of these programmes here identify several common themes that inform the development of integrated care. Description: The three pilot programmes shared the aim of better coordination between hospital and community-based health services and between health and social care. Each programme recruited local pilot sites that designed specific interventions to support inter-professional and inter-organisational collaboration. The pilots were highly heterogenous and results varied both within and between the three programmes. While staff were generally positive about their achievements, pilots had mixed success especially in reducing unplanned hospital admissions. Common facilitators to achieving pilots' objectives included effective senior leadership and shared values, simple interventions and additional funding. Barriers included short timescales, poor professional engagement, information and data sharing problems, and conflicts with changing national policy. Discussion: There was little stable or shared understanding of what 'integrated care' meant resulting in different practices and priorities. An increasing focus on reducing unplanned hospital use among national sponsors created a mismatch in expectations between local and national actors. Conclusion: Pilots in all three national programmes made some headway against their objectives but were limited in their impact on unplanned hospital admissions. [ABSTRACT FROM AUTHOR]

Introduction: This paper provides the results of a year-long evaluation of a large-scale integrated care pilot in north-west London. The pilot aimed to integrate care across primary, acute, community, mental health and social care for people with diabetes and/or those aged 75+ through care planning, multidisciplinary case reviews, information sharing and project management support. Methods: The evaluation team conducted qualitative studies of change at organisational, clinician and patient levels (using interviews, focus groups and a survey); and quantitative analysis of change in service use and patient-level clinical outcomes (using patient-level datasets and a matched control study). Results: The pilot had successfully engaged provider organisations, created a shared strategic vision and established governance structures. However, the engagement of clinicians was variable and there was no evidence to date of significant reductions in emergency admissions. There was some evidence of changes in care processes. Conclusion: Although the pilot has demonstrated the beginnings of large-scale change, it remains in the early stages and faces significant challenges as it seeks to become sustainable for the longer term. It is critical that National Health Service managers and clinicians have realistic expectations of what can be achieved in a relatively short period of time. [ABSTRACT FROM AUTHOR]

Background: Since 1991, there has been a series of reforms of the English National Health Service (NHS) entailing an increasing separation between the commissioners of services and a widening range of public and independent sector providers able to compete for contracts to provide services to NHS patients. We examine the extent to which local commissioners had adopted a market-oriented (transactional) model of commissioning of care for people with long term conditions several years into the latest period of market-oriented reform. The paper also considers the factors that may have inhibited or supported market-oriented behaviour, including the presence of conditions conducive to a health care quasi-market. Methods: We studied the commissioning of services for people with three long term conditions - diabetes, stroke and dementia - in three English primary care trust (PCT) areas over two years (2010-12). We took a broadly ethnographic approach to understanding the day-to-day practice of commissioning. Data were collected through interviews, observation of meetings and from documents. Results: In contrast to a transactional, market-related approach organised around commissioner choice of provider and associated contracting, commissioning was largely relational, based on trust and collaboration with incumbent providers. There was limited sign of commissioners significantly challenging providers, changing providers, or decommissioning services. In none of the service areas were all the conditions for a well functioning quasi-market in health care in place. Choice of provider was generally absent or limited; information on demand and resource requirements was highly imperfect; motivations were complex; and transaction costs uncertain, but likely to be high. It was difficult to divide care into neat units for contracting purposes. As a result, it is scarcely surprising that commissioning practice in relation to all six commissioning developments was dominated by a relational approach. Conclusions: Our findings challenge the notion of a strict separation of commissioners and providers, and instead demonstrate the adaptive persistence of relational commissioning based on continuity of provision, trust and interdependence between commissioners and providers, at least for services for people with long-term conditions. [ABSTRACT FROM AUTHOR]

Following recent reforms of both local government and the National Health Service, there is significant emphasis in both services on improving inter-agency collaboration, user involvement and strategic commissioning. In response, this article reviews historical debates about the relationship between local government and health care, before arguing that these two ‘partners’ need each other now more than ever. If local government is to be a ‘place-shaper’, then it needs significant influence over local health services, while the NHS needs to learn from the best of local government if it is to gain sufficient local legitimacy to take the difficult decisions it needs to take. Against this background, the article reviews different options for future joint working, exploring various options for enacting a new relationship between local government and the NHS. [ABSTRACT FROM AUTHOR]

Purpose. To evaluate and compare patients' preferences in receiving chemotherapy education from health care teams in community versus academic clinics. Methods. Results from a 13-question questionnaire about the chemotherapy education preferences of patients in three community gynecology oncology clinics were compared to the results from a similar study previously conducted in an academic gynecology oncology clinic. Results. A total of 57% of the 203 community-clinic respondents (116) and 67% of the 282 academic-institution respondents (189) who completed questionnaires had previously received chemotherapy. Of the patients treated in community clinics, almost 60% preferred chemotherapy education to be provided in written form and directly by a health care professional compared to 87% of the patients in academic clinics. Overall, 88% of the patients in the community clinics believed they received adequate information, compared to 63% of the patients in the academic setting. Patients in the community clinics wanted to get more in-depth answers to questions such as 'What is chemotherapy?' (54%) and 'How it is given?' (55%). In addition, community patients also wanted to know more about 'Why chemotherapy stops working?' (72%) and 'What to do and who to call about side effects?' (60%). In the academic setting, patients were less likely to want to know more about these chemotherapy related questions (42, 35, 57, and 49, respectively). Conclusions. Patients preferred to receive written chemotherapy education that was reviewed with a healthcare professional and that gave more detailed information about the chemotherapeutic drugs themselves and how to prevent and manage side effects. As a result of this questionnaire, the patient education materials used at our institution will be revised to better address patients' preferences in both treatment settings. [ABSTRACT FROM AUTHOR]

The corporatization of primary care in the USA and the UK over recent years has transformed the way that these services are managed and delivered. Traditional approaches based around small practices of doctors and their teams as the primary organizational unit have been largely overtaken by new models in which doctors, nurses and other primary care professionals work within much larger organizations. This article explores the experience in the USA and the UK of seeking to organize primary care more corporately, and suggests that a tightly managed organizational model does not work well in primary care. Looser, network-based models are needed in which some of the benefits of corporatization can be achieved while the traditional small-organization virtues of primary care can continue to thrive. [ABSTRACT FROM AUTHOR]

This article examines how the Government's `third way' is being implemented in relation to the involvement of primary care professionals in the commissioning of health services. Prior to 1997, the single preferred model of GP fundholding evolved into a diversity of approaches to commissioning and these approaches became increasingly collaborative rather than competitive. From this starting point, the authors examine the key assumptions underlying the present single model of the primary care group (PCG) as the commissioning body for the `New NHS'. They suggest that PCGs will also evolve into a diversity of models, but there will be tensions arising over the greater emphasis on central direction and performance management. [ABSTRACT FROM AUTHOR]

Complex Physical Therapy (CPT) is discussed and its principles outlined. CPT involves: 1. skin care, 2. a special lymphatic massage, 3. compression bandaging and (later) garments, 4. special exercises which supplement the massage. CPT was used on 78 patients with postmastectomy lymphoedema (17 with Grade 1 and 61 with Grade 2). There were significant differences between the Grades. In the first four-week course the mean Grade 1 was reduced from 121% of normal to 107% (the mean change in the oedema was 103 % of its initial value), and Grade 2 from 153 % to 123 % (with a mean change in oedema of 60%). All these were very highly significant. Over the next year there was a small, but very significant, decrease in the percentage of oedema. A further four-week course resulted in significant, and similar, reductions in the residual oedema. CPT was used to treat 128 lymphoedematous legs; 22 were Grade 1 lymphoedema, 84 were Grade 2 and 19 were elephantitic (Grade 3). After the first course of CPT the mean losses were: 1.1, 1.3 and 3.7 litres, respectively (all very significant). Over the next 11 months there were significant further reductions for all legs and in the amount of oedema of the unilateral legs. Some patients had a second course of CPT with similar reductions in the remaining oedema to that after the first course. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the authors discusses various reports within the issue on topics including the application of market concepts to the delivery of health care, commissioning from non-traditional providers in the English National Health Service (NHS).

Background: Commissioning is a term used in the English National Health Service (NHS) to refer to what most health systems call health planning or strategic purchasing. Drawing on research from a recent in-depth mixed methods study of a major integrated care initiative in North West London, we examine the role of commissioning in attempts to secure large-scale change within and between health and social care services to support the delivery of integrated care for people living with complex long-term conditions.Methods: We analysed data collected in semi-structured interviews, surveys, workshops and non-participant observations using a thematic framework derived both deductively from the literature on commissioning and integrated care, as well as inductively from our coding and analysis of interview data.Results: Our findings indicate that commissioning has significant limitations in enabling large-scale change in health services, particularly in engaging providers, supporting implementation, and attending to both its transactional and relational dimensions.Conclusions: Our study highlights the consequences of giving insufficient attention to implementation, and especially the need for commissioners to enable, support and performance manage the delivery of procured services, while working closely with providers at all times. We propose a revised version of Øvretveit's cycle of commissioning that gives greater emphasis to embedding effective implementation processes within models of commissioning large-scale change. [ABSTRACT FROM AUTHOR]

The article presents an editorial regarding the role of primary care trusts in improving public health, providing primary health care, and commissioning secondary and tertiary care services in Great Britain. Primary care trusts have allowed patients to choose to use a greater range of providers as well as conventional general practices. Primary care trusts have a role in relation to the need for stronger strategic purchasers and governors of local health systems as commissioning decisions pass to practices. The editor suggests that primary care trusts should no longer be health care service providers.

Presents an editorial about primary care trusts. History of primary care trusts in the National Health Service in England; Belief by some that these trusts have failed to fulfill expectations for health care; Expectation for mergers of primary care trusts in 2005; Speculation on how a structural reorganization of these trusts would benefit the health system.

Editorial. Discusses the British government's plans to reorganize the National Health Service. Proposal to abolish executive regional offices and a percentage of health authorities and create new primary care trusts; Public and political impatience with the quality of NHS services; Disapproval of the plan among doctors and health services managers; Argument that the government's plan is not based on evidence.

Introduction: Chemotherapy for breast cancer has been associated with cognitive problems; however, the impact of adjuvant hormone therapy is less clear. No studies have explored provider discussions about cognitive concerns or factors associated with neurocognitive treatment. This study examined cognitive problems, factors associated with having a provider discussion, and receipt of neurocognitive treatment.Methods: Female breast cancer survivors (N=2,537) from the Sister Study and the Two Sister Study who were at least 1 year post-treatment were surveyed in 2012 about their cancer therapies (confirmed by medical records); cognitive concerns; related provider discussions; and neurocognitive treatment. A total of 2,296 women were included in the current 2014 analysis. Extensive covariate information was also ascertained for predictive multivariate models.Results: The prevalence of self-reported cognitive problems after treatment was 60%. Of those reporting cognitive problems, only 37% had discussed those concerns with a provider and 15% had been treated for cognitive symptoms. The odds of reported cognitive concerns that started during and after treatment were elevated for those who received only hormone therapy and no chemotherapy (OR=1.64, 95% CI=1.15, 2.33); chemotherapy and no hormone therapy (OR=5.63, 95% CI=3.52, 9.00); or both (OR=6.33, 95% CI=4.21, 9.54) compared with those reporting neither treatment.Conclusions: The high prevalence of cognitive concerns underscores the importance of monitoring breast cancer survivors for potential neurocognitive effects of hormone and chemotherapy, discussions with survivors about those concerns, and treatment referrals. Monitoring changes over time can help to evaluate both psychosocial and neurocognitive care provided for survivors. [ABSTRACT FROM AUTHOR]