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. 2018 Feb 13;68(668):e168–e177. doi: 10.3399/bjgp18X694997

Table 1.

The impacts of a large-scale general practice collaboration (Tower Hamlets Managed General Practice Network) from quantitative studies

Authors and journal Title of paper Study methods Care package facilitated by Tower Hamlets Managed General Practice Network Key performance indicators Reported impact on processes and indicators of quality of care Reported impact on costs
Cockman et al (2011), BMJ 24 Improving MMR vaccination rates: herd immunity is a realistic goal Observational. Time-series study analysis. Comparison with trends in London and England.
Intervention phased in Sep 2009 to Jan 2010.
Period of data analysis presented quarterly between Q1 2006 and Q3 2010 (MMR1 vaccination)

  • Financial incentives.

  • Standardised recording of data.

  • Systematic call and recall with IT.

  • Monthly dashboard feedback on performance.

  • Training and education for clinicians.

  • Active follow-up of defaulters.

  • Regular meetings for peer review and ideas sharing

  • Achieve 95% uptake of all childhood immunisations

  • Uptake of first MMR1 vaccine before age 2 rose from 80% in Sep 2009 to 94% in Mar 2011.

  • Step change in rate of increase of MMR1 compared with before and after (P<0.001), London and England

  • Total for eight networks: £112 000 (used as financial incentive; £14 000/network).

  • 50% in advance, 50% dependent on performance. This was in addition to existing direct enhanced services funding for childhood immunisation
Hull et al (2014), BMJ Quality and Safety25 Improving outcomes for patients with type 2 diabetes using general practice networks: a quality improvement project in East London Observational. Time-series analysis. Comparison with trends in two neighbouring PCTs, London and England Intervention phased in Oct 2009 to Apr 2010. Period of data analysis presented yearly 2007–2012 (retinopathy screen), 2006–2012 (total cholesterol), 2006–2012 (BP), 2005–2012 (HbA1c)

  • Financial incentives.

  • Standardised recording of data.

  • Systematic call and recall with IT.

  • Monthly dashboard feedback on performance.

  • Bimonthly MDT meetings with diabetic specialist team.

  • Supported case management and education.

  • Rapid access to consultants via e-mail or phone

  • Number of care plans completed, target: 90%.

  • Proportion of patients attending retinal screening, target: 80%.

  • Proportion of patients achieving BP ≤140/80 mmHg and total cholesterol ≤4 mmol/l: target 50%

  • Network population average HbA1c: target 7.5%

  • Rise in care plans from 10% in Q1 2009 to 88% in Q1 2012.

  • Rise in retinal screening from 72% in Q1 2009 to 82.8% in Q1 2012: step change catch-up with London and England (no P-value).

  • Rise in joint BP and cholesterol target achieved, from 35.3% in Q1 2009 to 46.1% in Q1 2012 (did not meet target). Performed better than London and England (no P-value).

  • Average HbA1c fell from 7.8% in 2009 to 7.66% in 2012 (did not meet 7.5% target). Trend similar to London and England (no P-value)

  • Total for eight networks: £1.7 million (>£200 000/network)

  • 70% in advance, 30% dependent on performance
Hull et al (2014), Primary Care Respiratory Medicine26 Improving outcomes for people with COPD by developing networks of general practices: evaluation of a quality improvement project in East London Observational. Time-series analysis. Comparison with trends in London and England. Intervention phased in Apr 2010 to Jun 2010. Period of data analysis presented yearly 2010–2013 (annual review), 2005–2013 (influenza vaccination), 2005–2011 (COPD admissions)

  • Financial incentives.

  • Standardised recording of data (including comorbidities, medication review, encourage non-pharmaceutical interventions).

  • Systematic call and recall with IT.

  • Active follow-up of non-attenders.

  • Monthly dashboard feedback on performance.

  • Regular patient review

  • Quarterly MDT meeting including respiratory consultant and community respiratory team.

  • Supported case management and education.

  • Community-based pulmonary rehab.

  • Hospital admission avoidance service.

  • Rapid access to consultants via e-mail or phone

  • Increase number of COPD cases on network registers: target 10% increase in first year.

  • Increase in number of care plans: target 80% community-based pulmonary rehab target 75% in patients with MRC score ≥3

  • Improve influenza vaccination (no target, not financially incentivised as already incentivised by QOF).

  • Reduce smoking prevalence (no target, not financially incentivised as already incentivised by QOF).

  • Reduce emergency hospital admission for COPD (no target, not financially incentivised, only tracked)

  • COPD register increased by 21% between 2010 and 2013.

  • Annual reviews and care planning increased from 53% in 2010 to 86.5% in 2013.

  • Pulmonary rehab in patients from 45% in 2010 to 75% in 2013. No national comparator.

  • Influenza vaccination high before intervention, showed ‘steady improvement’. In 2012 it was ‘significantly higher’ than rate in England.

  • No improvement in smoking prevalence: in 2010, 39% of patients with COPD smoked; in 2013, 40.4% smoked.

  • Emergency COPD admissions ‘have fallen’ but remain higher than London average. Trend suggests a step change compared with London and England trends

  • Total for eight networks: £300 000/annum for 3 years.

  • 70% in advance, 30% dependent on performance
Robson et al (2014), British Journal of General Practice27 Improving cardiovascular disease using managed networks in general practice: an observational study in inner London Observational study. Comparison with trends in two local PCTs, London, and England. Intervention phased in 2008 to Apr 2010. Period of data analysis presented yearly. 2009–2011 (lipid-lowering prescribing), 2004–2012 (CHD BP <150/90 mmHg), 2004–2012 (CHD cholesterol <5 mmol/l), 2004–2010 (myocardial infarction mortality in patients <75 years)

  • Financial incentives.

  • Systematic call and recall with IT.

  • Standardised recording of data.

  • Monthly dashboard feedback on performance.

  • Three whole-time community specialist CVD nurses across all networks.

  • Training for practice nurses.

  • Clinical guidelines developed by local clinical effectiveness group

  • BP <140/90 mmHg for hypertension, stroke, and CHD.

  • Cholesterol <4 mmol/l for stroke, CHD, and diabetes.

  • BP <140/80 mmHg for diabetes.

From Apr 2010:

  • proportion of new heart attacks reviewed at GP surgery <3 weeks of hospital discharge;

  • attendance at cardiac rehab;

  • recording of care plan

  • Statin prescribing increased more than in two local PCTs between 2009 and 2011 (P<0.01).

  • Improvements in cholesterol levels and BP took place at a faster rate than London and England for patients with hypertension, stroke, CHD, and diabetes (P<0.05 to P<0.001).

  • Proportion of patients with a care plan increased from 42.7% in 2011 to 61.6% in 2012.

  • Proportion of people with a new heart attack seen <3 weeks of discharge increased from 68.9% in 2009 to 71.3% in 2012.

  • Attendance at cardiac rehab decreased from 34.8% in 2009 to 27.7% in 2012.

  • There was no change in influenza vaccination (83%) between 2009 and 2012.

  • Paper also reported a faster rate of decline in deaths from acute myocardial infarction between 2008 and 2012 than local PCTs, London, or England. It reduced by 43% compared with an average of 25% for the top 10 PCTs in 2008 ranked by mortality. The authors recognise association is speculative

  • Total for all eight networks for all four packages of care (CVD, COPD, diabetes, childhood immunisations): £10 million/annum for 3 years

BP = blood pressure. CHD = coronary heart disease. COPD = chronic obstructive pulmonary disease. CVD = cardiovascular disease. HbA1c = glycated haemoglobin. MDT = multidisciplinary team. MMR = measles, mumps, and rubella. MRC = Medical Research Council. PCT = primary care trust. QOF = Quality and Outcomes Framework. Rehab = rehabilitation.