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Primary Care

Primary Care Groups In The United Kingdom: Quality And Accountability

Abstract

 
With the introduction of primary care groups (PCGs), the British National Health Service has attempted to integrate delivery, finance, and quality improvement into a locally directed care system with a strong sense of community accountability. PCGs will eventually hold the budgets for primary care, specialist, hospital, and community-based services and have the flexibility to reapportion these budgets. Through clinical governance, PCGs are attempting to coordinate education, guidelines, audit and feedback, and other quality improvement approaches around health problems that are relevant to their patient panels and local communities. PCGs offer other nations attempting to improve the quality and accountability of health care an innovative approach that merits consideration.

Primary Care Groups

Top Primary Care Groups Building A Community-Focused... Clinical Governance Clinical-Governance Strategies... Barriers To Change Integrating The Quality Agenda... Applying The Lessons Of... NOTES

 
Each general practice in England has become a member of a PCG, with slightly different arrangements introduced in other parts of the United Kingdom. At the outset there were 481 PCGs ranging in size from 50,000 to 250,000 patients. A typical PCG has around 100,000 patients, fifty GPs, and a number of community health and social care professionals. PCGs have emerged with different baseline characteristics including socioeconomic characteristics of their populations and hospital admission rates.²

PCGs build on many aspects of the preceding policy of "fundholding" in which practices held the financial risk for primary care and specialty services.³ However, unlike fundholding, which was more market oriented and voluntary, membership in a PCG is compulsory for general practices. Furthermore, general practices did not have any choice over the PCG to which they were assigned, as PCG boundaries were drawn to reflect the boundaries of health authorities (local NHS administrative units) and local (municipal) government authorities. Within the U.S. context, the PCG can be thought of as a type of mandatory independent practice association (IPA)–like network. However, unlike the U.S. situation, the boundaries of each network are mutually exclusive.

PCGs are designed (1) to develop and plan primary care and community health services in their area, (2) to improve the quality of primary care and community health services (such as visiting nurses and social services) provided in their locality by implementing a program of clinical governance, (3) to take increasing responsibility for commissioning (contracting) secondary care (hospital) services for their local population, and (4) to improve the health of their population and address health inequalities (particularly socioeconomic inequalities).

PCGs are also expected to evolve over time. Over the next few years the NHS Executive (the central management unit) will regularly assess PCGs and assign them to one of four levels of financial and management responsibility. All PCGs launched in April 1999 started at the two lowest of four levels of development, and their local health authority maintained much administrative and financial responsibility. All groups will eventually receive a budget to cover hospital and community health services, outpatient prescribing, and the funds used to reimburse general practices for their practice staff, premises, and computing costs.⁴ Fully evolved level-four PCGs, known as primary care trusts (PCTs), are administratively independent of the local health authority and instead are governed by a consumer-dominated board. The first PCTs emerged in April 2000; the majority of PCGs are expected to advance to this level, either on their own or as a part of a consortium with geographically contiguous PCGs, over the next few years.

Recently, the NHS proposed the establishment of a new "level" of primary care trust, which will provide even closer integration of health and social care.⁵ These new "Care Trusts" will be able to commission and deliver social services for the elderly and other priority groups, as well as the health services that will be commissioned and supplied by all PCTs. This would require the pooling of local-authority budgets for social services and the PCT’s budget for health services.

Building A Community-Focused Integrated Provider Organization

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The PCG’s form and function concentrate the energies of the organization on the denominator population it serves. All persons residing in a geographically defined community are served by the same provider collective. This would be equivalent to everyone in a U.S. community having universal health insurance coverage and using the same health plan and associated provider network. The PCG will provide most primary care directly and will contract with other NHS providers for specialist, hospital, and community-based services. Some services (such as care at tertiary referral centers) will be excluded from PCG budgets. The entire fiscal and structural development of the PCG is meant to take into consideration the special needs of the local population. To achieve this goal, evolved PCGs will have the flexibility to reapportion their budgets from secondary to primary or community care.

To make PCGs responsive to their local community needs and not just the needs of those who present to physicians’ offices for care, PCGs are becoming active in performing needs assessment. At present, needs-assessment activities remain largely based in local health authorities. However, PCGs are contributing to the development of a community-based local Health Improvement Program (or HImP) as part of an NHS-wide attempt to promote public health and to target medical services to the special needs of local populations. ⁶ A major component of the HImP initiative is the development of community-based health indicators for common conditions (for example, heart disease, cancer, and substance abuse) relevant to each locale. These are being identified and will be monitored for each area over time. These priority areas will be interwoven into the PCGs, and eventually accountability for improvement in these indicators will be a focus of the annual review of PCG management.

To extend the reach of traditional medical practice, PCGs will eventually be responsible for a comprehensive outreach program. Some of this the PCG will do directly; other aspects will be commissioned to other parties. Other interventions will be influenced by the PCG through partnerships and collaborations with separate medical, public health, and social welfare agencies.

Some PCGs are performing or collaborating in special community-based health promotion projects known as "healthy living centers," which are storefront resource centers generally targeted at one or more special problems facing a community (for example, cardiovascular risk and teenage pregnancy). Some PCGs are working with schools and housing authorities to integrate health promotion activities into these organizations. For instance, some PCGs are working with schools by targeting issues that are important to teens, and others have introduced exercise and hip fracture prevention programs in assisted living for the elderly.⁷

The NHS in many locales also has well-developed community services that include a cadre of visiting nurses, home health care workers, and rehabilitative services. These services will in time be closely integrated with the activities and mission of the PCGs to promote systemic identification of at-risk persons not currently under treatment. In the future, many of these services will be directed and overseen by PCGs as part of their broader function.

With the PCG movement, the NHS has attempted to integrate delivery structure, finance, and quality improvement into a locally directed care system with a strong sense of community accountability. More than any other mainstream model, the PCGs represent the essence of what has been termed "Community Oriented Primary Care" (COPC).⁸ COPC is a primary care–led health care delivery strategy that incorporates epidemiology, public health, and financial management, whose goal is to maximize the health benefit for given target community. While much has been written about COPC, implementation on a wide scale has, until now, eluded most nations.

Clinical Governance

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A second key task for PCGs is to improve the quality of the care provided by primary care professionals. Through a process termed "clinical governance," PCGs have been given responsibility for continuously improving the quality of their services and safeguarding high standards of care.⁹ PCGs have a statutory duty to perform clinical governance and to establish and maintain arrangements for monitoring and improving the quality of the care that they provide. A considerable proportion of the early years of PCG operation has focused on this process.

One of the main targets of clinical-governance activities is the elimination of variation in practice. Numerous studies in the United Kingdom have documented variation in health care service delivery across small areas.¹⁰ As is the case in the United States, British policymakers and planners have promoted the concept that this variation represents inappropriate variation in physician decision making.

Clinical-Governance Strategies Adopted By PCGs

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Clinical governance requires the involvement of providers in the oversight of one another’s work and an integrated approach to quality improvement. GPs must work together within a PCG network and with other providers with whom that PCG commissions care. During their first year most PCGs have focused their clinical-governance activities on creating an administrative structure for reporting and acting upon information related to quality of care within their group and on identifying individuals in the PCG who would take a leadership role in clinical governance.¹¹

Our site visits to several PCGs suggested that PCGs are deploying many of the same tools that U.S.-based medical groups and managed care organizations (MCOs) have been using to influence physicians’ behavior. However, PCGs are beginning to use these strategies in new and integrated ways. For example, PCGs are linking continuing education activities for physicians with quality improvement goals. This is being done by having the GPs within a PCG first agree on a topic area, such as cardiovascular disease, for quality improvement. Then educational activities in the selected content area are organized at the PCG level. Many PCGs are focusing on the clinical content areas and management approaches described in evidence-based guidelines emerging from a new NHS agency, the National Institute for Clinical Effectiveness (NICE), reinforced by National Service Frameworks published by the Department of Health.

Before the emergence of PCGs, many primary care physicians would, as their U.S. counterparts do, attend postgraduate (continuing medical education) conferences on a topic of their choosing as a way to maintain and update their knowledge. There was no expectation that physicians would use this educational experience to more broadly educate other practitioners in their work environment. Because a physician would typically obtain this education in isolation from practice colleagues, there was little opportunity to reflect on the new material with them. Research studies have documented the relatively weak impact the traditional continuing educational experience has had on changing physician practice patterns. ¹² PCGs are attempting to extend the learning potential of these training sessions by having primary care physicians within a PCG attend them together. To encourage participation, PCGs are enabling GPs who participate to capture from the NHS the small incentive (approximately $3,000 per GP per year) that traditionally was only available when primary care physicians left their practice environment to gain this training. Thus, PCGs are reshaping postgraduate education from an individual GP-centered activity to a primary care local network–centered one.

In addition, some of the more ambitious PCGs have created audit and feedback tools linked to the education and the targeted quality improvement topic. The audit process is similar to the practice profiling that occurs in U.S. managed care settings. Practitioners are categorized according to their use of services overall and in association with managing specific sorts of patients. Since many of the GPs within a PCG participated through the education process in selecting the quality improvement topic and the associated measures of quality, they are invested in acting upon them. Differences in practice patterns are discussed among the primary care physicians, and, when necessary, PCG resources (financial and/or technical assistance) are invested in poorly performing practices to move them closer to the group’s average performance level.

For many PCGs there are only a limited number of clinical areas for which common data exist across practice sites. The most commonly available data are on pharmaceutical prescribing. Many PCGs already use these data to profile practices’ use of generic drugs, and plans are under way in some PCGs to coordinate their drug utilization review assessment on the same areas that are targeted for clinical improvement.¹³ In addition to pharmaceutical profiling, many PCGs are actively developing chronic disease registries across general practices with the expectation that this will enable them to assess variations in practice and to develop strategies to improve the management of sick patients across practices.¹⁴

The first wave of PCGs evolving to PCTs is less than a year old, so it is difficult to predict how PCTs will ultimately distinguish themselves from PCGs. One strategy that is being used in at least one PCT resembles disease management used by some U.S. managed care plans.¹⁵ Within this PCT, GPs are establishing specialty areas and are assuming the management of some conditions for patients in the panels of other GPs in their PCT. The NHS plan published in 2000 proposes the creation of 1,000 such "specialist general practitioner" posts over the next few years.¹⁶ Not only might this save the PCT the cost of having to pay specialists outside the PCT for consultative services, but it also provides a mechanism for GPs to develop high volumes of service in narrow clinical areas. This might result in quality improvement on the basis of a volume/outcome relationship that has been well described in hospital-based care.¹⁷

Barriers To Change

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Information technology. While the commitment to an organizational change in the NHS to improve quality is quite promising, pace of development has been impeded by several factors.¹⁸ First, necessary information infrastructure has been slow to develop because of limited financial investment and the challenge of integrating disparate existing information systems. A high percentage of general practices are computerized in the United Kingdom.¹⁹ sophistication of these systems varies from administrative and repeat prescribing support at one end to virtually paperless offices the other. Despite the availability of information technology, PCGs still have difficulty sharing and comparing data because of the incompatibility of the software being used across practices, and because of differences in the degree to which practices record information on patients’ morbidity on their computer systems.

There are examples of ongoing data collection efforts across large numbers of general practices that can support clinical measures quality. For example, the General Practice Research Database collects detailed information on visits, diagnosis, treatments, and referrals for approximately 5 percent of patients in England and Wales.²⁰ However, by and large these data are more limited and less prevalent in the United Kingdom than are performance measurement activities among U.S. managed care plans. Furthermore, the electronic information divide between primary care and specialist physicians is greater in the United Kingdom than in the United States.

The NHS is moving toward having all of its providers (primary care and specialists) on a single computerized network (NHS Net), which, when completed (target date 2005), will enable all appropriate providers to have access to patients’ electronic medical records. NHS Net links organizations in the NHS, including health authorities, PCGs, general practices, community clinics, and hospitals.²¹ Within NHS Net will be a new national Electronic Library Health, which will give clinicians access to up-to-date and relevant information. The NHS is also supporting programs, such as Primary Care Information Services (PRIMIS), which will enable the collected data to be turned into useful information on health care quality and provider performance.²² The costs of linking general practices to NHS Net, including hardware, software, and telephone costs, are being met by the NHS. Many PCGs are taking advantage of the opportunities offered by NHS Net to disseminate guidelines, provide access to planning and other PCG documents, and allow feedback of comparative data on the performance of individual practices. In many PCGs information on physician performance, such as referral and prescribing rates, is being shared in a nonanonymous format. With time, the NHS anticipates that electronic reminders will be integrated into quality improvement programs.

GP support. Second, although GPs are required to participate in clinical governance, and medical organizations, including the British Medical Association (BMA), have endorsed the government’s plan, it is not clear that rank-and-file GPs are entirely willing to support the policy.²³ After all, GPs did not choose their clinical governance partners. Also, some GPs express concern about the validity of quality improvement measures and whether the government will undermine their attempts to manage quality, particularly if it conflicts with what they believe to be the government’s main agenda, the need to control costs.²⁴ Even among GPs who are willing to engage in quality improvement, many find that competing clinical practice demands limit their ability to fully participate in clinical-governance activities. Some GPs have expressed their discontent by voting to slow their PCG’s development to a PCT.²⁵

In an attempt to ensure that practitioners take their clinical-governance responsibilities seriously, the government is implementing systems for externally monitoring the delivery of care. The government’s newly established Commission for Health Improvement (CHI) is developing and implementing an NHS Performance Assessment Framework comprising high-level performance indicators and an annual national survey of patients’ and users’ experiences in the NHS. The British government is considering whether the results of these assessments should be made public as a part of a "name and shame" campaign to encourage providers to improve their performance. ²⁶ The government is also working with physician professional societies to develop a recredentialing process for providers that will rely, in part, on PCG assessments of physicians’ performance and participation in clinical-governance activities.²⁷

Ultimately, the inherent tension between the government’s attempts to control the process while allowing PCGs to establish greater autonomy in their newly defined roles must be resolved. The fact that the Labour government’s PCG policy in many ways has extended rather than eliminated the Conservative government’s fund holding policy means that there is relatively little political opposition to PCGs per se. However, organizational changes in the NHS are occurring in the context of declining public confidence in the health system and, by extension, the government.²⁸ The public’s discontent may push the British government to pressure physicians to accelerate the development of their quality improvement activities. Some policy analysts have advocated a more rapid introduction of U.S. managed care strategies into PCGs as a means to accelerate change in the NHS. For example, Alain Enthoven argues that the NHS needs to encourage quality improvement by providing financial incentives to reward higher-performing practitioners.²⁹

Integrating The Quality Agenda With Public Accountability

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While the eventual plan is to incorporate some degree of performance-based incentives and public reporting of provider performance into the PCG schema, another new source of public accountability being put into place is the development of community-based boards to oversee the activities of PCGs. As a PCG’s financial and management responsibilities grow, it will evolve into a PCT; then, instead of reporting to a local health authority, it will become accountable to a local board that is in most cases controlled and directed by nonmedical laypersons. This evolution is just getting under way, with approximately twenty PCTs now in place across England.

In the past, several attempts were made to introduce greater community control within the U.S. health care system as well. These included the community health center, community health planning, and consumer cooperative health plan movements. Each initiative had as its central tenet that health care organizations should be controlled by and for the community within which they were based. These movements have had varying degrees of success, but such a structured approach to community consumerism has all but been eclipsed by competitive health care markets. Proponents of the market approach believe that the way for community members to get their way is not for a few board members to vote with a ballot once a quarter, but for individuals to vote with their health care dollars whenever they seek care or choose a plan.

Regardless of how one views the role of the marketplace in leading to a consumer-driven system, PCGs will offer lessons for how consumer boards and public participation can be used to augment market-driven approaches to best meet the needs of a whole community, not just individual consumers.

Applying The Lessons Of PCGs In The United States

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PCGs offer a series of potential lessons for improving health care quality and community accountability in the United States. Perhaps the most obvious lesson is the concept of all primary care providers in an area working together to take stock of the community’s needs and to design coordinated care systems and integrated interventions in direct response to this need.

Shifting the focus, even in part, to the community as patient (away from one patient at a time) will involve significant change in the current U.S. paradigms of medicine and health care delivery. The PCG framework represents a move in that direction. One essential ingredient for such a shift in the United States would be the development of government-sponsored or cross-MCO community needs assessments. Based on the results of such quantitative and qualitative assessments, collaborative community-based efforts targeted at the improvement of health levels could be mounted. This effort would of necessity involve medical care providers at all levels, public health agencies, and social services and support agencies. Most plans and providers do not have much experience in serving members of the community who do not seek services, so it will be essential that outreach efforts, probably spearheaded by community based agencies with special expertise, be part of the program.

In the United States one cannot readily foresee all primary care providers in a geographic area joining under a single administrative umbrella to fiscally and clinically integrate their services, but it might be more realistic to envision Medicare, Medicaid, or an employer consortium making membership in a community quality collective a prerequisite of contracting with them. This is being done by several business coalitions and a number of Medicaid agencies. State or local public health agencies or community-based quality review organizations (such as Medicare’s contracting Peer Review Organizations, or PROs) could facilitate such efforts with government or foundation support.

Build on current U.S. practices. Engaging clinicians in this process could evolve from the current U.S. approach to quality improvement, which includes many of the same elements found in the United Kingdom: performance measurement, clinical guidelines, and practice profiling. However, the British experience offers several potential amendments to the current U.S. strategy. First, performance indicators in the United States could be expanded to incorporate measures that demonstrate how well and how efficiently providers are meeting the unique health needs of their surrounding community. The current focus in quality measurement is generally population based only to the point of including patients who are covered by a health plan or provider network.

Second, U.S. clinicians need a public forum in which they can discuss the measured community-based indicators and consider plans for improvement among themselves and with the affected community. Clinicians have a tendency to dismiss the results many community-based measures of health, such as mortality rates, as issues that are not affected by medical care. While they are correct that the influence of medical care is only one contributor health, the lack of a means to communicate with the community meaningful way about their health indicators may play a role keeping clinicians from engaging in developing solutions.

Third, clinicians should be held accountable for their performance in meeting community-based goals for health care. In United Kingdom this is developing in the form of community boards overseeing primary care practice. Such an approach is not entirely foreign in the United States, but it has not been applied in serious way to care that occurs in the private sector. Community accountability in the U.S. context might also take the form of financial incentives for providers on the basis of their contribution toward meeting community-based health care goals. This would represent a dramatic departure from the current reward system, which tends to favor health plans and providers that avoid caring for patients with high levels of health care need.

Finally, in response to the challenge to eliminate variation practice and improve health care quality, U.S. clinicians could explore the potential benefits of applying quality improvement tools an integrated fashion as they are in PCGs. The limited research literature on changing physicians’ behavior suggests that multiprong approaches are more successful than isolated interventions.³⁰

Implementation challenges. In both countries there will many challenges associated with putting such a system in place: need for accurate data, difficulty in adjusting for the underlying of populations, and, in the United States, the problem of rapid enrollment turnover within plans. Forward-thinking MCOs provider consortia with stable populations should consider implementing such a revolutionary health-based accountability approach on a limited pilot basis. Civic-minded employers looking for workers in a tight job market might also be interested in supporting community wide approaches. Organizations and communities already doing this should be identified and studied.

In the United Kingdom primary care providers will take a role in setting budgets and developing contracts for all levels of care (community, primary, secondary, and tertiary) based on a comprehensive assessment of community needs, cost/benefit assessments of services, and consumer advisory panel input. Nobody in Britain believes that PCGs will be able to resolve all fiscal and quality ills by this budgeting process. But an argument could be made that having primary care physicians and nurses taking responsibility for program design might lead to an outcome that is more responsive to community and patient need than is one spearheaded by business people, fiscal managers, secondary care clinicians, or employee benefit managers, as is generally the case in most U.S. MCOs. In the overheated U.S. health care market, it is admittedly difficult to imagine a budget and contracting process based on these sources of input, but on a limited basis perhaps it can be tried. To get started, as in the United Kingdom, U.S. organizations could select problem areas (such as cardiovascular disease) for which it might be feasible to pilot an initiative reengineered by a primary care team at the design helm.

We realize that there are profound differences between the British NHS and the current U.S. medical market free-for-all. But even though the two health care systems are traveling down separate tracks, there have been a series of changes in both countries that increase the likelihood that the cross-fertilization of ideas could be feasible.³¹ While each nation’s starting point and reform destinations do not suggest that the trajectories are likely to intersect any time soon, the two health care systems’ travel lines are closer than one might expect. As the United States struggles to back off from what many perceive as market excesses, attempts are being made to instill increased patients’ rights and a focus on patient and community needs and equity. For their part, the British, with their long history of sensitivity to equity and welfare, are exploring ways to instill more market and consumer responsiveness.

We are enthusiastic about these innovative models in the United Kingdom. That is not to say they are (or ever will be) perfect. PCGs, like our own MCOs and provider groups, are diverse. There will always be significant variation across the almost 500 organizations. Moreover, we understand that much of what the PCTs will be attempting has not been completely implemented and evaluated in the United Kingdom, let alone the United States. So although we strongly support much of what the British are putting in place, we must underscore that PCGs and PCTs are still early in their development phase. The United Kingdom is supporting at least one large study to track the evolution of PCGs, but more could be done to articulate the policy’s measures of success.³²

One way or another, we believe that it is worth taking a look at the many ideas and frameworks laid down by the PCGs’ architects as well as the actual programs being put in place by the pioneer implementers. As the United States and other countries attempt to improve the quality and accountability of health care, such innovative strategies and perspectives are likely to offer some viable and alternative routes to the final destination.

Editor's Notes

 
Andrew Bindman is associate professor of medicine, epidemiology, and biostatistics at the University of California, San Francisco. Jonathan Weiner is professor and deputy director, Health Services Research and Development Center, at the Johns Hopkins School of Public Health, Baltimore, Maryland. Azeem Majeed is senior lecturer in general practice, University College London School of Public Policy.

Support for this project was provided by the Commonwealth Fund and the U.S. Public Health Service Fogarty Center. Azeem Majeed holds an NHS Primary Care Senior Scientist Award and is funded by the NHS Research and Development Directorate. Andrew Bindman and Jonathan Weiner were Atlantic Fellows in the United Kingdom during 1999–2000. The Atlantic Fellowship is supported by the British Foreign and Commonwealth Office. Bindman and Weiner acknowledge the kind assistance of many colleagues at the University College London, King’s Fund, and elsewhere in the United Kingdom who made their work as visitors in the United Kingdom possible.

NOTES

Top Primary Care Groups Building A Community-Focused... Clinical Governance Clinical-Governance Strategies... Barriers To Change Integrating The Quality Agenda... Applying The Lessons Of... NOTES

 

1. Secretary of State for Health, The New NHS: Modern, Dependable (London: Stationery Office, December 1997); and R. Klein, "Why Britain Is Reorganizing Its National Health Service—Yet Again," Health Affairs (July/Aug 1998): 111.
2. A. Majeed et al., "Cross-Sectional Study of Primary Care Groups in London: Measures of Socio-Economic and Health Status, and Association with Admission Rates," British Medical Journal (28 October 2000): 1057–1060.
3. J. LeGrand, N. Mays, and J. Mulligan, Learning from the NHS Internal Market (London: King’s Fund, 1998).
4. A. Majeed and L.Malcolm, "Unified Budgets for Primary Care Groups," British Medical Journal (20 March 1999): 772–776.
5. Secretary of State for Health, The NHS Plan: A Plan for Investment, A Plan for Reform (London: Stationery Office, July 2000).
6. Department of Health, Saving Lives: Our Healthier Nation, executive summary, <www.doh.gov.uk/ohn/execsum.htm> (February 2001).
7. Audit Commission, "The PCG Agenda—Early Progress of Primary Care Groups in ‘The New NHS,’" <www.audit-commission.gov.uk> (February 2001).
8. U.S. Department of Health and Human Services, Community Oriented Primary Care: From Principle to Practice, HRSA Pub. no. A-PE-86-1 (Washington: U.S. Government Printing Office, 1986); and S.L. Kark, Community-Oriented Primary Health Care (New York: Appleton Century Crofts, 1981).
9. NHS Executive, Clinical Governance: Quality Improvement in the New NHS (London: Department of Health, 1998).
10. J.N. Newton, V. Seagrott, and M.Goldacre, "Geographical Variation in Hospital Admission Rates: An Analysis of Workload in the Oxford Region, England," Journal of Epidemiology and Community Health (December 1994): 590–595; and K. McPherson et al., "Small Area Variations in the Use of Common Surgical Procedures: An International Comparison of New England, England, and Norway," New England Journal of Medicine (18 November 1982): 1310–1314.
11. R. Baker et al., "A Model for Clinical Governance in Primary Care Groups," British Medical Journal (20 March 1999): 779–783; and J. Huntington, S. Gillam, and R. Rosen, "Clinical Governance in Primary Care: Organisational Development for Clinical Governance," British Medical Journal (16 September 2000): 679–682.
12. A.D. Oxman et al., "No Magic Bullets: A Systematic Review of 102 Trials Interventions to Improve Professional Practice," Canadian Medical Association Journal (15 November 1995): 1423–1431.
13. A. Majeed, N. Evans, and P. Head, "What Can PACT Tell Us about Prescribing in General Practice?" British Medical Journal (6 December 1997): 1515–1519.
14. J. Gray et al., "Using Computerised Medical Records to Identify Patients with Ischaemic Heart Disease in General Practice," British Medical Journal (2 September 2000): 548–550.
15. A. Fernandez et al., "Physicians’ Experience with Disease Management Programs," Journal of General Internal Medicine (forthcoming).
16. Secretary of State for Health, The NHS Plan.
17. R.A. Dudley et al., "Selective Referral to High-Volume Hospitals: Estimating Potentially Avoidable Deaths," Journal of the American Medical Association March 2000): 1159–1166.
18. J. Hayward, R. Rosen, and S. Dewar, "Clinical Governance—Thin on the Ground," Health Service Journal (26 August 1999): 26–27.
19. N.T. Ellis and M.R. Kidd, "General Practice Computerisation: Lessons from the United Kingdom," Medical Journal of Australia (3 January 2000): 22–24.
20. D.H. Lawson et al., "The General Practice Research Database," Quarterly Journal of Medicine (June 1998): 445–452.
21. NHS Executive, Information for Health (Leeds: NHS Executive, 1998); and A. McColl et al., "Performance Indicators for Primary Care Groups: An Evidence Based Approach," British Medical Journal (14 November 1998): 1354–1360.
22. NHS Information Authority, Primary Care Information Services, <www.primis.nottingham.ac.uk>.
23. Secretary of State for Health, The NHS Plan.
24. A.M. Pollock, "The American Way," Health Service Journal (9 April 1998): 28–29.
25. W. Brett, "More PCT Bids Vetoed," Doctor (1 February 2000), 8.
26. Secretary of State for Health, The NHS Plan.
27. General Medical Council, Revalidating Doctors: Ensuring Standards, Securing the Future (London: General Medical Council, 2000).
28. European Task Force on Patient Evaluations of General Practice Care, "Patients in Europe Evaluate General Practice: An International Comparison," British Journal of General Practice (November 2000): 882–887.
29. A.C. Enthoven, "In Pursuit of an Improving National Health Service," Health Affairs (May/June 2000): 102–119.
30. L.A. Bero et al., "Closing the Gap between Research and Practice: An Overview of Systematic Reviews of Interventions to Promote the Implementation Research Findings," British Medical Journal (15 August 1998): 465–468.
31. D. Light, "Policy Lessons from the British Health Care System," in Health Care Systems in Transition: An International Perspective, ed. F. Powell and A. Wesen (Thousand Oaks, Calif.: Sage, 1999).
32. D. Wilkin et al., "The National Tracker Survey of Primary Care Groups and Trusts" (Manchester: National Primary Care Research and Development Centre, 1999).

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				T. Bodenheimer, A. Majeed, and A. B Bindman Primary care in the United States: Innovations in primary care in the United States * Commentary: What can primary care in the United States learn from the United Kingdom? BMJ, April 12, 2003; 326(7393): 796 - 799. [Full Text] [PDF]

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