Background Weighted capitation formulas are used in many countries to allocate primary care funding. Most rely heavily on demographic and area-level factors to weight payments, with limited direct adjustment for morbidity. This may disadvantage practices serving populations with greater morbidity or earlier onset of disease.Objectives To assess how well the current National Health Service (NHS) weighting formula reflects morbidity-related workload and how incorporating morbidity would alter national funding allocations.Design Retrospective observational study using patient-level electronic health records and national practice-level administrative data. Analyses comprised: (1) practice-level modelling of the NHS practice index (the ratio of formula-adjusted to registered patients); (2) patient-level fixed-effects regression of consultation workload and (3) national simulations applying coefficients from the demographic-only and morbidity-inclusive models to all practices to generate alternative practice weights for comparison.Setting Primary care in England (4440 general practices) for practice-level analyses and 627 UK general practices contributing over four million patients to a national electronic health record database for patient-level modelling.Primary outcome Annual primary care consultation workload (minutes per patient-year), estimated at patient level and applied in national simulations.Secondary outcomes Practice-level predicted workload, morbidity-based practice indices and proportional redistribution under alternative weighting models.Results In practice-level analyses of the NHS practice index, the multivariable model explained 77% of variation (R²=0.77). Deprivation, age structure and region accounted for most of this, whereas recorded morbidity contributed relatively little, indicating that the current weighting formula reflects demographic and area characteristics more strongly than morbidity burden. Mean consultation workload was 64.5 min per patient-year. In patient-level models, adding morbidity indicators to the demographic-only specification increased the proportion of variation in workload within practices explained from 16% to 26%. Morbidity was a strong independent predictor of workload and substantially reduced age and sex differences in predicted workload, although socioeconomic differences remained after adjustment. When coefficients from the morbidity-inclusive model were applied nationally to generate alternative practice weights and compared with the demographic-only specification, overall redistribution was modest: practice weights changed by about 2.5% on average. Across practices, 86.7% experienced changes within±5%, while 6.7% gained at least 5% and 6.5% lost at least 5%. Practices serving populations with higher morbidity tended to gain, whereas those serving older populations tended to lose. Practices in more deprived quintiles were significantly less likely to gain and more likely to lose.Conclusions The current demographic-based weighting formula captures age and regional variation but only weakly reflects recorded morbidity. Incorporating morbidity improves prediction of workload and produces modest redistribution towards populations with higher disease burden, although deprivation-related differences remain.

Background and ObjectiveWhile financial literacy is a plausible determinant of mental health, there are relatively few studies exploring the relationship between financial literacy and mental health, and the existing literature focuses on a single construct of financial literacy in high-income settings. Our study addresses this by investigating whether there is an association between financial knowledge, attitudes, and behaviours and mental health in Chinese adults.MethodsWe use data from the China Family Panel Studies, a nationally representative longitudinal survey. Mental health is measured using the Kessler Psychological Distress Scale (K6) and financial literacy is assessed using a unique module on financial literacy covering financial knowledge, financial attitudes and financial behaviours.ResultsWe found that overall financial literacy and two of its dimensions (financial attitudes and financial behaviours) are always positively associated with mental health. A positive association between basic financial knowledge and mental health is also apparent but is mediated by households' finances. Our results are robust to using different outcome variables and estimation methods. Finally, we found that compared with their counterparts without debt, indebted respondents show a stronger sensitivity of mental health to basic financial knowledge, as well as a significant association between advanced financial knowledge and mental health, which persist when we control for households' finances.ConclusionsOur findings suggest that investments in financial education might significantly benefit mental health in Chinese adults. This is especially the case among indebted adults.

Background Multidomain interventions in older adults offer the best opportunity to prevent, delay or reverse existing symptoms in the earlier stages of frailty and improve independence but can be costly, and difficult to deliver at scale. However, digital health interventions enable personalised care and empowerment through self-management of long-term conditions, used at any time and when combined with health coaching offer the potential to enhance well-being and facilitate the achievement of health-related goals. We aim to evaluate the feasibility and acceptability of a digital health platform for long-term disease management combined with health coaching for people living with mild-moderate frailty, targeting self-identified goals—activity, nutrition, mood, enhancing social engagement and well-being.Methods and analysis This is a non-randomised feasibility, single-group, pretest/post-test study, using qualitative and quantitative methods. The digital health coaching intervention (DIALOR—DIgitAL cOaching for fRailty) has been developed for implementation to older adults, aged 65 years or older with mild to moderate frailty and diagnosis of one or more long-term health conditions in the community. Participants will receive 12 weeks of health coaching and have access to a mobile health platform for 6 months. The primary outcome measure is the acceptability and feasibility of DIALOR along with a range of secondary outcome measures (including frailty, functioning measures, quality of life, social engagement, diet quality and self-reported indicators) collected at baseline and at 6 months. The findings will inform whether a wider effectiveness trial is feasible and if so, how it should be designed.Ethics and dissemination Ethical approval has been granted by the Southeast Scotland Research Ethics Committee 02 (reference: 22/SS/0064). Research findings will be disseminated in a range of different ways to engage different audiences, including publishing in open-access peer-reviewed journals, conference presentations, social media, dissemination workshop with patients, carers, and healthcare professionals and on institution websites.

BACKGROUND:Substantial increases in UK consulting rates, mean consultation duration, and clinical workload were observed between 2007 and 2014. To the authors' knowledge, no analysis of more recent trends in clinical workload has been published to date. This study updates and builds on previous research, identifying underlying changes in population morbidity levels affecting demand for primary health care. AIM:To describe the changes in clinical workload in UK primary care since 2005. DESIGN AND SETTING:Retrospective cohort study using GP primary care electronic health records data from 824 UK general practices. METHOD:Over 500 million anonymised electronic health records were obtained from IQVIA Medical Research Data to examine consulting rates with GPs and practice nurses together with the duration of these consultations to determine total patient-level workload per person-year. RESULTS:Age-standardised mean GP direct (face-to-face and telephone) consulting rates fell steadily by 2.0% a year from 2014 to 2019. Between 2005 and 2019 mean GP direct consulting rates fell by 5.8% overall whereas mean workload per person-year increased by 25.8%, owing in part to a 36.9% increase in mean consultation duration. Indirect GP workload almost tripled over the 15 years, contributing to a 48.3% increase in overall clinical workload per person-year. The proportion of the study population with ≥3 serious chronic conditions increased from 9.7% to 16.1%, accounting for over a third of total clinical workload in 2019. CONCLUSION:Findings show sustained increases in consulting rates, consultation duration, and clinical workload until 2014. From 2015, however, rising demand for health care and a larger administrative workload have led to capacity constraints as the system nears saturation.

BackgroundAlmost every patient and every healthcare condition are seen within primary care, but research is not yet embedded in general practice in the same way it is in secondary care. There is no well-defined pathway for a career combining research delivery and active clinical general practice.AimIn Wessex, we set out to design a career pathway for the clinically active GP that could sustain research involvement throughout their working lifetime and underpin research activity in primary care.MethodA lead for education on research was established, in 2021, to approach relevant organisations for funding, accreditation, and design of educational posts for research delivery in primary care.ResultsHealth Education England is currently looking to fund additional placements prior to completion of GP training. NIHR CRN Wessex also identified funding for posts after completion of training. The authors worked with the Southampton GP Education Unit who applied for and achieved the first national recognition of 15-month research placements to count towards completion of GP vocational training. A GP career pathway was designed starting with these posts and followed by GP Research fellow posts, which provide ongoing sessional research work at any stage of a clinical GP career.ConclusionNational recognition for education on research has been achieved and a career pathway for GPs to train in and then work in research has been established. This will help embed research expertise and interest within primary care. This should increase research delivery and hence a cycle of increased research funding for further similar posts.

Background:Elective hip replacement is a cost-effective means of improving hip function. Previous research has suggested that the supply of hip replacements in the NHS is governed by the inverse care law. We examine whether inequities in supply improved in England and Wales between 2006 and 2016. Methods:We compare levels of need and supply of NHS funded hip replacements to adults aged 50+ years, across quintiles of deprivation in England and Wales between 2006 and 2016. We use data from routine health records and a large longitudinal study and adjust for age and sex using general additive negative-binomial regression. Findings:The number of NHS-funded hip replacements per 100,000 population rose substantially from 272.6 and 266.7 in 2002, to 539.7 and 466.3 in 2018 in England and Wales respectively. Having adjusted for age and sex, people living in the most deprived quintile were 2.36 (95% CI, 1.69 to 3.29) times more likely to need a hip replacement in 2006 than those living in quintile 3, whereas those living in the least deprived quintile were 0.45 (95% CI, 0.39 to 0.69) as likely. Despite this, people living in the most deprived quintile were 0.81 (95% CI, 0.78 to 0.83) times as likely in England and 0.93 (95% CI, 0.84 to 1.04) as likely in Wales to receive an NHS-funded hip replacement in 2006 than those living in quintile 3. We found no evidence that these substantial inequities had reduced between 2006 and 2016. Interpretation:With respect to hip-replacement surgery in England and Wales, policy ambitions to reduce healthcare inequities have not been realised. Funding:This work was supported by Health Data Research UK.

OBJECTIVES:Government spending on social care in England reduced substantially in real terms following the economic crisis in 2008, meanwhile emergency admissions to hospitals have increased. We aimed to assess the extent to which reductions in social care spend on older people have led to increases in emergency hospital admissions. DESIGN:We used negative binomial regression for panel data to assess the relationship between emergency hospital admissions and government spend on social care for older people. We adjusted for population size and for levels of deprivation and health. SETTING:Hospitals and adult social care services in England between April 2005 and March 2016. PARTICIPANTS:People aged 65 years and over resident in 132 local councils. OUTCOME MEASURES:Primary outcome variable-emergency hospital admissions of adults aged 65 years and over. Secondary outcome measure-emergency hospital admissions for ambulatory care sensitive conditions (ACSCs) of adults aged 65 years and over. RESULTS:We found no significant relationship between the changes in the rate of government spend (£'000 s) on social care for older people within councils and our primary outcome variable, emergency hospital admissions (Incidence rate ratio (IRR) 1.009, 95% CI 0.965 to 1.056) or our secondary outcome measure, admissions for ACSCs (IRR 0.975, 95% CI 0.917 to 1.038). CONCLUSIONS:We found no evidence to support the view that reductions in government spend on social care since 2008 have led to increases in emergency hospital admissions in older people. Policy makers may wish to review schemes, such as the Better Care Fund, which are predicated on a relationship between social care provision and emergency hospital admissions of older people.

There is extensive empirical evidence that personality is associated with many outcomes and behaviours, such as educational outcomes, labour market participation, savings behaviour, health behaviours, physical health status and mortality. Use of preventive healthcare services (e.g., vaccinations, screening, etc.) is a potential pathway explaining the link between personality and health, and is an important component of healthy ageing. We examine the association between personality traits (the 'Big Five') and a variety of preventive healthcare utilisation measures in the older population. Using data from the Irish Longitudinal Study on Ageing (TILDA), we estimate Poisson models of preventive healthcare utilisation (influenza vaccination, blood cholesterol test, breast lump check, mammogram, prostate examination, prostate-specific antigen (PSA) test). We find that openness to experience is a significant predictor of breast lump check and mammogram in women aged 65+ after adjustment for other confounders and multiple hypothesis testing. While uptake of many preventive healthcare services remains below national recommendations for the older population, with the exception of breast lump checks and mammograms for women aged 65+, we find little evidence to link this heterogeneity in uptake to personality.

Background:Few data are available examining the determinants of vitamin D status exclusively in older adults. We aimed to investigate the prevalence and determinants of vitamin D deficiency in a representative sample of the older Irish population (aged 50-98 years). Methods:The concentration of 25-hydroxyvitamin D (25(OH)D) was measured in 5,356 community-dwelling older Irish adults from The Irish Longitudinal Study on Ageing (TILDA). Detailed demographic, geographic, lifestyle, and socioeconomic factors were assessed by questionnaire. Proportions of deficiency prevalence were generated by season sampled. Linear regression was used to investigate the association between 25(OH)D concentration and reported risk factors. Results:The prevalence of deficiency (25(OH)D < 30 nmol/L) was 13.1% (95% CI: 12.1-14.2). Deficiency status was more prevalent in nonsupplement users, in winter, in smokers, in obese adults, the physically inactive, those living alone, and in the oldest old (>80 years). The main predictors (p < .05) of 25(OH)D concentration were supplement use (coefficient nmol/L: 27.2 [95% CI: 15.3-39.2]), smoking (-8.9 [-12.6--5.2]), summer season (5.9 [2.7-9.1]), and obesity (-4.0 [-6.3--1.7]). Conclusion:Vitamin D deficiency is common among older Irish adults. These data indicate the need for targeted strategies within sections of the older population to improve vitamin D status.

This study compares rates of injurious falls and syncope in community-dwelling older adults in the Irish Longitudinal Study on Ageing with rates in the Systolic Blood Pressure Intervention Trial.

The objective is to understand what really drives prescription expenditure at the end of life in order to inform future expenditure projections and service planning. To achieve this objective an empirical analysis of public medication expenditure on the older population (individuals >= 70 years of age) in Ireland (n = 231,780) was undertaken. A two part model is used to analysis the individual effects of age, proximity to death (PTD) and morbidity using individual patient-level data from administrative pharmacy records for 2006-2009 covering the population of community medication users. Decedents (n = 14,084) consistently use more medications and incur larger expenditures than similar survivors, especially in the last 6 months of life. The data show a positive and statistically significant impact of PTD on prescribing expenditures with minimal effect for age alone even accounting for patient morbidities. Nevertheless improved measures of morbidity are required to fully test the hypothesis that age and PTD are proxies for morbidity. The evidence presented refutes age as a driver of prescription expenditure and highlights the importance of accounting for mortality in future expenditure projections. (C) 2017 The Authors. Published by Elsevier Ltd.

Background: Much recent work has focused on the value of heart rate recovery (HRR) as a marker of cardiovascular health and a predictor of mortality. This article explores socioeconomic variation in HRR following exposure to a potent physiological stressor. Methods: The sample involved a nationally representative cohort of 4,475 community-dwelling older persons aged 50 years and older participating in the Irish Longitudinal Study on Ageing (TILDA). Participants completed an active stand (ie, vertical stand from a supine position) as part of a detailed clinic-based cardiovascular health assessment. Beat-to-beat HRR to standing was monitored over a 2-minute time horizon using a finometer. Highest level of educational achievement served as the indicator variable for socioeconomic status and mediation analysis was undertaken to explore the pathways through which social inequality comes to affect the speed of HRR using the extensive array of covariates available in TILDA. Results: Participants with primary level education were characterized by a significantly slower HRR after standing compared with the tertiary educated (B = -1.15 bpm, CI95 = -1.78, -0.52; p<.001). Mediation analysis revealed that lifetime smoking accounted for a sizeable proportion (40.4%) of the educational differential. Adjustment for other objectively measured markers of lifestyle measured during the clinic visit accounted for only a small proportion (5.2%) of the difference. Discussion: Smoking may represent a major pathway through which the social environment becomes biologically embedded in the tissues and organs of the body precipitating earlier vascular ageing among more socially disadvantaged groups, emphasizing the need to address the causes of these inequalities.

An abstract is not available for this content. As you have access to this content, full HTML content is provided on this page. A PDF of this content is also available in through the ‘Save PDF’ action button.

Much recent work has focused on the prognostic value of heart rate recovery (HRR) as a risk factor for cardiovascular disease and cardiovascular mortality. This paper explores socio-economic variation in HRR following exposure to a potent physiological stressor. The sample involves a nationally representative cohort of 4475 community-dwelling older persons aged 50 years+ participating in the Irish Longitudinal Study on Ageing (TILDA). Participants completed an active stand (i.e. vertical stand from a supine position) as part of a clinic-based cardiovascular health assessment and heart rate and blood pressure responses to the stand were monitored over a two-minute time horizon using a finometer. Highest level of educational achievement served as our measure of socio-economic status. Mediation analysis was undertaken to explore the pathways through which social inequality comes to affect the speed of HRR using the extensive array of covariates available in the TILDA dataset. Participants with a primary level education were characterised by a significantly slower HRR following the stand compared with those with tertiary level education (B= -1.16 bpm, CI95% = -1.78, -0.55; p<0.001). Mediation analysis revealed that lifetime smoking history accounted for a sizeable proportion (~50%) of the educational differential. Additional adjustment for other objectively measured markers of lifestyle measured during the clinic-visit rendered the educational differential non-significant.

BACKGROUND:Concerns about the long-term sustainability of health care expenditures (HCEs), particularly prescribing expenditures, has become an important policy issue in most developed countries. Previous studies suggest that proximity to death (PTD) has a significant effect on total HCEs, with its exclusion leading to an overestimation of likely growth. There are limited studies of pharmaceutical expenditures in which PTD is taken into account.OBJECTIVE:This study presents an empirical analysis of public medication expenditure on older individuals in New Zealand (NZ). The aim of the study was to examine the individual effects of age and PTD using individual-level data.METHODS:This study uses individual-level dispensing data from 2008/2009 covering the whole population of medication users aged 70 years or older and resident in NZ. A case-control methodology was used to examine individual cost and medication use for a 12-month period for decedents (cases) and survivors (controls). A random effects two-part model, with a Probit and generalized linear model (GLM) was used to explore the effect of age and PTD on expenditures.RESULTS:The impact of PTD on prescription expenditure is not as dramatic as studies reporting on acute and/or long-term care. The 12-month decedent-to-survivor mean expenditure ratio was 1.95; 2.09 for males and 1.82 for females. The additional cost of dying in terms of prescription drugs decreases with age, with those who die at 90 years of age or older consuming fewer drugs on average and having a lower mean expenditure than those who died in their 70s and 80s. The following variables were found to have a decreasing effect on the mean monthly prescription expenditures: a reduction of 2.2 % for each additional year of age, 4.2 % being in the Maori ethnic group, and 7.8 % for Pacific Islanders. Increases in monthly expenditure were associated with being a decedent 32.1-62.6 % (depending on month), being of Asian origin 16.2 %, or being a male 12.6 %.CONCLUSIONS:Given the variance reported between survivors and decedents, future projections should include PTD in their models to improve accuracy. Policies targeted at reducing expenditures should not focus on age but on ensuring appropriate and cost-effective prescribing, particularly towards the end of life.