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By H. Lukar. Drake University.

Conversely purchase viagra capsules 100 mg, as CRH release in female abuse survivors may be explainable by differences in gender buy viagra capsules 100mg fast delivery, the PVN stimulates ACTH secretion from the pituitary and age buy 100 mg viagra capsules overnight delivery, trauma type, developmental epoch at the time of the trauma, thereby increases cortisol secretion from the adrenal glands, or timing within illness course. Glucocorticoid-mediated +/–, an equal number of studies support this finding and do not inhibition of NE-induced CRH stimulation may be evident support this finding; +, atleast one study supports this finding and primarily during stress, rather than under resting condi- no studies do not, or the majority of studies support the finding; ++, two or more studies support this finding, and no studies do not tions, as an adaptive response that restrains stress-induced support the finding; +++, three or more studies support this finding, neuroendocrine and cardiovascular effects mediated by the and no studies do not; ACTH, adrenocorticotropic hormone; CRF, corticotropin-releasing factor; CSF, cerebrospinal fluid; dec. NE, cortisol, and CRH thus appear tightly decrease; DST, dihydrostreptomycin; HPA, hypothalamic pituitary linked as a functional system that offers a homeostatic mech- adrenal axis; inc. A clinical phenomenon of anxiety disorders that may be specifically regulated by interactions between NE and glucocorticoid secretion involves the acquisition and consol- idation of traumatic memories. A characteristic feature of PTSD and PD is that memories of the traumatic experience development of PTSD and may comprise a risk factor for or the original panic attack, respectively, persist for decades developing PTSD in response to traumatic stress. In PD, the results of studies examining CRH-receptor In experimental animals, alterations of both brain catechol- and HPA-axis function have been less consistent (Table amine and glucocorticoid levels affect the consolidation and 63. Elevated plasma cortisol levels were reported in one retrieval of emotional memories (50,51). Glucocorticoids study (244), but not in another (245), and the results of influence memory storage by activation of glucocorticoid studies assessing urinary free cortisol have been similarly receptors in the hippocampus, whereas NE effects are me- inconsistent (177,246). In a study of 24-hour secretion of diated in part through -adrenoreceptor stimulation in the ACTH and cortisol, PD subjects had subtle elevations of amygdala (255). In humans, adrenocortical suppression nocturnal cortisol secretion and greater amplitude of ul- blocks the memory-enhancing effects of amphetamine and traradian secretory episodes relative to control subjects epinephrine (256), and propranolol impairs memory for an (247), but these findings await replication. Both normal emotionally provocative story, but not for an emotionally and elevated rates of cortisol nonsuppression after dexa- 'neutral' story (257). These data suggest that the acute methasone administration have been reported in PD (248). It is axis response was higher in PD subjects than in healthy conceivable that long-term alterations in these systems may controls, but the magnitude of this abnormality was less account for memory distortions seen in PTSD, such as the than that seen in depressed samples (249,250). The ACTH memory fragmentation, hypermnesia, and deficits in declar- ative memory. The extent to which pathophysi- ologic heterogeneity within PD samples may account for Several lines of preclinical and clinical evidence have estab- the inconsistency of these findings remains unclear. Central BZD receptors are ex- mediated through a GABAergic mechanism. These agents pressed are present throughout the brain, but they are most are effective for the treatment of a spectrum of anxiety disor- densely concentrated in the cortical gray matter. The BZD ders including social anxiety disorder, generalized anxiety and GABAA receptors form parts of the same macromolecu- disorder, PD, and PTSD. One of the multiple secondary lar complex, and although they constitute distinct binding effects of these agents involves potentiation of GABAergic sites, they are functionally coupled and regulate each other function. For example, in rats, the effective dose of phenel- in an allosteric manner (258). Central BZD-receptor ago- zine (15mg/kg) on the elevated plus maze administered nists potentiate and prolong the synaptic actions of the in- produces a more than twofold increase in whole-brain level hibitory neurotransmitter, GABA, by increasing the fre- GABA concentrations, whereas an ineffective dose of phe- quency of GABA-mediated chloride channel openings (258, nelzine (5. Microinjection of BZD-receptor agonists in limbic (267). Moreover, the N-acetylated metabolite of phenelzine, and brainstem regions such as the amygdala and the PAG N-2-acetylphenelzine, which potently inhibits monoamine exert antianxiety effects in animal models of anxiety and fear oxidase but does not change whole-brain GABA concentra- (260). Conversely, administration of BZD-receptor inverse tions, does not produce anxiolytic effects in the elevated agonists, such as -carboline-3-carboxylic acid ethylester, plus-maze test (267). Transgenic mouse studies have identified behavioral roles for specific GABAA-receptor subunits. The anxiolytic action of diazepam appears absent in mice with 2 subunit point Effects of Stress on Benzodiazepine-GABAA mutations, but it is present in mice with 1 or 3 subunit Receptors point mutations (264,265). These data suggest that the an- xiolytic effect of BZD agonists is at least partly mediated BZD- and GABA-receptor function can be altered by expo- by the GABA -receptor subunit, which is largely ex- sure to stress in some brain regions. In experimental animals A 2 pressed in the limbic system, but not by the subunit, exposed to inescapable stress in the form of cold swim or 3 which is predominately expressed in the reticular activating foot shock, the BZD-receptor binding decreases in the fron- system, or the subunit, which is implicated in mediating tal cortex, with less consistent reductions occurring in the 1 the sedative, amnestic, and anticonvulsive effects of BZDs hippocampus and hypothalamus, but no changes in the oc- (265,266). These findings hold clear implications for inves- cipital cortex, striatum, midbrain, thalamus, cerebellum, or tigations of the pathophysiology of anxiety disorders and for pons (268). Chronic stress in the form of repeated foot the development of anxioselective BZD-receptor agonists. The neurosteroid, allopregnenolone, ex- in BZD-receptor binding were associated with deficits in erts antianxiety effects in conflict paradigms that serve as maze escape behaviors that may have reflected alterations putative animal models of anxiety. The anticonflict effects in mnemonic processing (269,270). Some of these stress of allopregnenolone are reversed by either isopropylbicyclo- effects may be mediated by glucocorticoids, because chronic phosphate, which binds at the picrotoxinin site on the exposure to stress levels of CORT alters mRNA levels of GABAA receptors, or RO15-4513 (ethyl-8-azido-5,6-dihy- multiple GABAA-receptor subunits (271). Consistent with dro-5-methyl-6-oxo-4H-imidazo[1,5- ]-[1,4]benzodiaze- the effects of chronic stress on BZD-receptor expression, pine-3-carboxylate), a BZD-receptor inverse agonist that the Maudsley 'genetically fearful' rat strain shows decreased inhibits GABAA-activated chloride flux in neuronal mem- BZD-receptor density relative to other rats in several brain branes. In contrast, administration of the BZD-receptor an- structures including the hippocampus (272). Allopregnenolone may thus exert reduced BZD-receptor sites in the LC, the NTS, the frontal anxiolytic-like effects by stimulating the chloride channel cortex, and the CE and the LA of the amygdala, and reduced in GABAA receptors by binding at the picrotoxinin site or mRNA levels for the 2 subunit of the GABAA-receptor at a site specific for RO15-4513. The The antianxiety effects of antidepressant drugs with pri- extent to which these developmental responses to early-life Chapter 63: Neurobiological Basis of Anxiety Disorders 917 stress may alter the expression of fear and anxiety in adult- global reduction in BZD site binding in seven study subjects hood remains unclear. Anxiety Disorders found no differences in the Bmax, Kd or bound/free values The central BZD receptor has been implicated in anxiety for [11C]flumazenil in any brain region in ten unmedicated disorders on the basis of the anxiolytic and anxiogenic prop- PD study subjects relative to healthy controls (283). Hypotheses advanced regarding the role Acute stress increases DA release and turnover in multiple of GABAA-BZD–receptor function in anxiety disorders brain areas. The dopaminergic projections to the mPFC have proposed either that changes in the GABAA-BZD mac- appear particularly sensitive to stress, because brief or low- romolecular complex conformation or that alterations in the concentration or properties of an endogenous ligand intensity stressors (e. However, these hypotheses have not been conclu- absence of corresponding changes in other mesotelenceph- sively tested by in vivo or postmortem studies of anxiety- alic dopaminergic projections (284). In con- attacks and increases anticipatory anxiety in some subjects trast, stress of greater intensity or longer duration addition- with PD, but not in healthy controls. In addition, the sensi- ally enhances DA release and metabolism in other areas as tivity to the effects of diazepam on saccadic eye movement well (285). The regional sensitivity to stress appears to fol- velocity is abnormally reduced in PD, a finding implying low a pattern in which dopaminergic projections to the that the functional sensitivity of the GABA -BZD supramo- mPFC are more sensitive to stress than the mesoaccumbens A lecular complex is attenuated in brainstem regions control- and nigrostriatal projections, and the mesoaccumbens dopa- ling saccadic eye movements (275). Subjects with PD also minergic projections are more sensitive to stress than the show abnormally reduced sensitivity to the suppressant ef- nigrostriatal projections (284). Pa- tal (278–280), temporal (278,279), and occipital (278) cor- tients with PD were also shown to have a greater growth tices in subjects with PD relative to control subjects. However, Eriksson absence of medication-free PD study subjects and of healthy et al. A tween CSF HVA and anxiety severity or panic attack fre- SPECT-iomazenil study that quantitated BZD-receptor quency (288). In addition, genetic studies examining associ- binding by derivation of distribution volumes found re- ations between PD and gene polymorphisms for the DA duced binding in the left hippocampus and precuneus in D4 receptor and the DA transporter have produced negative unmedicated PD relative to healthy control samples and results (289). Another ies involving small subject samples reported abnormal re- SPECT-iomazenil study reported lower distribution vol- ductions in DA-receptor binding. These findings appeared social phobic relative to healthy control samples (290), pre- consistent with the evidence cited earlier that stress down- sumably reflecting a reduction in DA-transporter binding.

Use of the urea reduc- tion ratio (URR) is the simplest way to monitor the delivered dose of hemodialysis effective viagra capsules 100 mg. However discount viagra capsules 100mg amex, a shortcoming of this method compared with 1 buy viagra capsules 100 mg overnight delivery. For exam ple, a URR of 65% m ay correspond to a Kt/V as low as 1. FIGURE 6-12 Correction of anem ia in chronic renal failure. Anem ia is a pre- FIGURE 6-13 dictable com plication of chronic renal failure that is due partly All these com ponents are im portant as contributors to a successful to reduction in erythropoietin production. The Dialysis O utcom es Q uality Initiative thropoietin to correct the anem ia in patients with chronic renal (DOQI) recommendations should be followed to achieve an adequate failure has become standard therapy. The rate of increase in hemat- dialysis prescription, and the tim e on dialysis should be m onitored ocrit is dose-dependent. W hen the delivered dialysis dose is less that prescribed, venously three times per week. Current guidelines for the initiation the reversible factors listed in Figure 6-10 should be addressed first. Increases in dialyzer surface area and treatm ent tim e Adm inistration of erythropoietin subcutaneously has been shown also m ay be attem pted. In addition, attention should be paid to the to be more efficient than is intravenous administration. That is, on correct dialysis com position and to the ultrafiltration rate to m ake average, any given increm ent in hem atocrit can be achieved with certain that patients achieve a weight as close as possible to their less erythropoietin when it is given subcutaneously as com pared dry weight. In adults, the subcutaneous dosage of erythro- vitamin D supplementation to prevent secondary hyperparathyroidism poietin is 80 to 120 U/kg/wk (typically 6000 U/wk) in two to three and use of norm al saline or other volum e expanders are encouraged divided doses. KoA— constant indicating the from Eschbach and coworkers; with perm ission. O wen W F, Lew N L, Liu Y, Lowrie EG: The urea reduction ratio and 7. H akim RM , Breyer J, Ism ail N , Schulm an G: Effects of dose of dialysis 8. Gutierrez A, Alvestrand A, Bergstrom J: M em brane selection and on m orbidity and m ortality. H ornberger JC, Chernew M , Petersen J, Garber AM : A m ultivariate patient m ortality. H em odialysis Adequacy W ork Group: Dialysis O utcom es Q uality patients in the United States is im proved with a greater quantity of Initiative (DO Q I). H akim RM , W ingard RL, Parker RA: Effect of the dialysis m em brane 5. H em odialysis Adequacy W ork Group: Dialysis O utcom es Q uality in the treatm ent of patients with acute renal failure. H akim , RM : Clinical im plications of hem odialysis m em brane biocom - 12. Hamilton omplications observed in end-stage renal disease may be due to the side effects of treatment or to the alterations of pathophys- Ciology that go with kidney failure. This patient was switched from a cellulose acetate dialysis membrane to a cuprammonium cellulose one. W ithin FIGURE 7-1 8 m inutes of starting hem odialysis he developed apprehension, diaphoresis, pruritus, palpitations, and wheezing. This eruption Com plications associated with hem odialysis. Throm bosis can be a com - Dilation of a stricture of the left innom inate vein using balloon plication of reliance on subclavian catheters for vascular access for angioplasty in the patient shown in Figure 7-3. This was discovered during investigation of edem a of the left arm. O ccasionally the arteriovenous fistula results in radial-to- brachiocephalic steal, leaving inadequate blood supply to the fingers. This risk is especially com m on in diabetic patients. M ultiple carpal bone cysts without joint space narrowing in a patient treated with dialysis for 11 years. This phenom enon has been attributed to inadequate clearance of b-2microglobulin using low-permeability, cellulose dialysis membranes. Bladder perforation can be a com plication of blind insertion of a peritoneal catheter. It is recognized by the sudden appearance of glucose-positive “urine” on instillation of the first bag of dialysate. Instillation of radiographic contrast m edium confirm s the diagnosis. In continuous am bulatory peritoneal dialysis (CAPD) peritonitis can easily be recognized by the fact that drained peritoneal FIGURE 7-9 (see Color Plate) fluid becom es opacified. The inability to read the writing on the opposite side of the drained bag (or a newspaper through the bag) Tunnel abscess in patient undergoing continuous ambulatory peritoneal correlates with a peritoneal leukocyte count of m ore than 100 cells dialysis. Pericatheter infections are a com m on source of peritonitis. Som etim es, the findings are m ore subtle than in this case. If the infection fails to respond, rem oval of the catheter is indicated. This patient had several bouts of peritonitis during the course of her treatment on peritoneal dialysis. Abdominal computed tom ography revealed a hom ogeneous m ass filling the anterior peri- toneum. At laparotom y the m esentery was encased in a “m arble- like” fibrotic m ass. The patient required long-term hom e parenteral hyperalim entation for recovery. Pericardial tam ponade m ay present as dialysis-induced pericardial friction rub suggest pericarditis (a frequent hypotension. Pappas, M D, M edical College com plication of urem ia) especially in patients with chest of O hio. The skin of urem ic patients can be intensely Acquired cystic disease of the kidney. Earlier, it was attributed to deposition of calcium and raphy dem onstrates cystic disease in this patient, who had focal phosphorus in the skin. Today, we know that is the result of segm ental glom erulosclerosis com plicated by protein C deficiency repeated traum a to the skin associated with scratching. Eleven years after the initial diagnosis, he developed renal failure requiring hem odialysis. Two years after starting dialysis, he developed hem aturia, and these cysts were found. The appearance and clinical course are consistent with acquired cystic disease of the kidney.

Immunogenicity and safety of a meningococcal A conjugate vaccine in Africans buy generic viagra capsules 100mg online. The New England Journal of Medicine generic 100mg viagra capsules fast delivery, 2011 order 100mg viagra capsules with amex,364:2293-2304. Development of a group A meningococcal conjugate vaccine, MenAfriVac(TM). Prevention of HIV-1 infection with early antiretroviral therapy. The New England Journal of Medicine, 2011,365:493-505. How changes in coverage afect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys. Universal health coverage: friend or foe of health equity? Sodium stibogluconate (SSG) & paromomycin combination compared to SSG for visceral leishmaniasis in East Africa: a randomised controlled trial. The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries. Cochrane database of systematic reviews (Online), 2009,4:CD008137. Health research classifcation systems: current approaches and future recommendations. World report on knowledge for better health − strengthening health systems. Guidance for evidence-informed policies about health systems: rationale for and challenges of guidance development. National Center for Science and Engineering Statistics. Scientifc evidence alone is not sufcient basis for health policy. Research and development to meet health needs in developing countries: strengthening global fnancing and coordination. Report of the Consultative Expert Working Group on Research and Development: Financing and Coordination. Predictive risk stratification model: a randomised stepped-wedge trial in primary care (PRISMATIC). Health Services and Delivery Research ISSN 2050-4349 (Print) ISSN 2050-4357 (Online) This journal is a member of and subscribes to the principles of the Committee on Publication Ethics (COPE) (www. Print-on-demand copies can be purchased from the report pages of the NIHR Journals Library website: www. HS&DR programme The Health Services and Delivery Research (HS&DR) programme, part of the National Institute for Health Research (NIHR), was established to fund a broad range of research. It combines the strengths and contributions of two previous NIHR research programmes: the Health Services Research (HSR) programme and the Service Delivery and Organisation (SDO) programme, which were merged in January 2012. The HS&DR programme aims to produce rigorous and relevant evidence on the quality, access and organisation of health services including costs and outcomes, as well as research on implementation. The programme will enhance the strategic focus on research that matters to the NHS and is keen to support ambitious evaluative research to improve health services. For more information about the HS&DR programme please visit the website: http://www. The final report began editorial review in March 2016 and was accepted for publication in March 2017. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. However, they do not accept liability for damages or losses arising from material published in this report. This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Health Services and Delivery Research Editor-in-Chief Professor Jo Rycroft-Malone Professor of Health Services and Implementation Research, Bangor University, UK NIHR Journals Library Editor-in-Chief Professor Tom Walley Director, NIHR Evaluation, Trials and Studies and Director of the EME Programme, UK NIHR Journals Library Editors Professor Ken Stein Chair of HTA and EME Editorial Board and Professor of Public Health, University of Exeter Medical School, UK Professor Andrée Le May Chair of NIHR Journals Library Editorial Group (HS&DR, PGfAR, PHR journals) Dr Martin Ashton-Key Consultant in Public Health Medicine/Consultant Advisor, NETSCC, UK Professor Matthias Beck Professor of Management, Cork University Business School, Department of Management and Marketing, University College Cork, Ireland Dr Tessa Crilly Director, Crystal Blue Consulting Ltd, UK Dr Eugenia Cronin Senior Scientific Advisor, Wessex Institute, UK Dr Peter Davidson Director of the NIHR Dissemination Centre, University of Southampton, UK Ms Tara Lamont Scientific Advisor, NETSCC, UK Dr Catriona McDaid Senior Research Fellow, York Trials Unit, Department of Health Sciences, University of York, UK Professor William McGuire Professor of Child Health, Hull York Medical School, University of York, UK Professor Geoffrey Meads Professor of Wellbeing Research, University of Winchester, UK Professor John Norrie Chair in Medical Statistics, University of Edinburgh, UK Professor John Powell Consultant Clinical Adviser, National Institute for Health and Care Excellence (NICE), UK Professor James Raftery Professor of Health Technology Assessment, Wessex Institute, Faculty of Medicine, University of Southampton, UK Dr Rob Riemsma Reviews Manager, Kleijnen Systematic Reviews Ltd, UK Professor Helen Roberts Professor of Child Health Research, UCL Institute of Child Health, UK Professor Jonathan Ross Professor of Sexual Health and HIV, University Hospital Birmingham, UK Professor Helen Snooks Professor of Health Services Research, Institute of Life Science, College of Medicine, Swansea University, UK Professor Jim Thornton Professor of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, University of Nottingham, UK Professor Martin Underwood Director, Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, UK Please visit the website for a list of members of the NIHR Journals Library Board: www. Study aim: To evaluate the introduction of predictive risk stratification in primary care. Objectives: To (1) measure the effects on service usage, particularly emergency admissions to hospital; (2) assess the effects of the Predictive RIsk Stratification Model (PRISM) on quality of life and satisfaction; (3) assess the technical performance of PRISM; (4) estimate the costs of PRISM implementation and its effects; and (5) describe the processes of change associated with PRISM. Design: Randomised stepped-wedge trial with economic and qualitative components. Setting: Abertawe Bro Morgannwg University Health Board, south Wales. Participants: Patients registered with 32 participating general practices. Intervention: PRISM software, which stratifies patients into four (emergency admission) risk groups; practice-based training; and clinical support. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals v provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. ABSTRACT Main outcome measures: Primary outcome – emergency hospital admissions. Secondary outcomes – emergency department (ED) and outpatient attendances, general practitioner (GP) activity, time in hospital, quality of life, satisfaction and costs. Data sources: Routine anonymised linked health service use data, self-completed questionnaires and staff focus groups and interviews. Results: Across 230,099 participants, PRISM implementation led to increased emergency admissions to hospital [ΔL = 0. Quality-of-life scores related to mental health were similar between phases (Δ = –0. There was no evidence of any significant difference in deaths between phases (9. PRISM showed good general technical performance, comparable with existing risk prediction tools (c-statistic of 0. Qualitative data showed low use by GPs and practice staff, although they all reported using PRISM to generate lists of patients to target for prioritised care to meet Quality and Outcomes Framework (QOF) targets. Limitations: In Wales during the study period, QOF targets were introduced into general practice to encourage targeting care to those at highest risk of emergency admission to hospital. Within this dynamic context, we therefore evaluated the combined effects of PRISM and this contemporaneous policy initiative.

There is a need to bring the learning from operational experience with the new arrangement back into the commissioning arena buy viagra capsules 100mg overnight delivery. This can be seen as a further integrative element of clinical leadership safe viagra capsules 100 mg, spanning the commissioning and provider roles generic viagra capsules 100 mg otc. Case B: redesigning general practice and primary care This CCG is located in a part of Birmingham where the health of the population is generally worse than the England average. The CCG, which formed the site of this case study, derived its GP practices from three different former PCTs. The associated variability in practice and expectation is an important element in the case narrative. The CCG inherited huge variation in standards and coverage of care across its patch. The potential for GP practices that were to become unhappy with attempts at reform to renounce membership and join another CCG is also a significant feature. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 47 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. This was a very large CCG with > 100 GP practices and, as such, it saw a need to allow the localities a greater degree of influence than was often the case in other CCGs. Focus and theme of the case: the primary care improvement programme The research in this CCG focused on a major attempt that was made to redesign primary care across the whole patch. The particular focus of that initiative were the services provided by GP surgeries. The programme is of special interest here because it represents a service redesign initiative driven at the CCG strategic level and it used the official channels of the CCG. The problems to be tackled included unacceptable variation in the range and quality of care offered in GP practices across the CCG. There was also a lack of uniformity in the pattern of payments: practices were paid at differential rates for the same kind of work. It was the chairperson of the CCG and the accountable officer (both GPs) acting in concert who took the lead in identifying these issues as a priority. It is noteworthy that at the time (2014–15) many other CCGs were not viewing GP services and primary care as a main concern. Conversely, those CCGs with established teams of people who had a long history of working together in, for example, the previous PCTs may have been less inclined to make such a new determined effort. The first step was a baseline which all the practices were required to meet. This was a mandatory requirement to remain a member of this CCG. The second step was to standardise the local enhanced services offer. This meant that practices (in cluster form if necessary) were asked to improve their range of services so as to meet an acceptable standard. This started out as a voluntary exercise but increasingly became a requirement. The third step was a higher level of innovation in services offered. The CCG used a budget provided from the centre, which was geared towards care for the elderly, to invite bids for new enhanced services in this area. We first describe the primary care improvement programme (a pseudonym of the title actually used by this CCG) as it was presented in official terms. We then present an analysis of how the programme was received and understood by multiple agents, including some of the designers of the programme and those who were the recipients. The official picture The main initiative driven by this CCG was a service improvement programme designed to make a step change in the quality of primary care. The key declared objective was to: Reduce the level of variation in general practice and bring all practices up to the same standards of primary care. Through [primary care improvement programme] we will ensure there is universal coverage of services across our member practices and that these services are available for all patients, regardless of where they live. Case B: CCG policy document Attention focused on holistic care, integrated care, long-term conditions management and better care for the elderly and vulnerable. The constituent elements of the new model of primary care included universal coverage of some basic service standards across the whole CCG population; an overarching framework that allowed the freedom to identify creative solutions for how patients receive their care while ensuring accountability for care remains with practices; delivery of a patient-centred and integrated approach to improving primary care management of long-term conditions; and an up-skilled general practice workforce to deliver services that had previously been provided by secondary/community providers. Integration, access to mental health services and a transformation of urgent care were all elements of the total package of reform. The new plan from the top leadership duo was for a more integrated system built around general practices. This included new models of care with GPs and others working in new ways with support from secondary care, while also bringing in associated community services, community nursing and district nursing. Supporting elements included data sharing and use of the BCF to integrate social care. The problems of pressures on general practice, fragmentation and lack of a universal and equitable service provision were further reasons justifying action. In exchange for extra funding and support, the GP practices in the CCG were expected to offer care closer to home, delivering a wider range of tests and investigations in primary care settings, such as electrocardiography, spirometry and insulin initiation. These steps were expected to reduce referrals to secondary care. Each service area, such as diabetes care, chronic obstructive pulmonary disease and asthma, had an associated set of target outcomes. For example, the plan stated that 90% of patients with type 2 diabetes should be managed outside the acute trust. The plans also included a place for appraisal of practices in relation to their conformance. None of these interventions was without controversy. A number of GPs were very reluctant to accept the changes. The leadership skills of the CCG chairperson and accountable officer were very necessary. They undertook institutional work in conceptualising the required nature of the changes and in the creation of new institutional forms in place of long-standing and embedded institutional practices, which tended to emphasise and privilege professional autonomy. The programme included some elements of PPI and, as was indicated in the survey results, clinicians are sometimes leaders of this process, as in this case. Part of this was through ongoing channels, as in the cases of respiratory and mental health, but in addition there were some special stakeholder consultation events.

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