Salaried contracts in UK general practice: a study of job satisfaction and stress

OBJECTIVES: To compare job satisfaction and stress levels of general practitioners (GPs) employed on salaried contracts with GPs on a 'standard' performance-related contract paid by fee-for-service and capitation. METHODS: Job satisfaction and stress levels were assessed using data from two postal surveys of GPs: a national survey of 'standard' contract GPs carried out in 1998; and a survey of salaried GPs and their non-salaried GP employers in 1999. Differences in satisfaction and stress scores were assessed by t-tests; regression analysis was used to control for confounding factors and possible selection bias. RESULTS: We achieved a response rate of 77% in the 1999 survey of salaried and non-salaried GPs; 48% of 'standard' contract GPs responded in the 1998 survey. We found that salaried GPs were as satisfied overall as both non-salaried GP employers and GPs on the 'standard' contract, even after controlling for confounding factors and selection bias. Salaried GPs were more satisfied with their remuneration, working hours and the recognition they got for their work. They experienced more stress with two factors but less stress with 19 factors compared with the 'standard' contract GPs. CONCLUSIONS: Overall job satisfaction levels among salaried doctors were similar to those of doctors on contracts paid by mixed fee-for-service and capitation. Future studies of job satisfaction levels under different doctor payment systems need to take account of the extent to which doctors have preferences for different types of contract if they are to derive unbiased results.     

Service production and contract choice in primary physician services

Since payment systems for physicians may affect the efficiency of health care service provision, the design of compensation schemes is a major policy concern. According to standard labour economics and agency theory, fee-for-service contracts are likely to induce higher service production than salary contracts and (pure) capitation contracts. Payment systems may also influence service quality and the overall cost control. Despite the obvious policy significance of these issues, the available empirical research is very limited. This paper is an attempt to remedy this situation by addressing the impact of alternative contracts and payment systems on primary care physicians' service supply. The Norwegian primary physician service is an ideal setting for exploring the impact of payment systems. It is a centralised scheme where health services are mostly publicly financed. Until the June 1st 2001, there were two main types of primary care physicians: local government employees remunerated by a fixed salary, and contract physicians mostly financed by fee-for-service payments. We find that physicians with a fee-for-service contract produce a higher number of consultations and other patient contacts than physicians with a fixed salary. This difference is mostly due to longer working hours, but time efficiency is greater as well. Moreover, a part of the difference is due to a selection effect: salaried physicians prefer shorter working hours and prefer to work less intensively. When these and other effects are taken into account, we find that a change from a salary contract to a fee-for-service contract will increase service production by 20-40%.     

How do we compare with our colleagues? Quality of general practitioner performance in consultations for non-acute abdominal complaints.

OBJECTIVE: To investigate what factors influence the quality of general practitioner performance in consultations for non-acute abdominal complaints and to establish the extent to which performance quality differs between general practitioners (GPs). DESIGN: Explorative study in two parts: (i) detection of variables influencing quality scores of consultations; and (ii) comparison of mean quality scores of the consultations, selected by each GP. SETTING: Sixty-two family practices across The Netherlands. SUBJECTS: Eight-hundred and forty consultations concerning non-acute abdominal complaints, first encounters; 62 GPs. METHOD: Multilevel analysis was carried out to detect factors that influence quality. After correction for the effect of significant factors the mean quality scores of individual GPs were calculated and compared. RESULTS: Eighty-eight per cent of the total variance in quality scores was located at the consultation/patient level, and 12% at the GP level. One consultation characteristic had significant influence on quality: quality scores were higher in consultations of longer than average duration (>15 minutes). Several patient characteristics were of significant influence. Consultation quality scores were higher in consultations for patients with upper abdominal or non-specific abdominal complaints. Quality scores were lower in consultations with female patients and with patients aged >40 years. Together these characteristics explained 20% of the variance at the GP level. None of the GP characteristics investigated in this study appeared to have significant influence on the quality of their performance. After correction of the scores for the effect of significant factors the differences in performance quality between GPs remained significant. CONCLUSIONS: Quality of performance is far more influenced by consultation and patient characteristics than by GP characteristics. After correction for influencing factors, the mean quality scores of GPs still differed considerably and significantly. For many GPs the quality scores varied substantially between different consultations; to a large extent this variation remained unexplained. Consultation quality can be improved by booking more time per patient and by giving more medical/technical attention to female and older patients.     

Saying 'goodbye' to single-handed practices; what do patients and staff lose or gain?

BACKGROUND: The practice setting is, next to the GP and staff, an important determinant of the quality of care. Differences between single-handed practices and group practices in practice management and organization could therefore provide clues for improvement. An explorative, cross sectional survey was conducted in 766 general practices in The Netherlands comparing single-handed practices with group practices. OBJECTIVE: The study is looking for answers on aspects of the organization and management that are lost or gained when single-handed GPs and practices are replaced by group practices. METHODS: Between 1999 and 2003 GPs and their practices were assessed using a validated practice visit method (VIP) consisting of 303 indicators describing 56 dimensions of practice management. Instruments used consisted of questionnaires for patients, GPs, practice assistant and a direct observer in the practice. Single-handed practices (1 GP) were compared to group practices or health centres (>2.0 GPs) comparing raw scores on dimensions of practice management. In addition, data were analysed in a regression model with specific aspects of practice management as dependent variables using a general linear model procedure. Independent variables included 'single-handed/group practice', 'rural/ urban' 'part-time/full-time' and 'male/female'. RESULTS: Group practices scored better on nearly all aspects of infrastructure except those rated by patients. Patients gave single-handed practices higher marks for service, accessibility and even for the facilities. In single-handed practices GPs reported that they worked more and experienced higher levels of job stress. They delegated less of the medical technical tasks but there is no difference in delegation of preventive tasks/treatment of chronic diseases. Group practices had more computerized medical information and more quality assurance activities, but gave less patient information. Single-handed practices spent more hours on continuous medical education. DISCUSSION AND CONCLUSION: The quality of the practice infrastructure and the team scored better in group practices, but patients appreciated the single-handed practice better. The advantages of single-handed practices could be a challenge for group practices to give better personal, continuous care and to put the patient perspective before organizational considerations. This is underlined by the better score on patient information of single-handed practices. Single-handed practices can reduce their vulnerability and openness to high demand by opening up to the requirements of organised primary care.     

The new GMS contract: impact and implications for managing the changes.

BACKGROUND: In February 2003, a new General Practitioner (GP) contract was agreed between the profession's leaders and the government, which was later accepted following a national ballot of GPs. However, the ballot simply required respondents to vote for or against the proposal; it did not provide any opportunity to identify which aspects of the new contract were more or less acceptable. Since the proposed changes were far reaching, the implications of implementing and managing these were considerable. Consequently, some information about how GPs viewed various components of the new contract would enable a more targeted and effective management strategy to be developed that would facilitate the introduction of all aspects of the contract. OBJECTIVES: To survey GPs working within the West Midlands region regarding their opinions on each of the key features of the new contract. METHOD: A postal survey of 360 GPs was undertaken, using a specially devised questionnaire. RESULTS: Four factors emerged as the most acceptable aspects of the contract: option to opt out of out-of-hours work, flexibility in the services provided, prediction of future income levels and linking practice to performance targets. Least acceptable were: performance monitoring systems, the new financial formula for calculating income, greater patient involvement in service development and 24/48 hour access. With regard to potential outcomes of the contract, the most positive were considered to be increased proportion of salaried GPs, increased salaries, appropriate quality standards for care, earlier retirement; the factors least likely to be of potential benefit were: reduction in occupational stress, simplification of the regulatory framework, improved equity of workload and improved staff retention. Further analysis of the results using inferential statistics revealed a range of subgroup differences in reaction to the contract. CONCLUSION: Overall, those aspects of the new contract that are perceived to reduce workload and enhance salary were supported, while those that increase targets and bureaucracy were not. Generally, there was only moderate support for the changes, which could be explained by a general scepticism about any top-down modifications, the practicality and power of the changes to impact upon practice and/or a genuine belief that the modifications are unacceptable. Taken together, these results provide an indicative focus for managing the implementation of the new contract, especially with regard to its least acceptable components and the emerging differences between subgroups of GPs.     

Subjective health expectations at biological therapy initiation: a survey of rheumatoid arthritis patients and rheumatologists

In The Netherlands, the remuneration system for GPs changed in 2006. Before the change, GPs received a capitation fee for publicly insured patients and fee for service (FFS) for privately insured patients. In 2006, a combined system was introduced for all patients, with elements of capitation as well as FFS. This created a unique opportunity to investigate the effects of the change in the remuneration system on contact type and consultation length. Our hypothesis was that for former publicly insured patients the change would lead to an increase in the proportion of home visits, a decrease in the proportion of telephone consultations and an increase in consultation length relative to formerly privately insured patients. Data were used from electronic medical records from 36 to 58 Dutch GP practices and from 532,800 to 743,961 patient contacts between 2002 and 2008 for contact type data. For consultation length, 1,994 videotaped consultations were used from 85 GP practices in 2002 and 499 consultations from 16 GP practices in 2008. Multilevel multinomial regression analysis was used to analyse consultation type. Multilevel logistic and linear regression analyses were used to examine consultation length. Our study shows that contact type and consultation length were hardly affected by the change in remuneration system, though the proportion of home visits slightly decreased for privately insured patients compared with publicly insured patients. Declaration behaviour regarding telephone consultations did change; GP practices more consistently declared telephone consultations after 2006.     

The relationship between income and performance indicators in general practice: a cross-sectional study.

OBJECTIVE: To explore the relationship between the income of general practitioners (GPs) and the performance characteristics of their practices. DESIGN: Cross-sectional survey. SETTING: All practices (n = 166) in an inner city health authority, two years before the introduction of the new GP contract in April 2004 were studied. MAIN OUTCOME MEASURES: True income per GP was unavailable to us. Instead, the proxy measure - superannuable pay - was calculated (gross eligible income per GP minus the national average sum for GP expenses). Practice staff funding figures were also obtained. These two financial indicators were compared with practice characteristics and performance indicators. RESULTS: Data were available from 151 out of 166 practices. Based on regression analysis, larger list sizes and higher practice staff budgets predicted 31% of the variation in GP income (standardized beta = 0.66, P < 0.001; beta = 0.19, P = 0.02; respectively). Higher staff budgets were independently associated with better cervical smear and two-year-old vaccination rates (standardized beta = 0.24, P < 0.01; beta = 0.18, P = 0.03; respectively). No association was demonstrated between performance indicators and income. CONCLUSION: Under the previous contract, GPs were able to maximize their income by taking on more patients, whereas achievement of performance targets had very little impact on overall income. The opportunity costs of pursuing higher-quality care might have outweighed the modest financial rewards attached to performance targets. Provided rewards for good-quality care are sufficiently high, the new GP contract is likely to tip the balance in favour of generating earnings by improving the quality of clinical care. To deliver this care, as measured by available performance indicators, our findings imply that a greater investment in practice staff will be needed.     

General practitioner provision of preventive child health care: analysis of routine consultation data

ABSTRACT: BACKGROUND: GPs contribute to preventive child health care in various ways, including provision of child health surveillance (CHS) reviews, opportunistic preventive care, and more intensive support to vulnerable children. The number of CHS reviews offered in Scotland was reduced from 2005. This study aimed to quantify GPs' provision of different types of preventive care to pre-school children before and after the changes to the CHS system. METHODS: GP consultation rates with children aged 0-4 years were examined for the 21/2 years before and after the changes to the CHS system using routinely available data from 30 practices in Scotland. Consultations for CHS reviews; other aspects of preventive care; and all reasons were considered. RESULTS: Prior to the changes to the CHS system, GPs often contributed to CHS reviews at 6-8 weeks and 8-9 and 39-42 months. Following the changes, GP provision of the 6-8 week review continued but other reviews essentially ceased. Few additional consultations with pre-school children are recorded as involving other aspects of preventive care, and the changes to CHS have had no impact on this. In the 21/2 years before and after the changes, consultations recorded as involving any form of preventive care accounted for 11 % and 7.5 % respectively of all consultations with children aged 0-4 years, with the decline due to reductions in CHS reviews. CONCLUSIONS: Effective preventive care through the early years can help children secure good health and developmental outcomes. GPs are well placed to contribute to the provision of such care. Consultations focused on preventive care form a small minority of GPs' contacts with pre-school children, however, particularly since the reduction in the number of CHS reviews.     

GP responses to price regulation: evidence from a French nationwide reform

This paper uses a French reform to evaluate the impacts of overbilling restrictions on general practitioner (GP) care provision, fees and incomes. Since 1990, this reform has introduced conditions self‐employed GPs must fulfil to be permitted to bill freely. We exploit 2005 and 2008 public health insurance administrative data on GP activity and fees. We use fuzzy regression discontinuity techniques to estimate local causal impacts for GPs who established practices in 1990 and who were constrained by the new regulation to charge regulated prices (compliers). We find that those GPs practices to income effects. In the regulated fee regime, GPs face prices lower by 42% and provide 50% more care than they would do in the unregulated fee regime. Male care provision increasing reaction is larger than the female one, which results in a higher male labour income in the regulated fee regime than with unregulated fees, whereas it is the opposite for women. With regulated fees, GPs limit side‐salaried activities, use more lump‐sum payment schemes and occupy more often gatekeeper positions. Copyright © 2015 John Wiley & Sons, Ltd.     

Using simulated patients to develop doctors' skills in facilitating behaviour change: addressing childhood obesity

Medical Education 2010: 44 : 706–715 Objectives This study aimed to describe the application, feasibility and outcomes of using simulated patients (SPs) to increase the skills of general practitioners (GPs) delivering a behavioural intervention to reduce childhood overweight and mild obesity. Methods Five female actors were trained as SPs. A total of 67 GPs from 46 general practices in Melbourne, Victoria, Australia, conducted two simulated consultation visits regarding healthy lifestyle family behaviour change, during which they practised their skills and received formative feedback. The GPs and SPs rated GP performance immediately after each consultation. Subsequently, 139 parents of overweight or obese 5–9‐year‐old children rated GP performance during real‐life consultations. Other measures included child body mass index (BMI) Z‐scores (at baseline and at a 9‐month follow‐up) and GP‐reported levels of comfort and competence and the perceived value of SP visits. Results Simulated patient ratings, but not GP self‐ratings, of GP performance predicted both parent ratings of real‐life consultations (Spearman’s rho 0.39 for correlation with SP rating at Visit 1) and subsequent reductions in BMI Z‐scores between baseline and follow‐up (Visit 1, rho ? 0.45; Visit 2, rho ? 0.46). GP levels of comfort and competence were maintained during and after the SP visits. A total of 95% of GPs rated simulated consultations as useful, although only 18% said they would pay for them. Conclusions Simulated patient assessment may predict real patient feedback and clinical outcomes, helping to identify doctors who require further training in behaviour change techniques. Randomised controlled trials may establish whether SPs actually raise skills or improve outcomes.     

The value of case studies

Background: Studies describing GP consultation have identified duration of consultation as an important marker of patient satisfaction. Duration of consultation differs between countries. Objective: The aim of this study was to measure the duration of consultations and the different segments of the consultation in a representative sample of GPs in the Nantes district (France).

Material and methods: 150 GPs in the Nantes district were randomly selected from the telephone directory. A letter of explanation was sent, followed up by a telephone call asking the GPs to receive an observer into their surgery. The observer timed consultations and the different segments of the consultation. Results: 30 out of 150 GPs contacted agreed to participate. 329 consultations were observed. Average duration of consultation was 14 min and 24 s; it was 15 min in non-computerised practices and 12 min and 50 s in computerised practices. Consultations for psychological problems or with many reasons for consulting took longer. Doctors usually talked more than patients, except during long consultations. Patients were not examined in only 2% of consultations. Trainers in general practice had longer consultations. Discussion: Many GPs refused to receive the observer; the ratio of trainers within the group of respondents (40%) was higher than in the general GP population (7–10%). As in other studies, female GPs were overre-presented as active participants. In our sample, the average duration of consultation was longer than in other studies. The finding regarding the duration of consultation in computerised practices may need validation in other studies. EurJ Gen Pract 2000;6:88–92.     

Determinants of general practitioners' wages in England

We analyse the determinants of annual net income and wages (net income/hours) of general practitioners (GPs) using data for 2271 GPs in England recorded during Autumn 2008. The average GP had an annual net income of £97 500 and worked 43 h per week. The mean wage was £51 per h. Net income and wages depended on gender, experience, list size, partnership size, whether or not the GP worked in a dispensing practice, whether they were salaried of self‐employed, whether they worked in a practice with a nationally or locally negotiated contract, and the characteristics of the local population (proportion from ethnic minorities, rurality, and income deprivation). The findings have implications for pay discrimination by GP gender and ethnicity, GP preferences for partnership size, incentives for competition for patients, and compensating differentials for local population characteristics. They also shed light on the attractiveness to GPs in England of locally negotiated (personal medical services) versus nationally negotiated (general medical services) contracts. Copyright © 2010 John Wiley & Sons, Ltd.     

Dutch shared savings program targeted at primary care: Reduced expenditures in its first year

In countries where GPs fulfill a central role in the health care system, like in the Netherlands, the lack of value-based incentives in GP payment systems may have negative consequences for value delivered in other parts of the health care spectrum. We evaluate an experiment in which GPs were allowed to share in savings in total health care expenditures, conditionally on achieving quality targets. At least in theory, these so-called ‘shared savings contracts’ incentivize GPs to become critical gatekeepers, coordinate the provision of care and substitute for specialist services when appropriate. This study evaluates a Dutch shared savings program targeted at GPs. This study employs a difference-in-differences design using a regional control group of non-participating GPs. We find that program participation led to savings in health care expenditures (-2%), while patient satisfaction was unaffected and while the results for other quality indicators were ambiguous. Additional analyses show that savings have been predominantly realized by lowering the volume of specialist care, and that almost every participating GP displayed cost-saving behavior. This finding suggests that shared savings contracts, even when added as a mere complemented to existing volume-based payment models, already elicit substantive effort to increase the value of health care provided.     

Do minutes count? Consultation lengths in general practice

OBJECTIVE: To document the variability in consultation length and to examine the relative weight of different kinds of characteristics (of the patients, of the general practitioner (GP), or of the practice) in affecting consultation length, and, thus, to assess whether consultation length can legitimately be used as a quality marker. DESIGN: A multilevel statistical analysis of 836 consultations across 51 GPs in ten practices. SETTING AND SUBJECTS: Ten general practices across four regions in England with varying list sizes, number of partners and fundholding status. MAIN OUTCOME MEASURES: Length of time face-to-face with patients in consultation measured in minutes and fractions of minutes. RESULTS: There is substantial inter-practice variation in consultation length, from a mean of 5.7 minutes to one of 8.5 minutes. In some practices the longest average GP consultation time is about twice that of the shortest. Trainees and new partners spend, on average, about 1 minute less than their longer-serving colleagues. Consultation lengths for individual GPs range from a mean of 4.4 minutes to 11 minutes. Late middle-aged women (55-64 years) receive the longest consultations, followed by elderly people, with children receiving the shortest consultations. The number of topics raised affects the length of the consultation by about 1 minute per additional topic. When female patients consult female GPs, approximately 1 minute is added to the average consultation. A significant fraction of the variability in consultation lengths can be explained in terms of characteristics of patients, of GPs and of practices. CONCLUSIONS: The fact that there is little unexplained variation in GP consultation lengths that might be attributable to variations in quality (i.e. GP-related) throws doubt on the proposition that length of consultation can be used as a marker for quality of consultation in general practice.     

Patient and GP agreement on aspects of general practice care

OBJECTIVE: The aim of the present study was to compare patient and GP priorities for general practice care. METHODS: A questionnaire survey was carried out in general practice in Denmark which included 900 consecutive patients aged over 18 years from 15 practices collected in 1995, and 919 randomly sampled GPs in 1999. The postal questionnaire, developed by the EUROPEP group, contained 40 questions about eight aspects of primary care. Participants were asked to state their priorities for each question ranging from "not at all important" to "most important". A reminder questionnaire was sent to non-responders after 2 weeks. Top priority percentages ("very/most important") were calculated for each question as were differences between participant groups. RESULTS: Questionnaires were answered by 771 (85.7%) patients and 584 (64.2%) GPs. Their priorities were highly correlated (r = 0.754, P < 0.001). Patients gave higher priority than GPs to availability and accessibility of the practice and seeing the same GP. The GP should be capable of providing information on illness, investigations and treatments and patient associations, and should know the patient's history and be regularly updated through courses. CONCLUSIONS: Patient and GP priorities for primary care were highly correlated. The higher priority awarded by patients than by GPs to specific aspects of primary care should be acknowledged when organizing and developing general practice.     

Classical versus relational approaches to understanding controls on a contract with independent GPs in South Africa

Contracts have played a central role in public sector reforms in developed countries over the last decade, and research increasingly highlights their varied nature. In low and middle income countries the use of contracts is encouraged but little attention has been paid to features of the setting that may influence their operation. A qualitative case study was used to examine different dimensions of a contract with private GPs in South Africa. Features of the contract are compared with the notions of classical and relational contracts. Formal aspects of the contract such as design, monitoring and resort to sanctions were found to offer little control over its outcome. The relational rather than classical model of contracting offered a more meaningful framework of analysis, with social and institutional factors found to play an important role. In particular, the individual nature of GP practices highlighted the role played by individual motivation where a contract exercised little formal control. Due to the similarity of factors likely to be present, results are argued to be relevant in many other LMIC settings, and policy-makers considering contracts for clinical services are advised to consider the possibility of experiencing a similar outcome.     

Comparison of patients' and general practitioners' evaluations of general practice care

Objectives: To compare patients' and general practitioners' (GPs') evaluations of the quality of general practice care.

Design: Written surveys among patients and GPs.

Setting: General practice in the Netherlands.

Subjects: 1772 patients (from 45 GPs) and a random sample of 315 GPs.

Main outcome measures: Patients' and GPs' evaluations of 23 aspects of general practice care and GPs' perceptions of patients' evaluations using a 5 point scale.

Results: The response rate was 88% in the patient sample and 63% in the GP sample. The patients' ratings of care were significantly more positive (mean 4.0) than those of the GPs (mean 3.7) as well as GPs' perceptions of patients' evaluations (mean 3.5) (p<0.001). The overall rank order correlations between the patients' evaluations, GPs' evaluations, and GPs' perceptions of the patients' evaluations were 0.75 or higher (p<0.001). Patients and practitioners gave the most positive evaluations of specific aspects of the doctor-patient relationship ("keeping patients' records and data confidential", "listening to patients", and "making patients feel they had enough time during consultations") and aspects of the organisation of care ("provide quick service for urgent health problems" and "helpfulness of the staff (other than the doctor)"). The aspects of care evaluated least positively by patients as well as by GPs were other organisational aspects ("preparing patients for what to expect from specialist or hospital care" and "getting through to practice on the telephone").

Conclusions: GPs and patients have to some extent a shared perspective on general practice care. However, GPs were more critical about the quality of care than patients and they underestimated how positive patients were about the care they provide. Furthermore, specific aspects of care were evaluated differently, so surveys and other consultations with patients are necessary to integrate their perspective into quality improvement activities.

     

The effects of shifts in the balance of care on general practice workload.

BACKGROUND: The consequences of the move towards a primary-care-led NHS are shifts in activity from secondary care to primary care and more involvement of GPs in purchasing decisions. Although there are many anecdotal reports of an increasing primary care workload, there is little empirical evidence on the extent of such shifts. This paper reports the results of a survey of GPs in Grampian, in the north-east of Scotland, in which we attempted to gather information on the effects of shifts in the balance of care on general practice. OBJECTIVE: We aimed to examine GPs perceptions of the extent to which general practice workload has changed due to planned and unplanned shifts in the balance of care. METHODS: The design of the study was a self-reported questionnaire, which was administered in general practices in the Grampian Health Board, Scotland. The subjects were senior partners of all general practices and the main outcome measures were the types of changes which have taken place in general practice, their source, their effect on practice workload and how practices have reacted. RESULTS: A 60% response rate was achieved (52/86); 85% (44/52) of GPs claimed that their workload had increased due to shifts in the balance of care and that 72% of the shifts were initiated outside the practice. Geriatric care, early discharge and psychiatric and psychology services, as well as nursing home care, were reported to have had the greatest impact on workload. The main aspects of practice workload which had increased included the number of GP consultations, general stress at work and number of home visits, whereas the net income of the practice and health outcome of patients were reported to have decreased. Practices have dealt with the increase in workload by shifting tasks from GPs to nurses and absorbing the workload into existing practices/patterns. Responders reported that ideally more nursing and GP staffing would be required. Overall, GPs welcomed the shifts in the balance of care, were more concerned about poor communication rather than actual increases in workload and claimed that morale had fallen. CONCLUSION: GPs perceive that the move towards a primary-care-led NHS is increasing the workload in general practice. If the shift in the balance of care away from secondary care is to be successful, then more information is required about such shifts to support practices as change continues.