卫生保健服务领域中全科医生行为的规制

在卫生保健服务领域，初级卫生保健服务的作用越来越明显，而在初级卫生保健系统的管理中，全科医生的规制是其工作的核心。现就国际全科医生规划的理论与措施，以及各种卫生保健制度对全科医生的规制措施作了比较系统的介绍。     

中德初级卫生保健的比较研究

初级卫生保健无论在发达国家还是发展中国家都是卫生保健系统的一个明显特征。根据Starfield提出的不同国家初级卫生保健发展状况要素,对中德两国的初级卫生保健人员、资金来源和支付方式、服务方式及改革和发展趋势等进行比较研究。通过分析借鉴德国的初级卫生保健和全科医生制度,探讨我国初级卫生保健的实现途径,以促进卫生体制的深化改革。     

国内外全科医生制度现状及启示

全科医生面向居民提供着方便、连续、经济有效的医疗保健服务,是家庭和个人健康的保护人和初级卫生保健的主要提供者。随着中国医药卫生体制改革的不断深入,全科医生在转变服务模式,实现人人享有基本医疗卫生服务目标中的作用日益凸显。本研究在回顾欧美全科医学发展历程的基础上,分析了欧美主要国家的全科医生制度的经验,以期对中国     

关于加强以社区卫生服务为基础的初级卫生保健的探讨

通过文献回顾研究我国以社区为基础的初级卫生保健现状及存在的问题,提出相应的对策及建议,即提高全科医生的水平与竞争力、加大对公共卫生与初级卫生保健的投入,并保持其可持续性、建立双向转诊制度等,期望能够解决“看病贵、看病难”问题,优化卫生资源配置,实现初级卫生保健的功能与作用。     

英国全科医生制度建设对我国的启示

全科医生制度是一个成熟的医疗服务体系中非常重要的环节,其提供的初级卫生保健服务对于社区居民的健康管理具有长远意义.在介绍英国全科医生制度建设概貌,分析其全科医生规划、培养和管理实践的基础上,提出一些学习与借鉴的方面,为我国全科医生制度的建立与发展提供参考.     

全科医生与初级卫生保健

全科医生与初级卫生保健河北省石家庄市卫生防疫站常晖１９７８年９月１２日，《阿拉木图宣言》指出：“初级卫生保健是基于切实可行、学术上可靠而又为社会所接受的方式与技术之上的主要的卫生保健，通过群众个人及家庭的参与，并在本着自力更生及自决精神而发展的各个阶...     

发展全科医学势在必行

发展全科医学势在必行周东海（卫生部科教司１００７２５）＂２０００年人人享有卫生保健＂是世界卫生组织提出的全球战略目标，实现这一社会目标的基本途径是加强初级卫生保健，建立和发展全科医生队伍是提高初级卫生保健水平的重要基础。我国临床医学的发展，基本上走的...     

国外全科医生的薪酬支付方式探讨

作为社区卫生服务的主要提供者,全科医生在初级卫生保健体系中处于非常关键的位置。他们在处理居民的常见病、保障最基本的健康需求方面承担着非常重要的职能。全科医疗被世界卫生组织称为“最经济”、“最适宜”的医疗卫生保健服务模式。全科医生是高质量初级卫生保健的最佳提供者,更是健康保健系统的最佳“守门人”。作为一个担负如此重任的职业,全科医生的薪酬受到人们的关注。在美国,全科医生被认为是最有前途的职业之一。在许多欧美国家,全科医生扮演着家庭医生的角色,他们与家庭签约,承担着居民基本医疗保健的职责,不仅受人尊重     

嘉定区农村合作医疗改革与发展研究阶段性技术报告

嘉定区农村合作医疗改革与发展研究阶段性技术报告上海市嘉定区初级卫生保健委员会办公室ＷＨＯ上海嘉定初级卫生保健合作中心嘉定区于七十年代初全面建立农村合作医疗保健制度，２５年来一直比较巩固，但在市场经济迅速发展，经济体制重大变革的新形势下，也面临新的问题...     

我国城市实现“2000年人人享有卫生保健”的若干问题探讨

城市初级卫生保健是2000年人人享有卫生保健战略目标的重要组成部分,是解决城市卫生问题,提高城市居民健康水平的重要途径。1985年以来,上海、北京、哈尔滨、烟台等城市,相继开始了城市初级卫生保健的实践和理论探索;1990年8月我利曾系统地介绍了哈尔滨市道外区城市初级卫生保健的经验。随着这项工作的逐渐展开,需要对城市初级卫生保健工作涉及的政策、体制、方式、方法等一系列问题作出回答。为此,我们组织了这组专栏文章,其中有理论探讨,亦有经验介绍,希望能对城市初级卫生保健工作的开展起到推动作用。     

The effect of differential eligibility for free GP services on GP utilisation in Ireland

Internationally, there is extensive empirical evidence that a strong primary care-led health system is associated with improved health outcomes, increased quality of care, decreased health inequalities and lower overall health-care costs. Within primary care, factors influencing access to, and utilisation of, general practitioner (GP) services have been widely examined and this paper focuses on the role of user financial incentives. In particular, user charges for health care have been observed to deter health-care utilisation. Relative to other countries, the Irish health-care system is unusual in that the majority of the population are required to pay out-of-pocket for GP care. However, in 2005 the Irish government extended eligibility for free GP care to a further small subset of the population. Using micro-data from a nationally representative survey of the population in 2007, this paper analyses the impact of differential coverage of free GP services on GP utilisation in Ireland. Results from multivariate regression analysis indicate that GP utilisation is significantly more likely in the context of free GP care, controlling for a range of demographic, socio-economic and health factors. Interpretation of the results for the new category of coverage is complicated by possible pent-up demand and selection effects.     

Treatment of diabetes mellitus type 2 in family practice

In the care of type 2 diabetes mellitus, a combined approach is required to address the risk factors for micro- and macrovascular complications. In the Netherlands, type 2 diabetes care is mainly provided by the general practitioner (GP). GP care is often not provided in accordance with the guidelines, and the strict targets for glycaemic, blood pressure and lipid control are often not achieved. Therefore, the GP should be supported in the provision of diabetes care. GP support in providing diabetes care can range from the organisation of care within the individual GP practice, through to support from an organisation within primary care or to 'shared care' with a hospital in secondary care. There is still scarce scientific evidence for the effectiveness of models for the organisation of diabetes care in primary care in the Netherlands. Scientific research into the effectiveness and cost-effectiveness is necessary before models for the organisation of diabetes care in primary care can be widely implemented and structurally financed.     

Capacity census - a pilot study of general practices in Western Australia

The GP Super Clinics that will provide multidisciplinary primary care services are seen as a key feature of the Federal Government's health infrastructure development. They are designed to improve convenience for patients when accessing services – especially patients with multiple comorbidities requiring visits to multiple providers – as well as providing the space and equipment for teaching and research in primary care. In addition, Medicare Locals are seen as facilitating ‘investments in primary healthcare infrastructure, including GP Super Clinics’. Enhancements to existing private general practices to ‘support a broader team, teaching or visiting sessions from other health professionals’ are also seen as infrastructure development possibilities. Although no one model is provided for GP Super Clinics, it is intended that each ‘will bring together general practitioners, nurses, visiting medical specialists, allied health professionals and other healthcare providers to deliver better healthcare, tailored to the needs and priorities of the local community’.     

Child mental health services. Side by side

The appointment of a primary care mental health worker can relieve pressure on child and adolescent mental health services. In one health authority, GP practices with access to a liaison clinic run by a primary care mental health worker referred a third fewer cases to child and adolescent mental health services than practices without such access. Referrals by these practices were more likely to be assessed as appropriate and as high priority.     

Primary care involvement in human immune deficiency virus infection-a pan-European view. The Eurosupport Study Group

OBJECTIVE: The aim of this study was to compare the primary care experiences of human immunodeficiency virus (HIV)-positive individuals across Europe. METHODS: An anonymous self-administered questionnaire study was carried out between August 1996 and August 1997. A total of 15 HIV/AIDS treatment centres and 14 HIV support organizations in 11 European countries participated in the distribution of questionnaires. Overall, 1366 completed questionnaires were included in the analysis from a total of 2751 distributed (50% response rate). The majority of respondents were homosexual men (53.6%), and 54.2% had AIDS or symptomatic HIV disease. The main outcome measures were use of GP services in the preceding 6 months, GP involvement in HIV care provision, satisfaction with current service provision and reasons for non-involvement of the primary care services. RESULTS: Most patients (64.8%) had visited their GP at least once in the preceding 6 months, but 53.9% of respondents reported that their GP was not involved in their HIV care. Of these patients, 53.4% would like their GP to be involved. Patients from central European countries were more likely to have seen their GP than their counterparts from northern and southern countries (P < 0.005), and were less worried that the GP would not have enough knowledge about HIV (P = 0.002) or would not be sympathetic (P = 0.052). CONCLUSIONS: There are clear differences in GP utilization by HIV-positive individuals across Europe, reflecting in part local service provision but primarily patients' attitudes and beliefs. Strategies to promote the involvement of primary health care services need to address patients' core beliefs, if these are to be changed.     

Citizens Advice Bureaux in general practice: an illuminative evaluation

A number of Citizens Advice Bureaux (CAB) have entered into partnerships with Health Authorities in order to provide advice in general practice surgeries as part of the health care services offered by the primary health care team. This illuminative evaluation has involved an exploration of the impacts of the service from the perspective of its users, the CAB advisers and the referral agents. Data was collected from questionnaires, individual interviews and focus group interviews from participants in both a rural and urban setting. The findings of the study suggest that locating CAB advisers in GP surgeries facilitates access for people who would otherwise be effectively excluded by reason of age, poor health, poverty or lack of transport. Overall, consultations with the CAB advisers were perceived very positively. This study would suggest that Citizens Advice Bureaux in GP surgeries are a viable and useful adjunct to primary health care teams in terms of information-giving, social support, up-take of benefits and co-ordination of services.     

Cost-utility analysis of osteopathy in primary care: results from a pragmatic randomized controlled trial

BACKGROUND: Spinal pain is common and costly to health services and society. Management guidelines have encouraged primary care referral for spinal manipulation, but the evidence base is weak. More economic evaluations alongside pragmatic trials have been recommended. OBJECTIVE: Our aim was to assess the cost-utility of a practice-based osteopathy clinic for subacute spinal pain. METHODS: A cost-utility analysis was performed alongside a pragmatic single-centre randomized controlled trial in a primary care osteopathy clinic accepting referrals from 14 neighbouring practices in North West Wales. Patients with back pain of 2-12 weeks duration were randomly allocated to treatment with osteopathy plus usual GP care or usual GP care alone. Costs were measured from a National Health Service (NHS) perspective. All primary and secondary health care interventions recorded in GP notes were collected for the study period. We calculated quality adjusted life year (QALY) gains based on EQ-5D responses from patients in the trial, and then cost per QALY ratios. Confidence intervals (CIs) were estimated using non-parametric bootstrapping. RESULTS: Osteopathy plus usual GP care was more effective but resulted in more health care costs than usual GP care alone. The point estimate of the incremental cost per QALY ratio was 3560 pounds (80% CI 542 pounds-77,100 pounds). Sensitivity analysis examining spine-related costs alone and total costs excluding outliers resulted in lower cost per QALY ratios. CONCLUSION: A primary care osteopathy clinic may be a cost-effective addition to usual GP care, but this conclusion was subject to considerable random error. Rigorous multi-centre studies are needed to assess the generalizability of this approach.     

Improving general practitioner access to physiotherapy: a review of the economic evidence.

The provision of physiotherapy via general practitioner (GP) 'direct access' arrangements or in primary care itself has become increasingly common in the UK. Evidence on the economics and the cost-effectiveness of alternative methods of organizing access to physiotherapy services is reviewed, and the likely impacts of different organizational models are discussed. GP direct access physiotherapy and primary care provision appear to have a lower average cost than consultant access physiotherapy models, while GP direct access appears to minimize health care resource use per patient. Primary care physiotherapy provision appears to minimize the costs to patients of seeking care, and appears to generate a greater demand for service than other models. The extent to which physiotherapy provision in primary care can substitute for physiotherapy and other resources in the hospital sector is discussed, as is the extent to which patients may benefit from receiving physiotherapy in primary care. It is argued that continued expansion of access to physiotherapy should be critically appraised, and its ability to improve health status compared with that achievable in alternative patient groups who might benefit from physiotherapy in hospital or rehabilitation settings.     

Use of general practice, diagnostic investigations and hospital services before and after cancer diagnosis - a population-based nationwide registry study of 127,000 incident adult cancer patients

ABSTRACT: BACKGROUND: Knowledge of patterns in cancer patients' health care utilisation around the time of diagnosis may guide health care resource allocation and provide important insights into this groups' demand for health care services. The health care need of patients with comorbid conditions far exceeds the oncology capacity and it is therefore important to elucidate the role of both primary and secondary care. The aim of this paper is to describe the use of health care services amongst incident cancer patients in Denmark one year before and one year after cancer diagnosis. METHODS: The present study is a national population-based case-control (1:10) registry study. All incident cancer patients (n=127,210) diagnosed between 2001 and 2006 aged 40 years or older were identified in the Danish Cancer Registry. Data from national health registries were provided for all cancer patients and for 1,272,100 controls. Monthly consultation frequencies, monthly proportions of persons receiving health services and three-month incidence rate ratios for one year before and one year after the cancer diagnosis were calculated. Data were analysed separately for women and men. RESULTS: Three months before their diagnosis, cancer patients had twice as many general practitioner (GP) consultations, ten to eleven times more diagnostic investigations and five times more hospital contacts than the reference population. The demand for GP services peaked one month before diagnosis, the demand for diagnostic investigations one month after diagnosis and the number of hospital contacts three months after diagnosis. The proportion of cancer patients receiving each of these three types of health services remained more than 10% above that of the reference population from two months before diagnosis until the end of the study period. CONCLUSIONS: Cancer patients' health service utilisation rose dramatically three months before their diagnosis. This increase applied to all services in general throughout the first year after diagnosis and to the patients' use of hospital contacts in particular. Cancer patients' heightened demand for GP services one year after their diagnosis highlights the importance of close coordination and communication between the primary and the secondary healthcare sector.     

Recent developments in primary care in the United Kingdom: from competition to community-oriented primary care

In 1990, changes to the National Health Service (NHS) in the United Kingdom introduced a form of US-style competition that broadened the role of general practitioners (GPs). However, the changes (called GP fundholding) produced greater inequality between practices and reduced the capacity of the NHS to plan strategically. Alternative models have been developed that retain the increased influence of primary care, promote community-oriented primary care (COPC), and facilitate strategic planning. A recent proposal from the government turns away from the competition model of 1990 to encourage GP commissioning. It offers the opportunity to create an NHS that is led by a primary care agenda, including better links with the community, and a focus on public health and social services with the goal of improving the health of populations.