全科医学教育与社区卫生服务现况分析与对策

通过介绍国内外全科医学的起源、发展,全科医生在社区卫生服务中的地位和作用以及目前我国社区卫生服务人力资源存在的问题,揭示发展全科医学教育、培养全科医生的重要性和迫切性;探讨适合中国国情的全科医学教育模式。     

Independent sector mental health care: a 1-day census of private and voluntary sector placements in seven Strategic Health Authority areas in England

The aims of this study were (i) to map the extent of all mental health placements in the independent sector, for adults of working age, and elderly people (excluding those with a diagnosis of dementia placed in Local Authority care homes), on a census date, across the areas in which the study was commissioned; (ii) to identify the characteristics of the population in placements; (iii) to explore some of the characteristics of the placements and the patterns of use within the private and voluntary sectors; and (iv) to identify the funding source of placements, and cost differences between the private and voluntary sector. The study took place in seven Strategic Health Authority areas, and information was sought from all Primary Care Trust and Social Services commissioners of mental health services, including regional secure commissioning teams, within those areas. A cross-sectional sample was used. Information was requested in relation to every individual meeting the inclusion criteria, placed in independent (private or voluntary) psychiatric hospitals, registered mental nursing homes and care homes on a specified study 'census date' of 28 June 2004 in six of the Strategic Health Authority areas, and 7 October 2004 in the seventh. Information was recorded on a standard questionnaire specifically designed for the study. Information was obtained on 3535 adults and 1623 elderly people in private or voluntary facilities. The largest groups of adults and elderly people had diagnoses of severe mental illnesses (42.1% and 30.5%, respectively), and placements were described as 'continuing care' or rehabilitation, with a 'niche' in specialist forensic care. Around four-fifths of units were in the private sector, which for adults was significantly more expensive than the voluntary sector. A large proportion of units (47.2% of adult placements and 59.3% of placements for elderly people) had only single placements from particular commissioning authorities, whilst others had large numbers, raising issues for effective commissioning. The distance of placements from patients' area of origin, is also an issue highlighted by the study. The study findings are discussed in relation to commissioning practice, and the development of the independent sector in mental health care.     

Patient evaluations of accessibility and co‐ordination in general practice in Europe

Objective  To determine whether patient evaluations of the accessibility to general practice and co‐ordination with other care providers were associated with characteristics of general practice organizations. Background  In 1998 patients across Europe perceived that small general practices have better accessibility than large practices. Since then a number of changes in primary care have had impact on accessibility and co‐ordination of care. Design, setting and participants  The study was based on data from the European Practice Assessment study, an observational study in 284 general practices in 10 countries in 2004. Main outcome measures  Patient evaluations of general practice were measured with the 23‐item Europep instrument, from which seven items on accessibility and co‐ordination were selected in a principal factor analysis. Six practice characteristics were examined: percentage of female general practitioners, mean age of physicians, mean number of physician hours worked per week, number of general practitioners, number of care providers, urbanization level. Mixed regression models were applied, in which patients were clustered within practices, and practices within countries. Results  Practices with a higher numbers of care providers received less positive patient evaluations (b = −0.112, P = 0.004). The other practice characteristics were not related to patient evaluations. Only a small proportion of the total variation in patient evaluations of accessibility and co‐ordination (1.8%) was explained by characteristics of the general practice organizations. Conclusions  General practices have become larger in most developed countries in recent years, but patients seemed to prefer general practice organizations with fewer health professionals.     

Theorising lifestyle drift in health promotion: explaining community and voluntary sector engagement practices in disadvantaged areas

The past two decades have seen an increasing role for the UK community and voluntary sector (CVS) in health promotion in disadvantaged areas, largely based on assumptions on the part of funders that CVS providers are better able to engage ‘hard-to-reach’ population groups in services than statutory providers. However, there is limited empirical research exploring CVS provider practices in this field. Using ethnographic data, this paper examines the experiences of a network of CVS providers seeking to engage residents in health-promoting community services in a disadvantaged region in the North of England. The paper shows how CVS providers engaged in apparently contradictory practices, fluctuating between an empathically informed response to complex resident circumstances and (in the context of meeting externally set targets) behavioural lifestyle approaches to health promotion. Drawing on concepts from figurational sociology, the paper explains how lifestyle drift occurs in health promotion as a result of the complex web of relations (with funders, commissioners and residents) in which CVS providers are embedded. Despite the fact that research has revealed the impact of targets on the work of the CVS before, this paper demonstrates more specifically the way in which monitoring processes within CVS contracts can draw providers into the neoliberal lifestyle discourse so prevalent in health promotion.     

广东省全科医学教育社区实践基地卫生人力资源现状研究

目的:了解广东省全科医学教育社区实践基地卫生人力资源现状,为促进实践基地建设提供参考依据.方法:拟定统一的调查表,由各实践基地统一填报,并分为经济发达及欠发达地区进行统计分析.结果:广东省全科医学教育社区实践基地共87所,职工7233人,其中卫技人员占84%,硕士研究生占1.1 %,本科占26.5%;师级及以上占56.3%;临床医学和护理专业占58.6%,预防医学专业占3.1%;全科医学培训率28.2%.经济发达地区高学历高职称所占比例、接受全科医学培训率均高于欠发达地区.结论:广东省全科医学教育社区实践培训网络逐步形成,但部分实践基地规模小,学历偏低、职称不高,专业结构尚需改善.     

Data quality improvement in general practice

BACKGROUND: The importance of routine data generated by GPs has grown extensively in the last decade. These data have found many applications other than patient care. More attention has therefore been given to the issue of data quality. Several systematic reviews have detected ample space for improvement of data quality. A new review was conducted in order to find out which methods of improvement are effective. METHOD: The Medline database was searched using an iteratively composed set of terms and MeSH (Medical Subject Headings) headings. Only papers that focused on explicit attempts at improving data quality of medical records in general practice were included. RESULTS: Twelve studies met the inclusion criteria. No study used patient-based comparison of records with external sources as the method to assess data quality improvement. Ten studies used internal indicators or markers of data quality instead. Attempts at data quality improvement often involve some sort of individualized feedback, and nearly all attempts seem to have some positive effect. Only one of the included studies fulfilled the basic methodological requirements of an intervention study. The most recent studies used a simple before-after design. CONCLUSION: No intervention to improve data quality has been put to a rigorous enough test. We still lack empirical knowledge as to how improvement can be brought about.     

医院总务工作的特点与精细化管理实践

为了适应新形式的需要,根据医院总务工作的特点,南京医科大学第一附属医院河西分院进行了精细化管理实践,探索医院总务部门新的运作模式.     

Barriers and facilitators to partnership working between Early Intervention Services and the voluntary and community sector

Partnership working between health and the voluntary and community sector has become an increasing political priority. This paper describes and explores the extent and patterns of partnership working between health and the voluntary and community sector in the context of Early Intervention Services for young people with a first episode of psychosis. Data were collected from 12 Early Intervention Services and through semistructured interviews with 47 voluntary and community sector leads and 42 commissioners across the West Midlands of England. Most partnerships were described as ad hoc and informal in nature although four formal partnerships between Early Intervention Services and voluntary and community sector organizations had been established. Shared agendas, the ability to refer clients onto an organization that could provide a service they could not and shared training facilitated partnership working in this context. Barriers to closer working included differences in culture such as managing risk, the time required to make and maintain relationships and recognition of the advantages of remaining a small and autonomous organization. The four more formal partnerships were also built on the organizations' experience of working together informally, in one case through a specific pilot project. The voluntary and community organizations involved were also branches of larger national organizations for whom finding sustainable funding was less of an issue. In theoretical terms, eight Early Intervention Service: voluntary and community sector partnerships were at a stage of 'pre-partnership collaboration', three at 'partnership creation and consolidation' and one at 'partnership programme delivery'. The empirical data viewed through the lens of the partnership life-cycle model could help early intervention services, and voluntary and community sector professionals better understand where they are, why they are there and the conditions needed to realise the full potential of partnership working.     

Integrating partner professionals. The Early Explorers project: Peers Early Education Partnership and the health visiting service

Background A range of voluntary sector organizations are involved in the delivery of services to children, particularly within the Early Year's sector and children's centres. Peers Early Education Partnership (PEEP) Early Explorers project is one example of the way in which explicit partnerships are being forged across statutory and voluntary sectors with the aim of improving outcomes for children and families. This paper reports an exploration of stakeholder views and experiences of two Early Explorer clinics located in areas of high deprivation. Methods Semi‐structured interviews were conducted with a purposive sample of stakeholders (n= 25) from children's centres, PEEP, the health visiting service and service users. Data were fully transcribed and analysed using a thematic approach. Results The data suggest that the two key groups of stakeholders providing Early Explorer clinics (i.e. health visitors and PEEP practitioners) had quite different objectives in terms of their early goals for the clinic, but that despite these differences good progress was achieved in terms of working together effectively. All stakeholders including service users referred to the presence of PEEP as having improved the quality of the clinic environment, and participating mothers identified a wide range of benefits from the enhanced service. However, somewhat restricted views about the role of practitioners within the clinics were identified by users, and the findings suggest that although the early goals for the clinic had been exceeded, these may have been limited in terms of true ‘partnership’ working. Conclusions Early Explorer clinics appeared to have enhanced the service provided within traditional child health clinics and to have provided practitioners with access to hard‐to‐reach families and parents with access to services that are consistent with the broader policy aims of improving parent–infant interaction. However, questions remain as to whether the benefit of ‘partnership’ working was fully realized.     

广州市全科医学教育社区卫生服务实践基地卫技人员调查分析

目的:了解广州市全科医学教育社区卫生服务实践基地卫技人员队伍现状,为促进全科医学教育师资队伍建设提供依据.方法:采用问卷调查的方式对广州市全科医学教育社区卫生服务实践基地的在岗卫技人员进行普查.结果:广州市19家全科医学教育社区卫生服务实践基地共有卫技人员1849名,平均每家拥有卫技人员97人,公卫医师占6.00%;卫技人员中25～54岁占80.53%;大专以下学历人员占66.47%;高级职称、中级职称、初级、无职称人员分别占5.25%,17.85%,67.65%,9.25%;医(仅全科医师)护比为1∶0.95.结论:广州市全科医学教育社区卫生服务实践基地卫技人员队伍中,护士和公卫医师数量不足,学历、职称偏低,人力资源结构有待改善.     

Small-area estimates of general practice workforce shortage in rural and remote Western Australia

OBJECTIVE: To trial a measure of rural and remote GP access for small areas. Design: A cross-sectional study using geographical information systems software to calculate GP to population rates with a floating catchment of 100 km radius around census collection districts (CCDs). SETTING: Non-metropolitan Western Australia. PARTICIPANTS: The locations and full-time equivalents of GPs and other primary-care doctors were identified through a GP workforce survey. MAIN OUTCOME MEASURES: GP to population ratios for each CCD were classified as being above or below a benchmark of adequate GP access. CCDs with no GP sessions reported within 100 km were identified separately. These categories were investigated by divisions of general practice and by indigenous status, age and employment characteristics of the population. RESULTS: Small-area estimates detected greater variation in access than depicted by conventional methods. Sixty-four per cent of the non-metropolitan population live in CCDs with adequate GP access. Forty-five per cent of indigenous people and 52% of people working in rural industries live in CCDs with access below the benchmark. CONCLUSIONS: The floating catchment method is a powerful tool to identify small areas of inadequate service. It can be applied to measure access to other professionals, medical equipment or facilities.     

The care management interface with general practice: a case study

This paper reports on a care management initiative at the interface of social work, general practice and district nursing. The aims were to describe the organizational factors, operational criteria and the views of key managers, professionals and users of the care management pilot based in general practice. A multi-method case study design was used. This comprised: retrospective analysis of general practitioner (GP) referrals to social services, reviews of case records of clients in the care management system, and in-depth interviews with stakeholders, professionals, users and carers. This paper focuses on the analysis of the referral information to social services and district nursing from general practice and the themes arising from the interview data such as communication, referral pathways and professional role boundaries. The views of users and carers are presented in terms of satisfaction with continuity, responsiveness and appropriateness of the assessment and delivery of care. Although this care management pilot was discontinued when the funding ceased, the evaluation showed that there were benefits in terms of improved understanding between general practitioners, social workers, and district nurses of working systems, procedures and the organizational constraints of joint working.     

Social work, general practice and evidence-based policy in the collaborative care of older people: current problems and future possibilities

While collaborative (or joint) working between social services and primary healthcare continues to rise up the policy agenda, current policy is not based on sound evidence of benefit to either patients or the wider community. Both sets of practitioners report benefits for their own work from adopting new arrangements for collaboration. The underlying assumption behind much of this activity is that a greater degree of integration provides benefits to both users and their carers, a perspective that at times obscures the issue of resource availability, especially in the form of practical community services such as district nursing and home help. At the present time there is insufficient evidence to demonstrate that formal arrangements for collaborative working (CW) are better than those forged informally between committed individuals or teams. Furthermore, arrangements for CW have not hitherto been widely evaluated in systematic studies with a comparative design and focus on outcomes for users and carers rather than on processes. In this paper we propose a number of process measures for future evaluation of CW: (1) study populations must be comparable; (2) details of how services are actually delivered must be obtained and colocation should not be assumed to mean collaboration; (3) care packages in areas of comparable resources should be examined; (4) both destinational outcomes and user‐defined evaluations of benefit should be considered; (5) possible disadvantages of integrated care also need to be actively considered; (6) evaluations should include an economic analysis. Those implementing new policies in Primary Care Trusts have, at present, little sound evidence to guide them in their innovative work. However, they should take the opportunity to rigorously test the advantages and disadvantages of collaboration.     

Orientation for general practice in remote Aboriginal communities: a program for registrars in the Northern Territory

BACKGROUND: Remote general practice can be a highly rewarding career, but poses many personal and professional challenges. It is characterised by significant geographical, professional and social isolation and a requirement for practitioners with public health, emergency and extended clinical skills. The remote practitioner faces further challenges in the remote Aboriginal community setting, including language and cultural barriers. OBJECTIVES: This paper discusses the specific components of a remote Aboriginal community general practice registrar orientation program in the Northern Territory, and their particular importance and relevance to remote training and practice in this context. DISCUSSION: Northern Territory General Practice Education, the regional general practice training provider in the Northern Territory, has developed a model for a comprehensive orientation program for general practice registrars planning to work in remote Aboriginal community locations. This comprises a number of core components, including communication and cultural safety training; clinical and procedural skill development; population health; self-care and personal/professional role delineation; and organisational issues. We believe it is a program that is applicable to other disciplines undertaking work in remote Aboriginal communities.     

Factors influencing interprofessional collaboration between community pharmacists and general practitioners—A systematic review

Effective interprofessional collaboration is critical for sustaining high quality care in the context of the increasing burden on primary healthcare services. Despite this, there is limited understanding of the factors contributing to effective collaboration between general practitioners and community pharmacists. The aim of this systematic review was to identify the factors that impact on interprofessional collaboration between general practitioners (GPs) and community pharmacists (CPs). Keywords and synonyms were combined and applied to four databases (EMBASE, CINAHL, SCOPUS, and MEDLINE) to identify articles published between January 2000 to April 2017. Relevant journals and reference lists were also hand‐searched. A total of 37 articles met the eligibility criteria. Factors that posed a challenge to effective interprofessional collaboration were the perceived imbalance in hierarchy and power between the professions and a lack of understanding of each other's skills and knowledge. Experience of collaboration with the other party led to greater understanding of each other's capabilities and potential role in co‐delivering patient care. The physical environment was also identified as important, with co‐location and other resources to facilitate clear and regular communication identified as important facilitators of interprofessional collaboration. The review findings highlight a range of approaches that may positively influence interprofessional collaboration between GPs and CPS such as co‐location, co‐education to understand the professional capabilities of each group, and utilising compatible technologies to facilitate communication between the two professions.     

The impact of changes in incentives and governance on the motivation of dental practitioners

Recent changes to the system of remuneration and contracting arrangements with Primary Care Trusts (PCTs) has meant that dental practitioners in the UK have experienced several types of incentive and governance arrangements. This paper uses data from a qualitative study of 20 dental practitioners to examine the influence of different systems of incentives and governance on their motivational system. Results show that a perceived reduction in autonomy was the least acceptable aspect of the health reforms. The study also suggests that conflict between self-interested and altruistic motives may occur where medical professionals operate as independent contractors in a small business environment. Whilst dentists appeared to show altruistic motives towards their patients, priorities towards running an autonomous business enterprise meant that PCT managerial requirements, for example, to widen access were not welcomed, because of their impact on managerial autonomy. Moreover, whilst dentists' professional ethos appeared geared towards achieving technically high quality standards of work, this produced tensions against a background of cost containment in a fee-per-item system of remuneration. The paper raises issues such as the person-system interaction associated with professional and individual autonomy and the importance of reciprocity and fair payment.     

Soft governance,restratification and the 2004 general medical services contract: the case of UK primary care organisations and general practice teams

In the UK National Health Service, primary care organisation (PCO) managers have traditionally relied on the soft leadership of general practitioners based on professional self‐regulation rather than direct managerial control. The 2004 general medical services contract (nGMS) represented a significant break from this arrangement by introducing new performance management mechanisms for PCO managers to measure and improve general practice work. This article examines the impact of nGMS on the governance of UK general practice by PCO managers through a qualitative analysis of data from an empirical study in four UK PCOs and eight general practices, drawing on Hood's four‐part governance framework. Two hybrids emerged: (i) PCO managers emphasised a hybrid of oversight, competition (comptrol) and peer‐based mutuality by granting increased support, guidance and autonomy to compliant practices; and (ii) practices emphasised a broad acceptance of increased PCO oversight of clinical work that incorporated a restratified elite of general practice clinical peers at both PCO and practice levels. Given the increased international focus on the quality, safety and efficiency in primary care, a key issue for PCOs and practices will be to achieve an effective, contextually appropriate balance between the counterposing governance mechanisms of peer‐led mutuality and externally led comptrol.     

Patient satisfaction with availability of general practice: an international comparison.

OBJECTIVE: To identify associations between the characteristics of general practitioners and practices, and patients' evaluations of the availability of general practice. DESIGN: Written surveys completed by patients. SETTING: General practice care in nine European countries: Denmark, Germany, The Netherlands, Norway, UK, Belgium (Flanders and Wallonia), Switzerland, Slovenia and Spain. STUDY PARTICIPANTS: 15996 adult patients consecutively visiting the general practitioner (response rates per country varied between 47 and 89%). MAIN MEASURES: The Europep instrument to assess patients' evaluations of five aspects of the availability of general practice care: (1) getting an appointment, (2) getting through on the phone, (3) being able to speak to the practitioner on the telephone, (4) waiting time in the waiting room, and (5) providing quick services for urgent health problems. Each general practitioner recorded age, sex, number of years in the practice, number of practitioners and other care providers in the practice, and urbanization level of the practice. RESULTS: Patients' more positive evaluations were associated with fewer general practitioners in the practice, except for quick services for urgent health problems (range of conditional overall odds ratios, 1.69-2.02). In addition, a number of significant unconditional overall odds ratios were found, particularly those related to the number of general practitioners' working hours and the number of care providers in the practice. None of the associations was found consistently in all countries. CONCLUSION: Patients favour small practices and full-time general practitioners, which contradicts developments in general practice in many countries. Policy makers should consider how the tensions between patients' views and organizational developments can be solved.