ECRS (extra-contractual referrals). Mind the gaps

METHOD. Buckinghamshire HA's ECR account budget sheet was reviewed for a five-month period from April 1993, to identify adult mental health patients who were residents. Children under 16 and patients with physical disabilities were excluded from the study. All local consultant psychiatrists who either referred the patients or were responsible for their care were interviewed by a public health doctor, using a structured questionnaire. Basic demographic details, diagnoses, details of the ECR request, reasons for referral, current care needs and future patient plans were analysed for patients known by their consultants. RESULTS. Thirty-two patients were identified from the ECR account sheet. Twenty-eight patients were known by a local consultant and included in the analysis. Of the outstanding four patients (14 per cent), one had returned to their local provider unit but was still being invoiced as an ECR patient, and three were long-term chronically ill patients referred before ECRs were introduced.     

Efficiency of care at the primary-secondary interface: variations with GP fundholding

The aim of the study was to investigate the processes of referral for out-patients care and the interface with general practice, from the perspective of the patient, the patient's general practitioner and hospital specialist. The analyses reported here present variations with fundholding and non-fundholding general practice. The design was a questionnaire survey of out-patients, their hospital specialists and general practitioners, in six, randomly sampled district health authorities in the North Thames Region, with stratification by area. The measures included validated items and scales on process, quality and patient satisfaction with services. Fundholders were more likely to have technical equipment and services available within the practice. There were no differences between fundholders and non-fundholders and the number of out-patient attendances made by their patients, hospital out-patient waiting list times, patients' waiting times in hospital clinics, nor in patients' satisfaction with out-patients and other process indicators. Fundholding is currently being replaced with the proposed wider locality commissioning schemes, with GPs, health authorities and other purchasing bodies acting in partnership. Health authority commissioning will be required to reflect the preferences of GPs. Participants in these schemes will need to pay particular attention to the areas where research indicates that fundholding GPs made little difference to increasing the efficiency and effectiveness of health care both in their own practices and at the primary-secondary care interface.     

The continuing care guidelines and primary and community health services

The confirmation of NHS responsibilities for continuing health care has important implications for primary and community health services. In early 1996, during the period of consultation on draft local policies and eligibility criteria, exploratory interviews were carried out with general practitioners (GPs), community nursing managers, primary care development officers and social services purchasers in three health authority areas. The interviews indicated that few GPs had responded to local consultation and were only slowly becoming aware of the implications for the provision and purchasing of primary and community health services. Moreover, local continuing care policies had apparently not addressed two issues which GPs and community nursing staff indicated were currently highly problematic: their responsibilities in relation to independent sector residential and nursing home patients; and the consequences for primary health and community nursing services of hospital discharge decisions. The need for purchasers and commissioners of health services, whether health authorities or GPs, to begin collecting information on patients' potential needs for continuing care services was widely recognised as an urgent priority.     

Hospitals. The regeneration game

DGHs are faced with a choice between restricting their focus to intensive surgical and medical services or building up alliances with other agencies, including GPs. Their best hope for survival lies in robust relationships with GPs, local authorities, support groups and consumer organisations. Hospitals must pay more attention to discharge procedures. They must be prepared to manage demand in partnership with community providers.     

Organizing community nursing: an exploratory study

The NHS in the 1990s places increasing emphasis on primary care and puts pressure on general practitioners (GPs) and community nurses to deliver a broad range of high quality care in the most cost-effective possible way. In attempting to achieve these objectives, the British National Health Service (NHS) and its individual health authorities have re-examined the available range of organizational choices and increasingly the tendency is to organize community nursing around the focal point of general practice. The authors' evaluation of six innovative 'pilot projects' showed the effects of different organizational choices with respect to basing, purchasing, provision and management of community nursing services. It was found that there are some advantages to focusing primary care on the GP; basing of nurses on the practice is particularly advantageous. There are, however, some very clear indications that the adoption by GPs of multiple, and sometimes conflicting, roles of manager, provider and purchaser of community nursing inhibits the development of fully integrated primary health care teams and can be detrimental to the nursing function. It is concluded that the NHS needs to explore other less GP-centred organizational configurations within primary care.     

Prioritizing services: GPs' views, fundholders versus non-fundholders

Aims to assess the level of agreement between priorities of service provision in 20 discrete clinical areas, as laid out in a district health authority (DHA) purchasing plan, and the views of GPs in the catchment area of that authority and to test for a statistically significant difference between the views of fundholding and non-fundholding GPs. A 74 per cent response rate was achieved, and analysis suggested that local GPs' views were broadly in line with their DHA strategy, and that a significant difference existed between the views of fundholders and non-fundholders in only one treatment area, namely that of lithotripsy. Concludes that the postal questionnaire is a cheap and easy method of assessing the views of GPs on prioritizing issues. As yet there is little difference between fundholding and non-fundholding GPs in this area of decision making.     

Movement and change: independent sector domiciliary care providers between 1995 and 1999

Promoting the development of a flourishing independent sector alongside good quality public services was a key objective of the community care reforms of the last decade. This paper charts some of the ways the independent domiciliary care sector is changing, as local authorities shift the balance of their provision toward independent sector providers and away from a reliance on in-house services. Two surveys of independent domiciliary care providers were carried out in 1995 and 1999. The aims of the studies were to describe the main features of provider organisations, such as size of business, client group and funding sources; to examine the nature of provider motivations and their past and future plans; to consider how local authorities manage the supply side of social care markets; and to examine the effects on providers of the development of the mixed economy. The first survey in 1995 was conducted in eight local authority areas, which by 1999 had increased to 11 because of the creation of three new unitary authorities. The findings are based on 261 postal surveys together with 111 interviews between the two studies. The research illustrates a domiciliary care market that is still relatively young with many small but growing businesses. There are considerable differences in the split between in-house and independent sector services in individual authorities and a common perception among independent providers that in-house services receive favourable treatment and conditions. Spot or call-off contracts continue to be the most common form of contract although there are moves toward greater levels of guaranteed service and more sophisticated patterns of contracting arrangements. There remains an ongoing need to share information between local authorities and independent providers so that good working relationships can develop with proven and competent providers.     

GPs' views on their role in cancer genetics services and current practice.

BACKGROUND: Increasing demand for cancer genetics services has necessitated an urgent review of how these services are organized and, in particular, identification of an effective role for primary care. OBJECTIVES: We aimed to assess the views of GPs on their role in cancer genetics services and their confidence in performing that role; to assess their understanding of cancer genetics, current practice and referral behaviour; and to identify needs for information and training to enable GPs to play an effective role in these services. METHOD: A cross-sectional questionnaire survey of GPs was conducted through general practices in SE Scotland; 397 (response rate 59.3%) GPs returned a completed questionnaire. Outcome measures were: responders' perceptions of their role in cancer genetics services; confidence within that role; understanding of cancer genetics; current practice regarding patients presenting with concerns about their family history of cancer; and perceived information and training needs. RESULTS: GPs identified their role to be: taking a family history; making appropriate referrals to specialist services; providing emotional support; teaching breast self-examination; and discussing need for screening. Lack of confidence within this role was reflected in low levels of understanding of cancer genetics and in inappropriate referral practices. Concerns were expressed about the increasingly specialist role demanded of primary care. A desire for referral guidelines and community genetics clinics was identified. CONCLUSIONS: GPs readily identify a role for themselves in cancer genetics services, but admit to a lack of confidence in this area, calling for clear referral guidelines and specialist community support. Current inappropriate referral to specialist services results from a lack of confidence in estimating cancer risk, highlighting the need for the development of clear referral criteria. Given the rapidly increasing demand for cancer genetics services and the vital role of primary care, it is important to identify a model of these services that facilitates effective involvement of GPs without further increasing their workload.     

GPs' attitudes to minor ailments.

BACKGROUND: It is generally considered that a significant proportion of 'inappropriate' demand for GP services is generated by consultations for minor ailments. How GPs manage minor ailments is likely to affect how patients perceive and handle similar illnesses in the future. Whilst this potentially has significant implications for general practice workload, research investigating GP' attitudes towards minor ailments and their management is sparse. OBJECTIVE: Our aim was to describe GP' experiences and perceptions of minor ailment consultations and their attitudes towards minor ailment management. METHODS: A questionnaire survey was conducted in 1999, derived from a series of 20 qualitative interviews with practising GPs. The survey was sent to one GP randomly selected from each practice (n = 759) in eight English health authorities. Attitudinal statements were analysed using factor analysis. RESULTS: Four hundred and fourteen GPs (54.5%) completed and returned the questionnaire. Respondents were consulted regularly about minor illness or symptoms, with almost all (95.6%) having experienced a minor ailment consultation in the previous week. Factor analysis suggested four issues to be of importance in determining GP' attitudes to minor ailment management. These were attitudes towards pharmacists, attitudes towards patient empowerment, frustration with minor ailment consultations and attitudes towards caution/risk. CONCLUSION: Although GPs are clearly frustrated by the level of minor ailment consultations, this study suggests that there may be complex factors which influence their attitudes. For the optimal management of minor ailments, inter-professional relationships potentially are of great importance. With increasing patient demand, it is essential that finite health care resources are accessible, appropriate and used in an optimal way.     

Primary care in a post-communist country 10 years later Comparison of service profiles of Lithuanian primary care physicians in 1994 and GPs in 2004

OBJECTIVES: The study aimed, firstly, to assess changes in the service profile of primary care physicians between 1994, when features of the Soviet health system prevailed, and 2004, when retraining of GPs was completed. Secondly, to compare service profiles among current GPs, taking into account their positions before being retrained. METHODS: A cross-sectional repeated measures study was conducted among district therapists and district pediatricians in 1994 and GPs in 2004. A questionnaire was used containing identical items on the physicians' involvement in curative and preventive services. The response rates in both years were 87% and 73%, respectively. RESULTS: In 2004, physicians had much more office contacts with patients than in 1994. Modest progress was made with the provision of technical procedures. Involvement in disease management was also stronger in 2004 than in 1994, particularly among former pediatricians. Involvement in screening activities remained stable among former therapists and increased among former pediatricians. At present, GPs who used to be therapists provide a broader range of services than ex pediatricians. GPs from the residency programme hold an intermediate position. CONCLUSIONS: Lithuanian GPs have taken up new tasks but variation can be reduced. The health care system is still in the midst of transition.     

Perceptions of psychological problems in general practice: a comparison of general practitioners and psychiatrists.

All general practitioners and psychiatrists working in a single health district were sent a questionnaire on their perceptions of the prevalence of psychological problems among patients consulting in general practice. One hundred and twenty-one GPs (75%) and 10 (83%) psychiatrists responded. GPs and psychiatrists agreed that up to 20% of consulting patients were likely to be clinically depressed; they also agreed on the most appropriate management, although GPs tended to be more conservative than psychiatrists would advise on making use of hospital services. GPs, however, believed non-specific psychological problems to be significantly less common than did psychiatrists. This expectation may help explain the reported failure of GPs to diagnose all psychological problems identified by formal psychiatric instruments.     

Can primary care be both patient-centred and community-led?

Examines the relationships between the macro-, meso-, and micro-levels in the NHS at the end of the fundholding period and considers their contemporary implications for primary care groups (PCGs) and local health care co-operatives (LHCCs). Fundholding achieved some success in challenging the way in which services were provided at the micro-level (the practice), but had a less marked effect in terms of changing service provision at the health authority (meso-) level or in developing collaborative working with trusts and health authorities in strategic decision making. The health authorities prioritized alternative models of devolved commissioning. Trusts regarded fundholders as a distraction who exerted influence and commanded trust management time disproportionate to their "market share". PCGs and LHCCs represent a shift back to the meso-level in service planning and purchasing. As such there is a risk that the micro-level benefits of fundholding and other forms of devolved commissioning will be lost, while uncertainties remain regarding the capacity of PCGs and LHCCs to incorporate GPs into a collaborative approach to strategic decision making.     

A partial solution: a local mental health authority for the UK

BACKGROUND: the structural problems of the mental health system in the UK have been analyzed by a number of authors over the past several years as the "reforms" of the health and social service systems have continued (Kavanagh and Knapp, 1995; Mechanic, 1995). In a recent article, Hadley and Goldman (1995) suggest that one possible solution to some of these issues may be the creation of a local mental health authority. Such an authority would consolidate the funding, authority and responsibility in a single entity. We believe this model, which is typical of many local public mental health systems in the US, is at least part of the solution to the current problem of financial and service fragmentation of the current system in the UK. The numerous "reforms" of the health and social service systems (which include the Community Care Act, the development of the Internal Market, GP fundholding and the purchaser-provider split) were not designed for the care of the mentally ill (Han, 1996). These policy changes in the design of health and social services have created a complicated and difficult context in which services must be delivered. Too many agencies play a significant role in the delivery and management of mental health services. Health authorities, social service agencies and GP fundholders are direct and indirect funders of the system while community care trusts, social service agencies and GPs are service providers (Hadley, 1996a). RESULTS AND A PROPOSAL: We believe that the development of local mental health authorities may be part of the solution to the structural and economic problems of the current system in the UK. It is not the answer to limited resources or limited skills, but can create a new structure, which will permit and encourage the cooperation and innovation that is now possible only with unusual effort. Local mental health authorities have a number of crucial characteristics, but, most importantly, they refocus the system on the provision of care to the seriously mentally ill. This is the expressed priority of government, advocates and providers, alike.These new entities could be created at either the purchaser or provider level or, as exists in a number of jurisdictions in the US, at both levels, where a single purchaser may be responsible for multiple consolidated providers. This combination is now the emerging model for innovative services in the US. In the UK, the development of a local mental health authority at the purchaser and/or provider level might be relatively simple. Although the creation of a statutory authority would require primary legislation and is therefore probably not a short-term solution, there appears to be a variety of administrative options that would have the same effect. IMPLICATIONS FOR HEALTH POLICY FORMULATION: The creation of a local mental health authority may be a necessary first step towards the development of a coordinated and comprehensive system of care. It seems likely that there is currently more "political" support for the development of a purchaser model but the development of a sophisticated purchsaer is also likely to take considerable time and effort. Although all the structural and policy problems of the mental health system in the UK will not all be solved by local mental health authorities, they may be beneficial if responsibility for mental illness care is to be centralized and fragmentation is to be reduced. Without making structural changes, the best efforts by clinicians, policymakers and managers are most likely to be in vain. Without a clear point of ultimate purchasing and service responsibility, the fragmentation and inefficiency of the current system will remain (Hadley et al., 1996).     

Explaining regional variation in home care use by demand and supply variables

In the Netherlands, home care services like district nursing and personal assistance are provided by private service provider organizations and covered by private health insurance companies which bear legal responsibility for purchasing these services. To improve value for money, their procurement increasingly replaces fee-for-service payments with population based budgets. Setting appropriate population budgets requires adaptation to the legitimate needs of the population, whereas historical costs are likely to be influenced by supply factors as well, not all of which are necessarily legitimate. Our purpose is to explain home care costs in terms of demand and supply factors. This allows for adjusting historical cost patterns when setting population based budgets.Using expenses claims of 60 Dutch municipalities, we analyze eight demand variables and five supply variables with a multiple regression model to explain variance in the number of clients per inhabitant, costs per client and costs per inhabitant.Our models explain 69% of variation in the number of clients per inhabitant, 28% of costs per client and 56% of costs per inhabitant using demand factors. Moreover, we find that supply factors explain an additional 17–23% of variation. Predictors of higher utilization are home care organizations that are integrated with intramural nursing homes, higher competition levels among home care organizations and the availability of complementary services.     

Consultants' views of a district's services.

A postal questionnaire survey of consultants in the Bath Health District was conducted to establish a means for individual consultants to express their views about the provision of health services in the district, so that by working together a new relationship between the District Health Authority (DHA) as purchaser and the clinicians as providers of services could commence. A response rate of 84 per cent was achieved. The survey sought views on clinical and management issues to be used in the development of service agreements (contracts) and views on topics identified by general practitioners (GPs) as areas in need of improvement. Detail is given of results relating to out-patient services, issues of communication and the continuing role of community hospitals. Most consultants sanctioned the appropriateness of referrals by GPs to out-patient services but they identified some out-patient referrals as inappropriate. This justifies a further review of the out-patient services to be purchased by the DHA. Consultants were in agreement that there was scope for review of out-patient follow-ups. They agreed with GPs that discharge summaries could be provided within 24 hours of patient discharge to improve communication with GPs and that consultants should be available by pager to be contacted by GPs, but disagreed with GPs about the feasibility of giving patients on waiting lists a firm admission date at the time of going on the waiting lists. The majority of consultants were in favour of continuing support for community hospitals. They identified overall social value of community hospitals and greater clinical value of out-patient services than in-patient services in community hospitals.(ABSTRACT TRUNCATED AT 250 WORDS)     

Why is high-tech healthcare at home purchasing underdeveloped and what could be done to improve it?

Executive Letter (95)5 initiated a change of health policy preventing general practitioners (GPs) from prescribing packages of "high-tech healthcare at home" (HTHC). From 1 April 1995, district health authorities were required to establish contracts to purchase such care. Several reasons were behind this policy change including the belief that contracting would improve service quality by encouraging competition between potential suppliers, securing better value for money, and establishing service specifications and monitoring mechanisms. Our survey of 98 health authorities, however, highlighted that contracting for home total parenteral nutrition, intravenous antibiotics for patients with cystic fibrosis, intravenous chemotherapy and continuous ambulatory peritoneal dialysis is largely undeveloped. The majority of districts contracted with historic providers and authorities freely admitted that they did not know whether they were obtaining value for money or a service of adequate quality. Only three districts had developed a strategy for purchasing HTHC as required by the Executive Letter, and only 17 had plans to re-examine their approach. Contracting for HTHC presents practical problems, including the complexity of the process and the significant time demands for efficient and effective contracting. Phase two of this research sought to produce a "guide to good practice" for health authorities wishing to re-examine and improve their purchasing. We conducted case study analyses in districts that had made effective progress and those that had encountered difficulties, drawing upon lessons learned. We reported our findings to the NHS Executive and supplemented this with a "toolbox" that included sample documents covering areas such as tendering, monitoring mechanisms, service specifications and different purchasing approaches.     

Who can provide antenatal care? The views of obstetricians and midwives

Objective: To describe the types of antenatal services in NSW maternity hospitals and examine the views of midwives and obstetricians about who can provide adequate routine antenatal care.
Measurements: A mail-out questionnaire to nursing unit managers (NUMs) explored the types of antenatal services available in their hospitals. The questionnaire for 196 midwives and 114 obstetricians asked whether they believed six provider/service types could provide adequate antenatal care either alone or in conjunction with an obstetrician.
Findings: 80% of hospitals had GPs providing antenatal care, 53% had obstetricians and 3% had visiting midwives; 33% had a public antenatal clinic, 28% a shared care program with GPs and 26% midwives' antenatal clinics. Midwives were more likely than obstetricians to rate the following as able to provide adequate care alone: hospital antenatal clinic (4.7 times more likely); independent midwife (42.9x); and community midwives as an outreach hospital service (17x). Obstetricians were 8.2x more likely than midwives to rate private obstetricians as being able to provide adequate care. Midwives were more likely to perceive that independent midwives (24.7x more likely) and community midwives as an outreach hospital service (15.3x more likely) were able to provide adequate care either alone or in conjunction with an obstetrician.
Conclusion: Most NSW hospitals have GPs providing care, but midwives' clinics and independent midwives are less available. While midwives and obstetricians hold similar beliefs about GPs providing care, substantial differences emerged about the midwife's role. Such disparity in opinion may be central in providing options and consistency in care for women.     

Inducing or restraining demand: the market for night visits in primary care

We analyse the demand for and the supply of night visits in primary care. We present a model of general practitioners (GPs) choice between meeting demand by making visits themselves or passing them to commercial deputising services. We extend previous models of demand management to allow for demand discouragement as well as demand inducement. Demand and supply equations are derived and estimated using 1984/1985-1994/1995 panel data for English primary care health authorities. Demand is not affected by the likelihood that the visit is made by a GP or a deputy, suggesting that patients do not perceive these visits as being of different quality. The introduction of differential fees for GP and deputy visits in April 1990 led GPs to increase their own visits and to reduce the number made by deputies. The fee change also led to demand being managed downward where GPs used deputies and to demand inducement where they met demand themselves.     

Variation in purchasing for the invasive management of coronary heartdisease

This paper reports the results of a postal questionnaire survey of Directors of Public Health in all health authorities in the United Kingdom (as at March 1994). Our aim was to examine variations in the purchasing of coronary artery bypass grafting, percutaneous transluminal coronary angioplasty and coronary angiography. Information on planned service developments in cardiology was also sought. The response rate was 62%. The mean rate of CABG was 374 per million total population (range 162–710); PTCA 183 (range: 18–648); and coronary angiography 1,010 (range 581–2,334). The mean ratio of invasive treatment to angiography was 1 : 2. Variations in provision were not related to mortality from coronary heart disease or the availability of a local provider. Those districts purchasing higher levels of CABG tended to purchase higher levels of PTCA (Spearman's r=0.52). Observed variations in purchasing of invasive treatments and investigation for coronary heart disease do not relate to population ‘need’ as defined by mortality rates from CHD. The greatest variations are seen in the purchasing of PTCA, an intervention whose place in the management of CHD is as yet not fully defined. Consensus guidelines on the appropriate use of these interventions and on population needs are required.