What is the impact on individual health of services in general practice settings which offer welfare benefits advice?

Welfare benefits advice services are increasingly being provided on primary care premises. It is assumed that the relief of financial deprivation will also relieve ill health, although there is only limited evidence to support this. This paper reports the findings of a study designed to measure changes in individual health associated with income increase as a result of such advice. It was a longitudinal observational study of advice to service users, comparing the health of those whose income increased with that of those whose income did not, using the SF-36 as an outcome measure. The study took place in 2000 and 2001 in seven sites across England, and 345 people were interviewed at base line, 245 after 6 months and 201 after 12 months. Subjects were generally in the second half of life, with one or more chronic conditions. Those who increased their income (the Income Increase group) had significantly better outcomes in mental health and emotional role functioning at 12 months than those with no income increase. There were no other significant differences between groups at 12 months, and none at 6 months. However, if all those who dropped out of the study between 6 and 12 months are excluded, then the same changes observable at 12 months are also recorded at 6 months. Although improvements in health associated with income increase are modest, they make a significant contribution to patients' quality of life. Welfare benefits advice has a role to play as part of holistic care for low-income patients with chronic conditions.     

Who contracts for primary care?

The implications of the 1997 NHS (Primary Care) Act have been largely overlooked in the rush to establish Primary Care Groups. Allowing health authorities to develop local contracts for primary care has far-reaching implications and is an important departure from the national system of negotiation that has characterized general practice to date. This paper describes a content analysis of a sample of Personal Medical Services (PMS) pilot contracts. In the first year little attention has been given to achieving cost savings or greater efficiency and few contracts promote clinical guidelines. The difficulties of specifying services sensitive to local health needs are highlighted and the national Statement of Fees and Allowances (the 'Red Book') may not be swiftly supplanted. However, the pilots have introduced innovations such as salaried general practitioners, nurse-led services and NHS trust-managed care. The development of local contracts provides a valuable learning experience for general practitioners and health authorities in advance of the establishment of Primary Care Trusts.     

Familiarity breeds neglect? Unanticipated benefits of discontinuous primary care

BACKGROUND: Continuity of medical care is generally considered to be beneficial to patients. OBJECTIVE: The aim of this study was to investigate the possibility that familiarity with patients may sometimes discourage case finding. METHODS: Extensive qualitative interviews were carried out with a sample of Australian adults with type 2 diabetes, focusing in particular on their experience of diagnosis. RESULTS: Interviews were conducted with 119 participants, 75% of whom supplied sufficient information to enable the coding of whether diagnosis occurred under circumstances of discontinuity. Half of all participants (two-thirds of the coded subsample) had a diagnosis that could be categorized as resulting from discontinuous primary care: hospital admission, change of doctor, patient initiative and/or diabetic emergency. CONCLUSION: The same circumstances that enhance the management of chronic disease can at times hinder its diagnosis. Primary care service providers may need to instigate more active methods of case finding in order to avoid this paradoxical effect of familiarity with the patient.     

Physician advice for smoking cessation in primary care: time for a paradigm shift?

General practitioners are often exhorted to routinely counsel patients who smoke about quitting in light of current evidence-based medicine (EBM) guidelines suggesting that such brief interventions provide an easy and effective way of increasing quit rates. Drawing on semi-structured interviews conducted with 25 smokers and 10 general practitioners (GPs) in British Columbia, Canada, this article explores smokers’ and GPs’ perspectives on smoking cessation interventions in primary care settings. Study findings indicate that both patients and GPs believe smoking is best broached when it is patient-initiated or raised in the context of smoking-related health issues, and there was a broader consensus that the role of doctors is to provide education and information rather than coercing smokers to quit. However, smokers wanted further recognition of the difficulties of quitting smoking and many questioned the competence of GPs to deal with addiction-related issues. Similar barriers to smoking cessation were raised by smokers and GPs – primarily inadequate time and resources. Based on these findings, we argue that the assumption that primary care consultations provide an important venue for encouraging smokers to quit deserves reconsideration based on the complexity of this issue, the circumstances in which most GPs practice, and the danger of alienating smokers. Questions are raised about whether current EBM guidelines are an adequate tool for guiding individual clinical interactions between GPs and smokers.     

Who pays and who benefits from health care? An assessment of equity in health care financing and benefit distribution in Tanzania

Little is known about health system equity in Tanzania, whether in terms of distribution of the health care financing burden or distribution of health care benefits. This study undertook a combined analysis of both financing and benefit incidence to explore the distribution of health care benefits and financing burden across socio-economic groups. A system-wide analysis of benefits was undertaken, including benefits from all providers irrespective of ownership. The analysis used the household budget survey (HBS) from 2001, the most recent nationally representative survey data publicly available at the time, to analyse the distribution of health care payments through user fees, health insurance contributions [from the National Health Insurance Fund (NHIF) for the formal sector and the Community Health Fund (CHF), for the rural informal sector] and taxation. Due to lack of information on NHIF and CHF contributions in the HBS, a primary survey was administered to estimate CHF enrollment and contributions; assumptions were used to estimate NHIF contributions within the HBS. Data from the same household survey, administered to 2224 households in seven districts/councils, was used to analyse the distribution of health care benefits across socio-economic groups. The health financing system was mildly progressive overall, with income taxes and NHIF contributions being the most progressive financing sources. Out-of-pocket payments and contributions to the CHF were regressive. The health benefit distribution was fairly even but the poorest received a lower share of benefits relative to their share of need for health care. Public primary care facility use was pro-poor, whereas higher level and higher cost facility use was generally pro-rich. We conclude that health financing reforms can improve equity, so long as integration of health insurance schemes is promoted along with cross-subsidization and greater reliance on general taxation to finance health care for the poorest.     

Who pays for health care in Ghana?

Background  

Financial protection against the cost of unforeseen ill health has become a global concern as expressed in the 2005 World Health Assembly resolution (WHA58.33), which urges its member states to "plan the transition to universal coverage of their citizens". An important element of financial risk protection is to distribute health care financing fairly in relation to ability to pay. The distribution of health care financing burden across socio-economic groups has been estimated for European countries, the USA and Asia. Until recently there was no such analysis in Africa and this paper seeks to contribute to filling this gap. It presents the first comprehensive analysis of the distribution of health care financing in relation to ability to pay in Ghana.     

Who pays for health care in Asia?

We estimate the distributional incidence of health care financing in 13 Asian territories that account for 55% of the Asian population. In all territories, higher-income households contribute more to the financing of health care. The better-off contribute more as a proportion of ability to pay in most low- and lower-middle-income territories. Health care financing is slightly regressive in three high-income economies with universal social insurance. Direct taxation is the most progressive source of finance and is most so in poorer economies. In universal systems, social insurance is proportional to regressive. In high-income economies, the out-of-pocket (OOP) payments are proportional or regressive while in low-income economies the better-off spend relatively more OOP. But in most low-/middle-income countries, the better-off not only pay more, they also get more health care.     

Is frequent attendance in primary care disease-specific?

BACKGROUND: Sociodemographic characteristics of frequent attenders in general practice are known. It is not known whether frequent attendance is linked to specific diseases. OBJECTIVE: To investigate whether frequent consultation in primary care is related to specific morbidities and whether this relationship is influenced by the general practice which the patient attends. DESIGN: One-year survey of consultation data. SETTING: Nine general practices in North Staffordshire, UK. PARTICIPANTS: 1000 adults aged 18 years and over who had consulted primary care at least once during the study year were randomly selected from each practice and grouped into frequent (high and very high), medium and low frequency consulters. MAIN OUTCOME MEASURES: Type of morbidity coded at each consultation and number of repeat consultations for each morbidity (based on Read Code Chapters). RESULTS: All morbidity Chapters were associated with frequent consultation. Frequent consultation was also associated with repeated consultation within most morbidities. Stronger associations were seen with mental disorders, blood disorders, circulatory disorders, digestive disorders, endocrine diseases and with causes of injury and poisoning. Some variation between practices in the morbidities associated with frequent consultation were apparent; particularly for skin diseases and unspecified conditions. CONCLUSIONS: Frequent consulters in primary care are not restricted to particular groups of morbidities. There is some aspect of frequent consultation that is a characteristic of individuals regardless of the symptoms with which they consult. Some morbidities are more prominent than others in this group of consulters, and this may help guide practice policies and future research into frequent consulters.     

Who looks after people with diabetes: primary or secondary care?

Because the prevalence of type 2 diabetes has increased greatly over the past decade, UK general practitioners have been encouraged to develop services for people with diabetes and to offer structured diabetes care. The resultant shift from secondary care can place considerable demands on primary health care teams. Data were obtained from 108 practices in two English health districts followed up in primary and secondary care. Nearly two-thirds of the people with diabetes were being followed up only in general practice, the remainder in hospital or both. The proportion managed in primary care varied from 5.6% to 94.6%. The settings where diabetes care was most likely to be offered were training practices, practices with good nursing support, practices with a high prevalence of diabetes, and practices in which a high proportion of diabetic patients were controlled by diet or hypoglycaemic agents. Tight control of glycaemia and blood pressure is now seen as important in diabetes, and is best achieved in general practice. This survey revealed large variations in delivery of general-practice diabetes care that need to be addressed by better organization and funding.