Competition in the NHS internal market: an overview of its effects on hospital prices and costs

The 1989 reforms of the UK National Health Service (NHS) introduced competition in the supply of hospital services. This paper synthesizes both the theory underlying the introduction of competition into the NHS, and the limited existing evidence on whether competition affects the prices posted by sellers of medical services, and the costs of producing these services. The results indicate high levels of price variability, widespread disregard for average cost pricing rules and some indication that competition had some effect on prices. It appears that lower prices may be offered to smaller purchasers, such as General Practice Fund Holders (GPFH). This effect of competition on price was mirrored, with a delay, in hospital costs. © 1998 John Wiley & Sons, Ltd.     

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.     

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.     

市场竞争与国有综合医院战略人力资源管理

中国经济市场化的深度与广度不断增强，在市场经济环境中，国有综合医院的垄断地位被打破，资金短缺和人才流失是公立医院特别是国有综合医院可持续发展中亟待破解的两大难题。本文通过对国有综合医院市场竞争环境的分析，参考企业的理论研究，提出国有综合医院应兼顾当前和长远进行战略人力资源管理设计与实践，以提高市场核心竞争能力，求得生存和发展机会。     

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。     

Model of data structure and flow in general practice: a guide to evaluation of practice management software

Despite its benefits, the computerisation of Australian general medical practices has been delayed, partly due to user concerns about the format of data dictated by available software and the portability of such data. This article proposes certain essential criteria for practice management software, which may provide a framework for its evaluation by users. A set of simple guidelines for database maintenance is also proposed. The author believes that users should become familiar with basic software architecture and drive the market to develop packages that conform to these minimal criteria.     

Health professionals' views of the effectiveness of nutrition care in general practice setting

Aim: The current qualitative study aimed to explore the perceptions of key health professionals relating to the effectiveness of nutrition care provided in the general practice setting. Methods: Twenty‐eight health professionals across a range of disciplines (general practitioners (n = 11), practice nurses (n = 3), dieticians (n = 5), naturopaths (n = 5) and exercise physiologists (n = 4)) individually participated in a semistructured telephone interview, guided by an inquiry logic informed by the literature. Interviews were transcribed verbatim and analysed thematically using a constant comparison approach. Results: Health professionals, including general practitioners, perceived that nutrition care provided in the general practice setting was mostly ineffective at improving patient nutrition behaviour. This was reported to be due to nutrition care competency deficits among general practitioners, a general practice reimbursement system that encourages practices inconsistent with quality nutrition care, and a low prioritisation of nutrition care in general practice. Tensions were apparent between health professional groups, which may be hindering the successful implementation of interdisciplinary nutrition care for patients with chronic disease in this setting. Conclusion: Without systematic changes to Australian primary health care model, the demand on general practitioners as primary providers of nutrition care will continue, therefore mandating support for general practitioners providing care in this context. Further research is required to identify strategies to improve nutrition care and opportunities to facilitate integrated health care provided to the general public within the general practice setting.     

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.     

The practice characterization model: the importance of organizational life cycles and targeted interventions in general medical practice

In response to a climate of constant change and increasing demand for services, general practice in the UK has undergone significant modification over the last 10 years. It has become a multi-disciplinary organisation encouraged by funding bodies to plan for service delivery using a more structured team based approach. In Tayside in 1996, practices were charged with producing formal Practice Development Plans (PDPs) which would focus on priority areas aligned with the Health Boards own strategic plan--those were teamwork, information management and technology, and clinical service delivery. The University of Dundee's Department of General Practice successfully applied for funding to develop ways of facilitating practices so that they could a) identify their own development priorities, and b) plan and implement action and learning to see these priorities through. Using action research methodology, the project attempted to create a climate for change, provide support and training to see the changes implemented, and ensure commitment to the changes from all members of the practice team. The Facilitator adopted a flexible style varying her role between expert, guide and support. Analysis of progress made by different practices, coupled with the Facilitator's in depth knowledge of them, suggested the importance of certain key aspects of practice organisation and culture. A practice characterisation model identified practices which were stable, currently coping, proactive and ready to face the challenge of change as best placed to engage in a full scale development programme. Other profiles suggested a range of alternative interventions as more likely to be acceptable and productive.     

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.     

Organizational values in general practice and public involvement: case studies in an urban district

A multiple case study design was used to explore dimensions of organizational values in general practice with respect to developing public involvement. The study was undertaken in an urban district in England with data collected through in-depth individual and focus group interviews with service providers and service users. Four general practice organizations were randomly selected for study after sorting all in the district according to their record of developing involvement activities. The case studies provide evidence of how organizational values can differ markedly in general practice in relation to ideas of public involvement, with consequences for the quantity and quality of activities for involving local people and service users. The differences manifest themselves in the beliefs and attitudes of service providers about the purpose of the organization and the types of relationships that are appropriate with service users and local people. Service users appear to be very perceptive to the underlying ethos and purpose to their practice organization and this affects their responsiveness to initiatives for their involvement. The dimensions of the different values found in the study appear to be essentially the same as a number of established empirical findings of variations in values in general practice: an orientation to a narrow medical role and to general practice as a business are associated with a low valuation of involvement; an orientation to teamwork and to a broader social role appear more congruent with the development of involvement. Power is a critical issue in this setting with evidence in the study of the dominance of the medical practitioners in establishing organizational values and the nature of public involvement activities.     

三城市社区全科医学培训现状与需求分析

目的了解社区全科医学培训现状及需求情况，为制订相应的培训策略和方法提供依据。方法采用定性与定量相结合的方法，调查成都、沈阳、上海三城市社区卫生服务中心或服务站的全科医学培训及需求情况。结果在所调查的171名医生中，接受过全科培训的占39，8％；162名护理人员中，接受过全科培训的占12．3％；67名预防保健人员中，接受过全科培训的占35，8％。接受过全科培训的医务人员对培训效果的评价并不高，但对全科医学培训却有着较高的需求。结论建议建立全科医生培养基地，强化对社区卫生服务人员的培训，提高人员素质。     

Evaluation of welfare rights advice in primary care: the general practice perspective

Income maximisation may reduce enduring poverty-related health inequalities. Specialist welfare rights advice in primary care has been proposed and, in some areas, implemented, but evaluation data from the general practice perspective is needed. The present study aimed to evaluate the impact on general practice of specialist welfare rights advice, comparing practices with and without in-house provision of welfare advice using a cross-sectional postal questionnaire. This study was conducted in general practice surgeries in an inner-London health authority with high indicators of deprivation. Questionnaires were sent to practice managers. Comparative data (according to whether specialist advice was currently offered) addressed processes of identifying and meeting welfare needs and outcomes in terms of efficiency of provision. Seventy-nine surgeries participated. Those with welfare rights advisers (n = 42) were significantly more likely to report that current provision was adequate, that it was easier for staff to access advice on their patients' behalf (and by patients themselves) and that the process of advice provision ran smoothly. Lack of funding and space were the principal reasons for not having in-house advice. Surgeries wish provision to be expanded within practices. Welfare rights advice in surgeries improves ability to meet welfare needs via specialist advisers. Referral processes are simplified, enabling general practitioners to ensure that relevant advice is provided without the need for welfare knowledge themselves. General practices welcome the expansion of provision, with the proviso that adequate resources are identified. The current lack of basic information in surgeries must be addressed (e.g. information on local providers, printed information detailing range and eligibility criteria of welfare benefits).     

Referral patterns between the child health service,general practitioners,and secondary healthcare: A prospective descriptive study in the Netherlands

Background: In the Netherlands, preventive child health service (CHS) screening plays an important role in the early detection of congenital, developmental, physical, and mental disorders. Objective: To obtain insight into the referral patterns of children from CHS to general practitioners and from general practitioners to medical specialists. Methods: Prospective study over 6 months in a semi-urban area in the Netherlands. All correspondence from the participating doctors was sticker marked and, after each contact, a registration card was sent to a central secretariat. The referral stream between general practitioners and specialists or allied health professionals was extracted from a central database. The general practitioners and the participating paediatricians were asked to complete a questionnaire about the quality and necessity of the referral. Results: Out of an estimated 2600 examinations, 45 children were referred to their general practitioners for further examination. The problems of eight children were settled by the GP, 10 children were referred to allied health professionals, and 24 children were referred to specialists. The median time span of showing up at the GP's office was 6.5 days. Sixteen per cent showed up long after having been referred by the CHS. The parents of three children did not comply. Of the 397 referrals from GPs to medical specialists and allied health professionals, 8.5% were initiated by the CHS.

Conclusion: The amount of referrals from the CHS to GPs and of referrals from GPs to medical specialists and allied health professionals initiated by the CHS is low in terms of absolute percentages. Most referrals by the CHS were considered useful.     

Price regulation and generic competition in the pharmaceutical market

In March 2003 the Norwegian government implemented yardstick-based price regulation schemes on a selection of drugs subjected to generic competition. The retail price cap, termed the index price, on a drug (chemical substance) was set equal to the average of the three lowest producer prices on that drug, plus a fixed wholesale and retail margin. This is supposed to lower barriers of entry for generic drugs and to trigger price competition. Using monthly data over the period 1998–2004 for the six drugs (chemical entities) included in the index price system, we estimate a structural model enabling us to examine the impact of the reform on both demand and market power. Our results suggest that the index price helped to increase the market shares of generic drugs and succeeded in triggering price competition.     

Electronic records suggest suboptimal management of chronic kidney disease in general practice

Objective: To examine electronic records of GP management of chronic kidney disease. Design: Cross‐sectional study. Setting: Thirteen general practices. Participants: Fifteen thousand four hundred and fiftteen active patients aged 50 years and over. Main outcome measure: Recorded estimated glomerular filtration rate (eGFR) and diabetes, and rate of prescribing of angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers (ACE/ARBs). Results: Six thousand and fifty‐nine (39%) patients had hypertension and 1859 (12%), diabetes. Two thousand six hundred and eighty‐nine (17%) patients were recorded with eGFR < 60 mL min^–1 (1.73 m²)^–1, while 3344 (22%) did not have an eGFR result recorded. Hypertension, diabetes and eGFR <60 mL min^–1 (1.73 m²)^–1 were shown to be significantly related to prescribing of ACE/ARBs; however, 31% of known diabetics and 23% of diabetics with an eGFR < 60 mL min^–1 (1.73 m²)^–1 are not recorded as receiving ACE or ARB therapy. Forty‐two per cent of patients with eGFR < 60 mL min^–1 (1.73 m²)^–1, are also not recorded as receiving ACE or ARB therapy. There was a 23% variation in the rates of prescribing of ACE/ARBs by practice for patients with diabetes and eGFR < 60 mL min^–1 (1.73 m²)^–1. Conclusion: The overall recording of eGFR and the recorded prescribing of ACE or ARB therapy in known diabetics and patients with eGFR < 60 mL min^–1 (1.73 m²)^–1appear suboptimal. Also, the variations in prescribing between practices require further investigation.     

医学生参与社区卫生服务对社区全科医疗建设的作用

目的　了解杭州市社区全科医疗现状和居民的需求 ,探索医学生社区志愿服务在完善社区全科医疗 ,推动全科医疗服务发展中的作用。方法　通过对杭州市社区全科医疗服务提供和需求情况进行调查。结果　杭州市社区全科医疗服务存在全科医学人才缺乏 ,卫技人员学历层次低 ,医疗卫生服务单一等问题 ;杭州市居民慢性病发病率较高 ,对社区全科医疗服务需求意识不足 ,对“健康使者”社区卫生服务表示支持。结论　医学生参与社区卫生服务对社区全科医疗建设的作用在于①缓解社区全科医疗人力资源的不足。②改善当前社区全科医疗服务单一的情况。③提高居民对社区全科医疗的认识。④促进全科医学人才的培养     

Health promotion in general practice: On meanings and aims in interaction

The enterprise of health promotion in medicine involves a responsibilityof distinguishing between the concepts of health and absenceof disease and of reflecting on the notions of illness and sickness.In this paper the importance of human dialogue is stressed bothas a means and end of the doctor-patient relationship and asthe main means of genuine health promotion. The outcome of healthwork is proposed to depend mainly on the way the patients areencountered. Their efforts to make themselves seen as beingsick should not on all occasions be diagnosed and treated. Bymeans of a reflected, dialogic practice patients may be listenedto and inspired to reconstruct their symbol-based relationshipto the world of meaning. The conception of health primarilyincludes man's relationship to himself. Illness is looked uponas the subject's experience of illhealth, whereas disease isunderstood as a functional imbalance of bodily organs. Thereis a tacit meaning in being ill (and found sick) that can berealized and attended to best in close relationship with thepatient. Physicians – preferably general practitioners– involved in health promotion should, it is concluded,both assist the patients to give up their sick role and continuallyelaborate their own professional competence to see and successfullyencounter the manifold specifically human issues underlyingtheir patients' presented symptoms.