Primary health care and the Vietnamese community: a survey in Greenwich

It is more than a decade since Vietnamese refugees arrived in Britain in any considerable numbers, but there is evidence that they are still disadvantaged in terms of employment, housing and health. Although several studies were carried out by the various agencies concerned with Vietnamese refugees in the years immediately after 1980, the year with most admissions to Britain, there has been little recent research which addresses the health care needs of this community. This paper reports a survey of the primary health care needs of a sample of Vietnamese families living in the London Borough of Greenwich. Respondents were satisfied in general with health services they received but there were specific areas of dissatisfaction and concern. The majority of respondents needed an interpreter when visiting their general practitioner (GP) and lack of access to formal interpreters was a barrier to the use of many primary care services. An additional barrier to services such as ophthalmic care, which may not have been experienced before arrival in Britain, was lack of information. High immunization and GP registration rates suggest that Western primary care services were widely accepted. However, a third of the respondents used traditional practitioners and medicines not covered by the National Health Service (NHS).     

Research into the use of health economics in decision making in the United Kingdom--Phase II. Is health economics 'for good or evil'?

The purpose of this phased research project is to better understand the role of health economic arguments in the decision making process of healthcare providers and purchasers in the United Kingdom. Phase I of the research was directed at General Practitioners (GPs); in phase II we broadened the scope of the research to include different agents who influence resource allocation and the wider health care environment. The objective of phase II was to determine the relevance and appeal of diverse health economic measures to different decision makers. This phase of qualitative research involved 34 decision makers in 17 duo interviews. The study has provided a rich source of qualitative evidence on the role of health economics in decision making. The main conclusions to emerge are; different individuals seek different outcomes; health economic studies should report actionable conclusions; and any cost savings must be applicable. To succeed, economists need to demonstrate a better understanding of the contracting and budgetary processes of the National Health Service. Opinions of the value of health economic evaluations varied widely, however most respondents believed it would become increasingly influential in the prioritisation process in the National Health Service of the future.     

Using private health insurance. A study of lay decisions to seek professional medical help

This paper examines the decision making process associated with the use of private health insurance. In particular, it focusses on the criteria respondents draw on to decide when to use the private health sector and when not to. This is an important issue as it gives insight into how the use of the private sector relates to use of the National Health Service. It also informs the theoretical debate about help-seeking behaviour, in particular, the usefulness of the notion of choice and ‘shopping around’ in the health care market. It is concluded that users of health care do exhibit a reasoned approach in deciding between different medical care settings, although due to lack of knowledge and passivity in the patient role, the final decision is usually made by their general practitioner.     

An online survey of nurses' perceptions, knowledge and expectations of the National Health Service modernization programme

We conducted an online survey to investigate nurses' perceptions, knowledge and expectations of the National Health Service (NHS) modernization programme in the UK. The questionnaire was available for 28 days via the Website of the Royal College of Nursing. The questionnaire was completed by 2020 nurses, midwives and health visitors working in all sectors of the health service in a wide range of specialties and environments of care. Less than one-quarter of respondents felt that they had adequate information about NHS information technology (IT) developments. In all, 528 (26%) said this was the first they had heard of the initiatives. Only 383 respondents (19%) felt adequately informed about the development of electronic health records; 470 (23%) felt inadequately informed and 456 (23%) had only heard something about it. The findings of this survey suggest that nursing staff are not widely aware of current IT plans and programmes in the NHS. They suggest that nurses also lack confidence in using advanced IT, which is compounded by lack of training.     

Marginal-cost contracting in the NHS: results of a preliminary survey.

Market disciplines and incentives were expected to improve efficiency in the UK National Health Service following the introduction of an 'internal market' in 1991. An exploratory survey of all Health Authorities and Trusts in the UK was undertaken to investigate whether players in the NHS managed market are behaving as economic theory predicts they should. The focus was on how and to what extent marginal costing has been used in the contracting process and on whether in some instances an inappropriate use of marginal costing may be resulting in inappropriate investment decisions. Twenty of 29 responding Health Authorities (69%) and 16 of 39 Trusts (41%) stated that they had considered purchasing/providing services on a marginal-cost basis and all of these led to contracts. Marginal-cost contracting appears to be fairly commonplace and the process does not appear to be causing insurmountable conflicts between players. Most marginal-cost contracts were specifically to meet waiting-list initiative targets. Overall results suggest that economic principles are not being particularly adhered to, with expansion in output rarely being related to available capacity. As increased responsibility for commissioning passes to primary care teams and local health groups, there are lessons for those involved in this more disaggregated approach to service shaping and service delivery.     

Factors associated with variations in older people's use of community-based continence services

Many people who have urinary incontinence and who may benefit from healthcare and professional advice do not currently access UK National Health Service services, even though effective treatments are available in the community. Older people have an increased prevalence of incontinence and a correspondingly increased need for continence services. Therefore, increasing older people's access to continence services has the potential to reduce inequalities and improve quality of life. The present study aimed to identify older people with urinary incontinence living in the community, to describe and compare the characteristics of users and non-users of continence services, and to identify factors which prevent older people seeking help. A cross-sectional postal survey of patients aged over 65 years registered with four general practices in an urban area found an overall prevalence of 39% of older people with urinary incontinence, only 15% of whom had accessed services. Two-thirds of respondents who reported that they experienced urinary leakage several times per week to all the time, and up to two-thirds of those reporting leakage of moderate or large volumes of leakage had not accessed services. The majority of older people are in regular contact with health professionals, and the greatest single influence on use of services was that of being asked whether there were continence problems by a health professional. Being married or having a partner, experiencing less pain generally, and suffering relatively high frequency and volumes of urinary leakage also appeared to be associated independently with continence service use. In conclusion, there appears to be considerable unmet need for continence services. Health professionals should be aware that incontinence is an important health problem for older people, and by asking older people specifically about urinary leakage, they could reduce inequalities in use of services.     

Impact of the Griffiths reforms of National Health Service management: the views of psychiatrists.

The Griffiths Report of 1983 recommended a number of reforms to the management of the National Health Service. These were strongly opposed in principle by the British Medical Association though some physicians saw them as potentially beneficial. This paper reports a survey of Psychiatrists in one English Region, whose responses suggest that although there remains little opposition in principle and respondents do see some beneficial effects, the new system tends to be seen in terms of its pragmatic disadvantages, with special reference to a perceived lack of managers' understanding of patients' needs.     

The asthma health outcome indicators study

Abstract: Health outcomes have become an important public health policy focus in Australia. The New South Wales Health Department's Health Outcomes Program includes asthma as one of its priority areas. This study combined a survey of a non-random sample of 14 asthma researchers and clinicians and the results of a literature review to determine the current status and validity of outcome indicators used in relation to asthma. A written questionnaire was used to present individual patient, clinical trial, school intervention and public health scenarios, and respondents were asked to nominate asthma outcome indicators they would use in each scenario as well as their estimate of the indicators' validity. The results provide a critical appraisal of a variety of asthma outcome indicators with regard to their repeatability, and their concurrent and predictive validity.     

Junior doctors'' views about careers in academic medicine

OBJECTIVE: To investigate junior doctors' views about careers in academic medicine. DESIGN: Postal questionnaire survey. SETTING: National Health Service in England. SUBJECTS: Doctors in university posts at specialist registrar level, Medical Research Council and Wellcome Trust training fellows, and specialist registrars in National Health Service posts. RESULTS: Incentives to pursue an academic career which respondents rated as strong related to the challenge of research and the intellectual environment of research units. The strongest disincentives were perceived difficulties in obtaining research grants and uncertainty regarding pay parity with National Health Service colleagues. Medical Research Council and Wellcome fellows had much more protected research time than other academic doctors but were less satisfied with their clinical training. Academic doctors who were not fellows reported spending less than half their time on research and the great majority agreed that their research suffers when there is pressure on the service side. CONCLUSIONS: The job content of academic posts should be kept under regular review to ensure that clinical service pressures do not inappropriately erode research time while also ensuring that postholders have adequate clinical training. Training programmes need flexibility to accommodate the needs of clinical academics in their progress through higher specialist training.     

Equity of access to health care. Evidence from NHS Direct in the UK

In the UK National Health Service (NHS), NHS Direct, the national 24-h telephone helpline, has been available in England and Wales since 2000 and has been termed a 'single gateway' to health care. We conducted a population survey of 15,004 people in areas covered by the service, which included questions about NHS Direct use and socio-economic characteristics. After removing undeliverable questionnaires, the survey response rate was 60% (8750/14,516). In all, a quarter of respondents had ever used NHS Direct (26%, 95% confidence interval 25-27), ranging from 32% of the population in Preston/Chorley (888/2,794) and Newcastle and North Tyneside (515/1,621) to 17% (2,215/8,536) in Sheffield, which had introduced the service 20 months later. Logistic regression showed that those from poorer socioeconomic groups or with communication difficulties were less likely to have used the service than others. Overcoming this apparent bias against those likely to have the greatest need is an unsolved problem not confined to telemedicine.     

Benefits of information technology training to National Health Service staff in Wales

The use of computers in the National Health Service (UK) as a workplace is fundamental to its future. However, there is evidence of a paucity of information technology skills within the workforce and therefore, information technology skill training is essential. The National Health Service in Wales has been using the European Computer Driving Licence qualification to educate its staff in order to cover this skill gap. This paper reports on an evaluation of the perceived benefits to staff, both clinical and non-clinical, working for the National Health Service in Wales of information technology training through the European Computer Driving Licence qualification. Results show that there is an increase in confidence in terms of tasks undertaken but also towards other general life skills. Additionally, for those respondents with clinical contact, there is a perceived increase both in the time available with and the quality of care, given to patients. As the continued move towards a computer orientated healthcare system occurs, the information technology skills obtained through but not limited to training schemes such as European Computer Driving Licence will become of paramount importance, particularly as the single most important failure for technology-related projects in healthcare is a lack of readiness.     

Using economic evidence to support decision making: a case study of assertive community treatment within the UK National Service Framework for Mental Health

This study illustrates a process of accessing and utilising clinical and economic evidence in health care decision making. The scenario examined was that of a UK Health Authority evaluating evidence prior to the introduction of assertive community treatment (ACT), as part of guidance from the UK National Service Framework for Mental Health. The consistency between clinical and cost evidence from a number of sources (Cochrane Database of Systematic Reviews (CDSR), Database of Reviews of Effectiveness (DARE), HTA database, NHS Economic Evaluation database (NHS EED)) was also addressed, as was the usefulness of structured abstracts on NHS EED. The findings showed that within specified caveats ACT tends to be more effective and also less costly than alternative interventions; there is general agreement between sources principally reporting effectiveness and economic evaluations; and NHS EED abstracts are useful in the decision making process where information gaps exist. In terms of health care policy in the health authority examined, two ACT teams were subsequently introduced in the city of Leicester. Although systematic reviews and appraisals of evidence are arguably the gold standard in health care decision making, the study illustrates how the use of databases of structured abstracts can assist in making optimal choices in real life decision making scenarios.     

Factors affecting the utilization of systematic reviews. A study of public health decision makers.

OBJECTIVE: To determine the extent to which public health decision makers used five systematic reviews to make policy decisions, and to determine which characteristics predict their use. METHODS: This cross-sectional follow-up study of public health decision makers in Ontario collected primary data using a telephone survey and a short, self-administered organizational demographics questionnaire completed by the administrative assistant for each Medical Officer of Health. Independent variables included characteristics of the innovation, organization, environment, and individual. Data were entered into a computerized database developed specifically for this study, and multiple logistic regression analysis was conducted. RESULTS: The participation rate was very high, with 85% of public health units and 96% of available decision makers completing the survey. In addition, 63% of respondents stated they had used at least one of the systematic reviews in the previous 2 years to make a decision. The most important predictors of use were one's position, expecting to use a review in the future, and perceptions that the reviews were easy to use and that they overcame the barrier of limited critical appraisal skills. CONCLUSIONS: Utilization of the systematic reviews in Ontario was very high. The utilization rates found in this study were significantly higher than those reported in previous utilization studies. One's position was found to be the strongest predictor of use, identifying program managers and directors as the most appropriate audience for systematic reviews.     

Survey of the perceived professional, educational and personal needs of physiotherapists in primary care and community settings

The emphasis of UK Government policy on primary-care-based services has led to more physiotherapists working in the community. The aims of the present study were to identify the perceived professional, educational and personal needs of community physiotherapists, and to determine good practice in meeting these needs. A survey of physiotherapists working in 15 National Health Service community trusts in the West Midlands was carried out in September 2000. The survey questionnaire was developed through focus groups and mailed to a random sample of 200 community physiotherapists. The response rate was 67%, and the median age group of the respondents was 21-30 years. The participants worked mainly in 'urban but not inner city' areas, most commonly in domiciliary (31%, n = 38) and general practitioner surgery/health centre (26%, n = 32) locations. Fifty-one per cent (n = 66) of respondents had no specific learning objectives for continuing professional development (CPD); those with such objectives were more positive as to their helpfulness than those without them (Mann-Whitney U-test z = 2.519, P = 0.012). Fifty-three per cent (n = 68) also often/very often found it problematic getting cover for their caseloads so that they could take part in CPD activities. Access to library resources and use of computers were problems, as were confidence in appraising literature and opportunities to discuss research evidence with colleagues. Fifty-nine per cent (n = 77) of respondents indicated that they often/very often felt stressed by the size of their caseloads. Colleague support included mentorship, peer review, journal clubs, clinical interest groups and multidisciplinary in-service training; respondents with experience of these resources expressed more positive attitudes to them than those without (Mann-Whitney U-test z = 2.871, P < 0.0005 for each). Forty-two per cent (n = 54) indicated that there were problems with safety issues. This study has identified needs that will have an impact on the ability of community physiotherapists to meet the demands of clinical governance. National Health Service management at all levels has a responsibility to facilitate the education, training and support of community physiotherapists.     

Health technology assessment for the NHS in England and Wales

In healthcare decision making, there is an important functional separation between assessment and appraisal. In the U.K. National Health Service (NHS), this distinction is illustrated by the separation of roles between the Health Technology Assessment Programme and the National Institute for Clinical Excellence. However, it can be seen at every level within the healthcare system. Assessment of a technology is a scientific task that synthesizes all relevant evidence on effectiveness and cost-effectiveness; its results are therefore generalizable. Appraisal of the technology is informed by the assessment but adds context-specific judgments on the applicability of the evidence, the feasibility and impact of alternative options, relative priorities, and wider social and ethical aspects. An explicit distinction between assessment and appraisal is helpful in achieving clarity, consistency, and consensus. It also makes clear the need for a wide range of assessment reviews to support decision making by commissioners, providers, and users of health services. Increasingly, the secondary research supported by the NHS R&D Programme is being distributed electronically. It is also being used to identify areas in which further primary research should be commissioned.     

Factors relating to patients' reports about hospital care for coronary heart disease in England

OBJECTIVES: All health care providers in England are required to conduct surveys of their patients' experience of health care. Data from such surveys contribute to the 'star rating' performance indicators. However, there are concerns that these subjective measures may be influenced more by characteristics of patients than by true variations in the quality of care. The purpose of this paper is threefold: to determine the relationship between demographic characteristics and an index measure of patients' reported experience; to explore the extent to which patients' experiences may be accounted for by the particular National Health Service (NHS) trust they attended; and to assess how meaningful a summary index is in terms of its ability to discriminate between providers. METHODS: Data from patients in the National Survey of National Health Service Patients treated for coronary heart disease in 194 NHS trusts. Patients were sent questionnaires after discharge, with a covering letter and a prepaid stamped addressed envelope. Up to two reminders were sent to non-responders. Multi-level linear regression models were used to estimate the extent to which patients' experiences differed between trusts and the association of demographic variables with the summary index. RESULTS: In total, 116,872 patients were sent questionnaires, but 3399 proved to be ineligible for the survey. Responses were gained from 84,310 (74.3% of eligible respondents). Age and sex were most strongly associated with reported patients' experiences. However, the actual impact of age and sex on patients' experience is small, accounting for less than 3% of the variance. The proportion of the variance that was accounted for by the hospital trust in which patients were treated was only 5%. CONCLUSIONS: Demographic characteristics do not appear to account for differences between hospital trusts in patients' experience of health care. However, there is considerable variation in patients' experience within each provider. This would suggest that summary indices of patients' experience should not be used to rank providers, although detailed information from patient surveys have a useful role in determining priorities for quality improvement within individual hospitals and for assessing changes over time.     

Managerial objectives in the NHS

Discusses managerial objectives in the National Health Service and compares service to patients with financial considerations. Reviews the growing influence of financial criteria and the manner in which financial objectives have been introduced. Asks if managers see their mission in terms of financial targets or patient service. Reports on the results of a questionnaire survey of all the managers in the provider units within two District Health Authorities. Managers were asked to rank a set of five statements in order of the extent to which they agree with them. Analysis of the overall results shows a large measure of agreement within the group of respondents that service to patients ranks first, with financial aspects coming last. The same outcome occurred when the results were disaggregated to NHS Trust/non-Trust level and between staff categories.     

Estimated alcohol consumption in the 1995 National Health Survey: Some methodological issues

OBJECTIVE: This paper critically examines the methodology used to ascertain alcohol consumption in the 1995 Australian Bureau of Statistics National Health Survey (NHS). METHOD: The 1995 NHS was the second in a series of regular, five-yearly population surveys designed to obtain national benchmark information on a range of health-related issues and enable the monitoring of trends over time. The first survey was conducted in 1989-90. In the 1995 NHS, respondents were asked about the quantity of each of seven types of alcohol consumed on up to three days of the week before the interview day. In the 1989-90 NHS, however, respondents were asked about alcohol consumption on each of the seven days before the interview. This paper uses Unit Record Data from the 1989-90 National Health Survey to investigate the methodology used in 1995. RESULTS: It is shown that the estimates of alcohol consumption obtained using the 1995 methodology are highly dependent on the day of the week on which the interviews were conducted. CONCLUSION: It is recommended that the 1995 methodology not be used in future NHS surveys. The 1989-90 methodology of seven-day retrospective diaries would seem a better choice for future National Health Surveys.