Prescribing at the hospital-general practice interface. II: Impact of hospital outpatient dispensing policies in England on general practitioners and hospital consultants.

OBJECTIVE--To assess the impact on general practitioners and hospital consultants of hospital outpatient dispensing policies in England. DESIGN--Postal questionnaire and telephone interview survey of general practitioners and hospital consultants in January 1991. SETTING--94 selected major acute hospitals in England. PARTICIPANTS--20 general practitioners in the vicinity of each of 94 selected hospitals and eight consultants from each, selected by chief pharmacists. MAIN OUTCOME MEASURES--Proportions of general practitioners unable to assume responsibility for specialist drugs and of consultants wishing to retain responsibility; association between dispensing restrictions and the frequency of general practitioners being asked to prescribe hospital initiated treatments. RESULTS--Completed questionnaires were obtained from 1207 (64%) of 1887 general practitioners and 457 (63%) of 729 consultants. 570 (46%) general practitioners felt unable to take responsibility for certain treatments, principally because of difficulty in detecting side effects (367, 30%), uncertainty about explaining treatment to patients (332, 28%), and difficulty monitoring dosage (294, 24%). Among consultants 328 (72%) wished to retain responsibility, principally because of specialist need for monitoring (93, 20%), urgent need to commence treatment (64, 14%), and specialist need to initiate or stabilise treatment (63, 14%). The more restricted the drug supply to outpatients, the more frequently consultants asked general practitioners to prescribe (p less than 0.01) and complete a short course of treatment initiated by the hospital (p less than 0.001). CONCLUSIONS--Restrictive hospital outpatient dispensing shifts clinical responsibility on to general practitioners. Hospital doctors should be able to retain responsibility for prescribing when the general practitioner is unfamiliar with the drug or there is a specialist need to initiate, stabilise, or monitor treatment.     

National survey of current arrangements for diversion from custody in England and Wales.

OBJECTIVES--To assess the extent and nature of psychiatric assessment schemes based at magistrates'' courts in England and Wales for the early diversion of mentally disordered offenders from custody and to determine the response of the NHS to new initiatives concerning alternatives to custody for this group. DESIGN--Postal survey of the probation service, petty sessional divisions, mental health provider units, and district purchasing authorities in England and Wales. SUBJECTS--All chief probation officers (n = 55), clerks to the justices (n = 284), managers of mental health provider units (n = 190), and purchasers of mental health services (n = 190) in each of the district health authorities. MAIN OUTCOME MEASURES--Number of psychiatric assessment schemes, practical difficulties in their operation, extent of regular liaison with health and social services; current and future intentions to purchase or provide services for diversion from custody. RESULTS--Data were obtained from every magistrates'' court. Forty eight psychiatric assessment schemes were identified with another 34 under development. Particular problems were lack of adequate transport arrangements, difficulties with hospital admissions, and overdependence on key people. There was little liaison between health, social services, and members of the criminal justice system. Twenty five of the 106 purchasers who responded had a policy dealing with diversion, and 39 had a scheme under development; 56 purchasers had no current or future plans about diversion. Sixty nine of the 150 providers who responded reported that diversion was included in their current or next business plan. CONCLUSION--Schemes to divert mentally disordered offenders from the criminal justice system are often hampered by lack of adequate transport arrangements, difficulties in hospital admissions, and overdependence on key people.     

北京市公立医院试点医事服务费调查

北京市在公立医院试点医药分开,取消药品加成、挂号费和诊疗费,收取医事服务费。对试点医院门诊调查发现,医院改变传统管理和经营模式,从关注创收转变为控制成本,从多开药转变为合理用药,门诊患者数量明显增多,多数患者对现行的医事服务费政策支持并感到满意。部分医院管理者认为采用医事服务费并取消药品加成没有真正切断医生和药品之间的利益关系,对医院和医护人员长期影响有待进一步观察。     

Is the money following the clients with learning disabilities?

For the past decade patients with learning disabilities living in long stay mental handicap hospitals have been resettled in the community. Local authorities have also taken on the care of new patients who would once have been long stay residents. The imperfect data that are available suggest that in England about half the residents in mental handicap hospitals in 1981 are now the responsibility of local authorities; the figures for Wales and Northern Ireland are 38% and 33%. Data on revenue suggest that the savings to the health service are much less--perhaps 9% in Northern Ireland and 3.6% in England, although there have also been capital gains through the sale of hospitals. Existing methods of transferring money from health to local authorities--joint finance and "dowries" for individual patients--do not seem adequately to have compensated local authorities. Moreover, as patients still to be transferred are more severely disabled local authorities will require larger sums--about 26 000 pounds per patient per year plus 39 200 pounds in capital. If the government chooses not to transfer these resources from health authorities it will be switching funds away from learning disabled people to other care groups.     

Allocating resources to health authorities: development of method for small area analysis of use of inpatient services.

Every year about 22 billion pounds is allocated to health authorities for hospital and community services in England. The distribution of most of these funds is based on a formula developed to reflect the population''s needs, but the existing formula has been criticised on several grounds. This paper describes the development of a method to determine the health needs for small geographical areas. Data from the hospital episodes statistics and 1991 census together with information on vital statistics and supply of health care facilities were used in the model. Two stage least squares regression was used to identify true indicators of need, and these were entered into a multilevel model to take account of variations in practice in different health authorities. The resulting formula should be more statistically robust and more sensitive to needs than previous approaches.     

大型医院可下沉门诊病人的筛选方法与实证研究

准确测算大型医院可以下沉的门诊病人数量,有助于明确分级诊疗潜力和评价分级诊疗政策的实施效果。通过专家咨询、数据模拟分析等方法,建立了大型医院可下沉门诊病人的数据库筛选方法,并以华东某大型城市为样本地区进行实证模拟,发现其50家大型医院2016年可下沉门诊病人数占比为18.76%,其中能被社区医疗机构承接的门诊病人次占比为11.23%。     

Role of community pharmacies in prevention of AIDS among injecting drug misusers: findings of a survey in England and Wales.

OBJECTIVE--To determine the current and potential roles of community pharmacists in the prevention of AIDS among misusers of injected drugs. DESIGN--Cross sectional postal survey of a one in four random sample of registered pharmacies in England and Wales. SETTING--Project conducted in the addiction research unit of the Institute of Psychiatry, London. SUBJECTS--2469 Community pharmacies in the 15 regional health authorities in England and Wales. MAIN OUTCOME MEASURES--Willingness of pharmacists to sell injecting equipment to known or suspected misusers of drugs; pharmacists'' attitudes to syringe exchange schemes, keeping a "sharps" box for use by misusers of drugs, and offering face to face advice and leaflets; and opinions of community pharmacists on their role in AIDS prevention and drug misuse. RESULTS--1946 Questionnaires were returned, representing a response rate of 79%. This fell short of the target of one in four pharmacies in each family practitioner committee area in England and Wales, and total numbers of respondents were therefore weighted in inverse proportion to the response rate in each area. The findings disclosed a substantial demand for injecting equipment by drug misusers. After weighting of numbers of respondents an estimated 676 of 2434 pharmacies were currently selling injecting equipment and 65 of 2415 (3%) were participating in local syringe exchange schemes; only 94 of 2410 pharmacies (4%) had a sharps box for used equipment. There was a high degree of concern among pharmacists about particular consequences of drug misusers visiting their premises, along with a widespread acceptance that the community pharmacist had an important part to play. CONCLUSIONS--Promoting the participation of community pharmacists in the prevention of AIDS among misusers of injected drugs is a viable policy, but several problems would need to be overcome before it was implemented.     

What are health authorities doing about the health problems caused by unemployment?

Unemployment is over three million in Britain, and unemployment is known to be associated with poor health. It has been suggested that health authorities should produce a comprehensive response to the health problems caused by unemployment, and a survey was undertaken to find how many had done so. All the regional and district health authorities in England, the health boards of Wales, Scotland, and Northern Ireland, and the family practitioner committees of England and Wales were asked by letter what they were doing to respond to the health problems of unemployment. A list of suggestions of what they might be doing was enclosed. The overall response rate was 77% (255/331), and 50% (127/255) of the respondents were doing something--33.3% (3/9) of the regional health authorities, 64% (101/158) of the district health authorities and health boards, and 26% (23/88) of the family practitioner committees. The paper describes what they were doing. A relation was sought between the level of unemployment in an area and the extent of the response, and a significant association was found. Half of Britain''s health authorities are now responding in some way to the health problems associated with unemployment.     

Socioeconomic and ethnic group differences in self reported health status and use of health services by children and young people in England: cross sectional study

ObjectivesTo examine whether self reported health status and use of health services varies in children of different social class and ethnic group.DesignCross sectional study from the 1999 health survey for England.Subjects6648 children and young adults aged 2-20 years.SettingPrivate households in England.ResultsLarge socioeconomic differences were observed between ethnic subgroups; a higher proportion of Afro-Caribbean, Indian, Pakistani, and Bangladeshi children belonged to lower social classes than the general population. The proportion of children and young adults reporting acute illnesses in the preceding two weeks was lower in Bangladeshi and Chinese subgroups (odds ratio 0.41, 95% confidence interval 0.27 to 0.61 and 0.46, 0.28 to 0.77, respectively) than in the general population. Longstanding illnesses was less common in Bangladeshi and Pakistani children (0.52, 0.40 to 0.67 and 0.57, 0.46 to 0.70) than in the general population. Irish and Afro-Caribbean children reported the highest prevalence of asthma (19.5% and 17.7%) and Bangladeshi children the lowest (8.2%). A higher proportion of Afro-Caribbean children reported major injuiries than the general population (11.0% v 10.0%), and children from all Asian subgroups reported fewer major and minor injuries than the general population. Indian and Pakistani children were more likely to have consulted their general practitioner in the preceding fortnight than the general population (1.86, 1.35 to 2.57 and 1.51, 1.13 to 2.01, respectively). Indian, Pakistani, Bangladeshi, and Chinese children were less likely to have attended outpatient departments in the preceding three months. No significant differences were found between ethnic groups in the admission of inpatients to hospitals. Acute and chronic illness were the best predictors of children''s use of health services. Social classes did not differ in self reported prevalence of treated infections, major injuries, or minor injuries, and no socioeconomic differences were seen in the use of primary and secondary healthcare services.ConclusionsChildren''s use of health services reflected health status rather than ethnic group or socioeconomic status, implying that equity of access has been partly achieved, although reasons why children from ethnic minority groups are able to access primary care but receive less secondary care need to be investigated.

What is already known on this topic

Children from lower socioeconomic classes and from Indian ethnic subgroups may make more use of general practitioners'' services than other childrenAfro-Caribbean, Indian, Pakistani, and Bangladeshi children are less likely to be referred to outpatient and inpatient services at hospitals than white children

What this study adds

Indian, Pakistani, and Bangladeshi children reported less acute and chronic illness, asthma, and injuries than the general population, whereas Afro-Caribbean children reported moreChildren''s self reported health status and use of health services did not vary by social classIndian and Pakistani children make more use of general practitioners'' services, but Indian, Pakistani, Bangladeshi, and Chinese children are less likely to be referred to outpatient clinicsSelf reported health status rather than socioeconomic status or ethnicity is the best predictor of use of primary and secondary services     

Referral to medical outpatients department at teaching hospitals in Birmingham and Amsterdam.

A method of comparing the referral of patients by general practitioners to medical outpatients departments at teaching hospitals in Amsterdam and Birmingham was devised. This was applied to 89 referral letters to medical specialists at the Free University Medical School Policlinic in Amsterdam and to 88 referral letters to clinics at Birmingham University Medical School, UK. The standards of referral were lower in the Netherlands than in Britain, and this may be related to differences in the health care systems, in the culture, or in the organisation of general practice. The delay between the general practitioner''s referral and the consultation to the outpatient department was four times greater in Britain than in the Netherlands.     

Utilisation by homeless people of acute hospital services in London.

OBJECTIVES--To estimate the numbers and distribution of homeless people in London; to quantify the utilisation of acute inpatient services by homeless people in two health authorities; and to predict the total numbers of admissions in homeless people in district health authorities across London. DESIGN--Data were collected from various sources on the distribution of homeless people across London boroughs. All unplanned acute inpatient admissions during November 1990 to relevant hospitals were identified. SETTING--Bloomsbury and Paddington and North Kensington, two former inner London district health authorities. SUBJECTS--Homeless people in London residing in bed and breakfast and private sector leased accommodation, residing in hostels, and of no fixed abode. MAIN OUTCOME MEASURES--Number and cost of acute unplanned admissions in homeless people in two health authorities in November 1990; predicted number of such admissions each year in district health authorities in London. RESULTS--There were at least 60,000 homeless people in London in March 1990. The majority were housed in temporary accommodation (55,412). There were at least 3295 hostel dwellers and 651 people sleeping rough. Homeless people accounted for 105 (8%) of the 1256 acute unbooked admissions in residents of Bloomsbury and Paddington and North Kensington health authorities in November 1990. Considerable variations in the pattern of acute unplanned admissions in homeless people were observed in the two districts with respect to housing status and specialty of admission. The total number of acute unplanned admissions in homeless people across London each year was estimated at 7598, ranging from 38 in Bexley to 1515 in Parkside. CONCLUSIONS--The results have fundamental implications for resource allocation across London. Allocation must take better account of the heterogeneity, uneven distribution, and extra health needs of homeless people.     

Financial incentives of subregional RAWP.

Accounting for the cross boundary flows of residents from one health authority treated by another has been considered by the review of the Resource Allocation Working Party (RAWP) formula by the National Health Service Management Board. A common concern is that the approximate costs used are unfair to those authorities (typically those with teaching hospitals) that are likely to treat more complex cases. This paper argues that when spending exceeds the target allowance for acute services this is more likely to be due to district residents using services at a high rate than to inadequate compensation for inflows. Districts where residents make a high use of services are often those where there are large flows across district boundaries. Since authorities cannot control outflows there is little they can do to reduce their residents'' high use of services. Furthermore, curious financial incentives can be inferred for clinicians in these districts if they were to take effective action to bring their district''s spending to target levels. These problems are discussed to illuminate problems of accounting for cross boundary flows that alternatives to current practice must resolve.     

BCG immunisation in England and Wales: a survey of policy and practice in schoolchildren and neonates.

OBJECTIVE--To determine the policy and practice of district health authorities in England and Wales for BCG immunisation in schoolchildren and neonates. DESIGN--Self completion postal questionnaire survey. PARTICIPANTS--District immunisation coordinators. SETTING--199 district health authorities in England and Wales. RESULTS--Questionnaires were received from 186 districts, a response rate of 94%. Considerable uniformity was observed in many aspects of BCG immunisation policy and practice but some important variations were found. 15 districts no longer carry out a routine schools programme. 148 districts offer BCG to selected groups of neonates and five to all neonates, but 31 districts do not offer BCG to this age group. The recommended action in response to different levels of tuberculin sensitivity in schoolchildren and neonates varied among districts. CONCLUSIONS--Despite the recommendations of the Joint Committee on Vaccination and Immunisation some districts do not offer BCG immunisation to neonates at high risk of tuberculosis and there are important variations in other aspects of BCG policy.     

European Ethical Review Committee: the experience of an international ethics committee reviewing protocols for drug trials.

An international ethics review committee, founded seven years ago, has several unusual features: it selects its own members, who are independent of the drug industry; it includes members with no medical or paramedical background, such as lay people and lawyers; and it reviews protocols together with the study''s sponsor. Membership of 31 from nine European countries enables frequent meetings and there is a full meeting of the committee every year to review progress and consider policy. Of the first 294 protocols for phase I, II, or III trials reviewed, 37 were admitted outright, 243 were amended (usually during the discussion of the protocol), and 14 were rejected. It is suggested that, to overcome the problem of ethics review in smaller institutions, regional health authorities in Britain might consider establishing similar committees.