The extent of the two tier service for fundholders.

OBJECTIVE--To examine possible differential changes in outpatient referrals to orthopaedic clinics, attendances, and waiting times between fundholding and non-fundholding general practitioners. DESIGN--Observational controlled study of referrals by general practitioners to orthopaedic outpatients between April 1991 and March 1995. SETTING--District health authority in south-west England. SUBJECTS--10 fundholding practices with 108,300 registered patients; 22 control practices with 159,900 registered patients. MAIN OUTCOME MEASURES--Changes in age standardised referral and outpatient attendance ratios for the year before and the two years after achieving fundholder status; changes in outpatient waiting times. RESULTS--In the year before achieving fundholding status both groups were referring more patients than were being seen. Two years later, referral and attendance ratios had increased by 13% and 36% respectively for fundholders and 32% and 59% for controls, and both groups were referring fewer patients than were being seen. Attendances represented 112% of referrals for fundholders and 104% for controls. In 1991-2, a similar proportion of patients in the two groups was seen within three months of referral. The two hospitals that set up specific clinics exclusively for fundholders showed faster access for patients of fundholders by 1993-4, as did a third hospital without such clinics by 1994-5. CONCLUSIONS--Fundholders increased their orthopaedic referrals less than did controls and achieved a better balance between outpatient appointments and referrals. Their patients were likely to be seen more quickly, particularly if the hospital provided special clinics exclusively for fundholders. Lack of case mix information makes it impossible to judge whether these differences benefit or disadvantage patients.     

Can telemedicine be used to improve communication between primary and secondary care?

OBJECTIVE: To test feasibility and acceptability of teleconferencing routine outpatient consultations. DESIGN: Exploratory trial of teleconferenced outpatient referrals of general practitioners. SETTING: An inner city teaching hospital and surrounding general practices. SUBJECTS: Six general practices linked to hospital outpatient clinics. MAIN OUTCOME MEASURES: Levels of participants'' satisfaction measured with self administered questionnaires. RESULTS: 54 teleconsultations were performed in 10 different specialties. Few serious technical problems were encountered, and high levels of satisfaction with the consultations were reported by patients, hospital specialists, and general practitioners. CONCLUSIONS: Teleconferenced consultations for routine outpatient referrals with joint participation of general practitioner were feasible. These may have an important potential benefit for improving communication between primary and secondary care.     

Effect of NHS reforms on general practitioners' referral patterns.

OBJECTIVE--To compare outpatient referral patterns in fundholding and non-fundholding practices before and after the implementation of the NHS reforms in April 1991. DESIGN--Prospective collection of data on general practitioners'' referrals to specialist outpatient clinics between June 1990 and March 1992 and detailed comparison of two time periods: October 1990 to March 1991 (phase 1) and October 1991 to March 1992 (phase 2). SETTING--10 fundholding practices and six non-fundholding practices in the Oxford region. SUBJECTS--Patients referred to consultant outpatient clinics. RESULTS--After implementation of the NHS reforms there was no change in the proportion of referrals from the two groups of practices which crossed district boundaries. Both groups of practices increased their referral rates in phase 2 of the study, the fundholders from 107.3 per 1000 patients per annum (95% confidence interval 106 to 109) to 111.4 (110 to 113) and the non-fundholders from 95.0 (93 to 97) to 112.0 (110 to 114). In phase 2 there was no difference in overall standardised referral rates between fundholders and non-fundholders. Just over 20% of referrals went to private clinics in phase 1. By phase 2 this proportion had reduced by 2.2% (1.0% to 3.4%) among the fundholders and by 2.7% (1.2% to 4.2%) among the non-fundholders. CONCLUSIONS--Referral patterns among fundholders and non-fundholders were strikingly similar after the implementation of the NHS reforms. There was no evidence that fundholding was encouraging a shift from specialist to general practice care or that budgetary pressures were affecting general practitioners'' referral behaviour.     

Improving care: a study of orthopaedic outpatient referrals.

OBJECTIVE--To identify aspects of outpatient referral in which general practitioners'', consultants'', and patients'' satisfaction could be improved. DESIGN--Questionnaire survey of general practitioners, consultant orthopaedic surgeons, and patients referred to an orthopaedic clinic. SETTING--Orthopaedic clinic, Doncaster Royal Infirmary. SUBJECTS--628 consecutive patients booked into the orthopaedic clinic. MAIN OUTCOME MEASURES--Views of the general practitioners as recorded both when the referral letter was received and again after the patient had been seen, views of the consultants as recorded at the time of the clinic attendance, and views of the patients as recorded immediately after the clinic visit and some time later. RESULTS--Consultants rated 213 of 449 referrals (42.7%) as possibly or definitely inappropriate, though 373 of 451 patients (82.7%) reported that they were helped by seeing the consultant. Targets for possible improvement included information to general practitioners about available services, communication between general practitioners and consultants, and administrative arrangements in clinics. Long waiting times were a problem, and it seemed that these might be reduced if general practitioners could provide more advice on non-surgical management. Some general practitioners stated that they would value easier telephone access to consultants for management advice. It was considered that an alternative source of management advice on musculoskeletal problems might enable more effective use to be made of specialist orthopaedic resources. Conclusion--A survey of patients'' and doctors'' views of referrals may be used to identify aspects in which the delivery of care could be made more efficient. Developing agreed referral guidelines might help general practitioners to make more effective use of hospital services.     

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.     

Referrals to hospital by general practitioners: a study of compliance and communication.

To determine the extent of non-attendance at first hospital appointments 269 hospital referrals made in one practice over 14 weeks were analysed retrospectively. Non-attendance was more likely among patients referred to outpatient departments than to casualty or for admission. Fifteen per cent (41/269) of all patients and 20% (33/167) of outpatients failed to keep their initial appointments. Prolonged waiting times from referral to appointment were significantly related to non-attendance. Twenty weeks after the last referral had been made no communication had been received by the practice for 24% (61/252) of all referral letters received by the hospital. Minimum delays to appointments and improved communication between hospitals and general practitioners would help general practitioners to make appropriate referrals and improve compliance.     

Fundholding: a two tier system?

The Calverton practice is one of 30 fundholding practices in Nottinghamshire. Three years after the inception of fundholding, it has achieved a lower outpatient waiting time for its specialist clinics than non-fundholding practices in the region. Its district nursing and health visiting services have been strengthened. Prescribing costs remain below the national average, and making further cost reductions has not been easy. The business plan has allowed the practice to work within a defined budget and develop expertise in the purchasing of services. Through the provision of specialist clinics and increased patient demand the workload of general practitioners has risen by 15% in the past year. But fundholding is still a minority activity in Nottinghamshire--a non-fundholders'' group has been set up to ensure that purchasing of good quality secondary care is equitably distributed among all patients, and this group is extremely active.     

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.     

Effect of fundholding and indicative prescribing schemes on general practitioners' prescribing costs.

OBJECTIVE--To compare general practitioners'' prescribing costs in fundholding and non-fundholding practices before and after implementation of the NHS reforms in April 1991. DESIGN--Analysis of prescribing and cost information (PACT data; levels 2 and 3) over two six month periods in 1991 and 1992. SETTING--Oxford region. PARTICIPANTS--Three dispensing fundholding practices; five non-dispensing fundholding practices; and seven non-dispensing, non-fundholding practices. MAIN OUTCOME MEASURES--Percentage change in net cost of ingredients, number of items prescribed, average cost per item, and proportion of generic drugs prescribed after NHS reforms. RESULTS--Prescribing costs increased in all practices in the six months after the reforms. The net costs of ingredients increased among dispensing fundholders by 10.2%, among non-dispensing fundholders by 13.2%, and among non-fundholders by 18.7%. The number of items prescribed also increased in all three groups (by 5.2%, 7.5%, and 6.1% respectively). The increase in average cost per item was 4.8% for dispensing fundholders, 5.3% for non-dispensing fundholders, and 11.9% for non-fundholders. Dispensing fundholders increased the proportion of generic drugs prescribed from 26.9% to 34.5% and non-dispensing fundholders from 44.5% to 48.7%; non-fundholders showed no change (47%). Five of the eight fundholding practices made savings in their drugs budgets at the end of the first year of fundholding (range 2.9-10.7%; the three other practices overspent by up to 3.6%). All non-fundholding practices exceeded their indicative prescribing amounts (range 3.2-20.0%). CONCLUSIONS--Fundholding has helped to curb increases in prescribing costs, even among dispensing general practitioners, for whom the incentives are different. Indicative prescribing amounts for non-fundholding practices do not seem to have had the same effect.     

Survey of general practitioners' attitudes to AIDS in the North West Thames and East Anglian regions

As the numbers of people suffering from human immunodeficiency virus infection and the acquired immune deficiency syndrome (AIDS) increase, so will the contribution to care required from general practice. A postal questionnaire survey was therefore carried out among general practitioners in the North West Thames and East Anglian regions to determine their attitudes to AIDS and the issues it raises for them. One hundred and thirty seven questionnaires were returned (response rate 57%) and four factors underlying the doctors'' attitudes identified; these concerned disease control, general practitioner care, patient support, and perception of seriousness. There were wide divergencies of attitude among the general practitioners, younger doctors being more in line with specialist thinking on AIDS than older colleagues, and evidence of important gaps between policies advocated by AIDS specialists and bodies of opinion in general practice.Attitudes to AIDS in general practice may partly be a function of personal experience; further study is required.     

Malaria prophylaxis: postal questionnaire survey of general practitioners in south east Wales.

Postal questionnaires were sent to 494 general practitioners in south east Wales asking about their experience and understanding of antimalarial prophylaxis; 293 were returned, giving a response rate of 59%. Forty eight (16%) of the respondents reported being consulted by immigrants returning home for advice about malaria prophylaxis, of whom 13 (27%) overestimated the time for which their protective immunity might last after leaving the malarious area. Two hundred and eighty respondents (96%) considered that they were responsible for advising travellers and 195 (67%) would always consult a publication before giving chemoprophylactic advice (magazines were particularly popular), but only 18 (6%) would always consult a specialist centre--the Ross Institute in eight cases (3%), a local centre in 39 (13%). Only about half of the doctors were aware of chloroquine resistance in Kenya and Thailand. Over half would withhold chloroquine in pregnancy, and many chose pyrimethamine alone or sulfadoxine-pyrimethamine as suitable chemoprophylactic drugs, though neither is still recommended by the World Health Organisation. One hundred and ninety two respondents (66%) would give advice about protective measures other than chemoprophylaxis. More must be done to encourage general practitioners to contact specialist centres and to educate them in the use of antimalarial chemoprophylactic drugs.     

Making the internal market work: a case for managed change.

The internal market in the NHS is meant to ensure that provider units compete on the basis of price and quality and that money follows patients into efficient units. But the example of what happened to one local ophthalmology unit suggests what may go wrong when entrepreneurial activity is applied in a market that does not work perfectly. In 1991-2 the unit had a high workload but also comparatively high prices (because of crude pricing in the local hospital); because of pressure of work the waiting times lengthened and general practitioners increasingly complained about the service. The staff in the unit reopened a longstanding debate about the need for a third consultant ophthalmologist, but neither the purchasers (including fundholders) nor the provider unit were able to fund the post. Fundholders in a neighbouring district, however, together with that district health authority, decided to place their contracts elsewhere for the following year. Although the withdrawal of contracts jeopardised the clinical and financial viability of the ophthalmic unit, patients continued to use the service. When general practitioners in the district realised that their local service might collapse they pressed to keep the service open. The fundholders and the host purchaser finally agreed to fund a third consultant and drew up standards for the service. As a result the waiting times fell and the service is now described as "excellent." Short term market decisions may have unforseen long term implications for services to patients. This needs to be addressed as part of the evolution of the reformed NHS.     

Usefulness of letters from hospitals to general practitioners.

In an investigation of the communication between specialist hospital departments and general practitioners 97 general practitioners were asked to say how important selected items of information that the hospital could pass on would be for management of a patient receiving chemotherapy. In addition, the records of 68 patients were examined for coverage of these topics. General practitioners considered technical topics to be more important than social ones. Hospital letters covered technical topics well, apart from details of possible side effects, but did not do the same even for the two social topics that most doctors considered to be essential--namely, what patients have been told about their diagnosis and prognosis. Letters from hospitals to general practitioners cover technical topics well but should include more information relating to the social aspects of the patient''s disease.     

Understanding variation in rates of referral among general practitioners: are inappropriate referrals important and would guidelines help to reduce rates?

OBJECTIVES--To determine the extent to which variation in rates of referral among general practitioners may be explained by inappropriate referrals and to estimate the effect of implementing referral guidelines. SETTING--Practices within Cambridge Health Authority and Addenbrooke''s Hospital, Cambridge. MAIN OUTCOME MEASURES--Data on practice referral rates from hospital computers, inappropriate referrals as judged by hospital consultants, and inappropriate referrals as judged against referral guidelines which had been developed locally between general practitioners and specialists. Effect of referral guidelines on referral patterns as judged by general practitioners using the guidelines in clinical practice. RESULTS--There was 2.5-fold variation in referral rates among general practices. According to the specialists, 9.6% (95% confidence interval 6.4% to 12.9%) of referrals by general practitioners and 8.9% (2.6% to 15.2%) of referrals from other specialists were judged possibly or definitely inappropriate. Against locally determined referral guidelines 15.9% of referrals by general practitioners were judged possibly inappropriate (11.8% to 20.0%). Elimination of all possibly inappropriate referrals could reduce variation in practice referral rates only from 2.5-fold to 2.1-fold. An estimate of the effect of using referral guidelines for 60 common conditions in routine general practice suggested that application of guidelines would have been unlikely to reduce rates of referral in hospital (95% confidence interval -4.5% to 8.6% of consultations resulting in referral). CONCLUSION--The variation in referral rates among general practitioners in Cambridge could not be explained by inappropriate referrals. Application of referral guidelines would be unlikely to reduce the number of patients referred to hospital.     

Waiting times: monitoring the total postreferral wait.

OBJECTIVES--To determine whether the period spent on the true inpatient waiting list is a valid indication of the total time that patients have to wait for an operation; and to assess the feasibility of monitoring the total "postreferral waiting time" by using existing computerised information systems. SETTING--Three randomly selected Scottish hospitals. SUBJECTS--Waiting list patients admitted to hospital for operations during June to August 1993 in six major specialties, separate attention being focused on cataract operations and hip and knee replacements. MAIN OUTCOME MEASURE--The total time that patients have to wait for an operation after the initial general practitioner referral--the postreferral waiting time--compared with that spent at the final stage of the process on the true inpatient waiting list. RESULTS--In the specialties investigated roughly half (58 days; 53%) of the average postreferral wait of 110 days was spent on the true inpatient waiting list, one third (35 days; 32%) being spent on the outpatient waiting list and one sixth (17 days; 15%) waiting between waiting lists. Only a quarter of cataract patients (73/292) were treated within three months of general practitioner referral compared with over three quarters (228/292) within three months of being placed on the inpatient waiting list. Nevertheless, within a year over 99% of patients (290) had been treated whichever date was taken as the starting point. CONCLUSIONS--Monitoring postreferral waiting times would provide a much more accurate picture for purchasers and patients of waiting times for treatment than is obtained by focusing exclusively on the true inpatient waiting list and facilitate fairer comparisons between NHS trusts in national league tables. Stringent national and local monitoring is essential to ensure (a) that future reductions in the time waiting on true inpatient waiting lists are not gained at the expense of longer periods waiting to be placed on the lists, and (b) that no increases occur in the number of patients placed instead on deferred waiting lists or exempted from the normal maximum waiting time guarantees.     

Consultants' workload in outpatient clinics.

The impact on hospital resources of variability in referral rates among general practitioners was of concern throughout the 1980s. The overall number of patients referred to outpatient clinics, however, has increased only slowly since the NHS began; in contrast, the number of new outpatients seen by each hospital consultant has declined appreciably. Ironically, despite this decline, further increasing the number of consultants in now being presented as a solution to the demand for outreach clinics in general practice.     

Communication of results of necropsies in north east Thames region.

OBJECTIVE--To evaluate the adequacy of reporting of results of necropsy to referring clinicians and to general practitioners. DESIGN--Questionnaire survey of referring clinicians and general practitioners of deceased patients in four districts in North East Thames region. Patients were selected by retrospective systematic sampling of 50 or more necropsy reports in each district. SETTING--One teaching hospital, one inner London district general hospital, and two outer London district general hospitals. PARTICIPANTS--70 consultants and 146 general practitioners who were asked about 214 necropsy reports; coroners'' reports were excluded. MAIN OUTCOME MEASURES--Time taken for dispatch of final reports after necropsy, consultants'' recognition of the reports, general practitioners'' recognition of the reports or of their findings, and consultants'' recall of having discussed the findings with relatives. RESULTS--Only two hospitals dispatched final reports including histological findings (mean time to dispatch 144 days and 22 days respectively). 42 (60%) consultants and 83 (57%) general practitioners responded to the survey. The percentage of reports seen by consultants varied from 37% (n = 13) to 87% (n = 36); in all, only 47% (39/83) of general practitioners had been informed of the findings by any method. Consultants could recall having discussed findings with only 42% (47/112) of relatives. CONCLUSIONS--Communication of results of necropsies to hospital clinicians, general practitioners, and relatives is currently inadequate in these hospitals. IMPLICATIONS AND ACTION--A report of the macroscopic findings should be dispatched immediately after necropsy to clinicians and general practitioners; relatives should routinely be invited to discuss the necroscopic findings. One department has already altered its practice.     

Secondary care beyond Tomlinson: an opportunity to be seized or squandered?

The Tomlinson report''s emphasis on primary care and its essentially quantitative analysis of hospital care in London leaves little space for a picture of how secondary care for Londoners should look. In this article Fiona Moss and Martin McNicol argue that most outpatient work does not need to be done in hospitals. With proper organisation and better premises a genuinely specialist consultative service can be provided in primary health care centres, with benefit to patients and communication between primary and secondary care doctors. Hospitals would then house those outpatient services that needed major investigative facilities and much reduced inpatient capacity. It may no longer be necessary for each acute unit to offer a full range of services. Such a pattern of secondary care will have implications for the organisation of accident and emergency services and for postgraduate training. Above all Moss and McNicol argue that Tomlinson''s recommendations demand that general practitioners and specialists should re-examine the services hospitals provide and agree on the best settings for different sorts of health care and the most appropriate skills to provide it.