First year of an inner city general practitioner community hospital.

The first inner city general practitioner community hospital opened on 4 January 1982. This paper describes the operation of the hospital over the first 12 months. There were 316 admissions, with an average length of stay of 13 days. The average age of the patients was 73 and the most common reason for admission was disease of the respiratory system. Thirty five per cent of patients were admitted because of an acute illness and 37% were admitted on the same day as the request for admission. The policies of intermittent or phased care allowed for the admission of patients at regular intervals to relieve carers, and the assessment of the home circumstances of all patients allowed for planning the patient''s return home.     

"Homeward bound": a minimal care rehabilitation unit.

A 20 bed minimal care rehabilitation unit was set up by Newham District Health Authority in a small hospital originally scheduled for closure when a new district general hospital was opened. During the first year 114 patients were admitted (throughput 5.7), with a median length of stay of 30 days; in the second year 173 patients were admitted (throughput 8.65) with a median length of stay of 28.5 days. The cost per inpatient day was less than that of an inpatient day at the district''s long stay geriatric unit. Before the unit opened 24% of the acute beds had been occupied for more than six weeks, whereas two years later only 6% of the acute beds were occupied for such a period.     

TUBERCULOSIS AND REHABILITATION—Dynamic Physical Restoration of Patients with Active Disease

In a study carried out over a period of seven years, 454 patients with active tuberculosis were placed on a program of intensive physical exercise, combined with chemotherapy and antibiotics.In the initial group of 155 patients studied from 1956-1960, the intensive rehabilitation program was not instituted until the last two months of the patient''s stay in hospital, whereas in a late phase of the study 1960-1963 the dynamic physical restoration program was instituted early for 299 patients and was carried on simultaneously with chemotherapy and antibiotics.The beneficial results of these programs appear to show that the concept of minimum exercise and prolonged bed rest in the hospital and a prolonged convalescent period after discharge, is no longer justified.     

Home based care and standard hospital care for patients with severe mental illness: a randomised controlled trial.

OBJECTIVE--To compare the efficacy of home based care with standard hospital care in treating serious mental illness. DESIGN--Randomised controlled trial. SETTING--South Southwark, London. PATIENTS--189 patients aged 18-64 living in catchment area. 92 were randomised to home based care (daily living programme) and 97 to standard hospital care. At three months'' follow up 68 home care and 60 hospital patients were evaluated. MAIN OUTCOME MEASURES--Use of hospital beds, psychiatric diagnosis, social functioning, patients'' and relatives'' satisfaction, and activity of daily living programme staff. RESULTS--Home care reduced hospital stay by 80% (median stay six days in home care group, 53 days in hospital group) and did not increase the number of admissions compared with hospital care. On clinical and social outcome there was a non-significant trend in favour of home care, but both groups showed big improvements. On the global adjustment scale home care patients improved by 26.8 points and the hospital group by 21.6 points (difference 5.2; 95% confidence interval -1.5 to 12). Other rating scales showed similar trends. Home care patients required a wide range of support in areas such as housing, finance, and work. Only three patients dropped out from the programme. CONCLUSIONS--Home based care may offer some slight advantages over hospital based care for patients with serious mental illness and their relatives. The care is intensive, but the low drop out rate suggests appreciation. Changes to traditional training for mental health workers are required.     

Comparative study of short-term recovery of mental efficiency after anaesthesia.

Two common general anaesthetic techniques were compared to evaluate the time taken for the patient''s mental efficiency to recover sufficiently for him to be escorted home after inguinal herniorrhaphy. Recovery in performance efficiency to at least 60% of the patient''s own maximum is suggested as a criterion for discharge, and this needs a stay in hospital of seven to nine hours.     

Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial.

OBJECTIVES: To assess whether intraoperative intravascular volume optimisation improves outcome and shortens hospital stay after repair of proximal femoral fracture. DESIGN: Prospective, randomised controlled trial comparing conventional intraoperative fluid management with repeated colloid fluid challenges monitored by oesophageal Doppler ultrasonography to maintain maximal stroke volume throughout the operative period. SETTING: Teaching hospital, London. SUBJECTS: 40 patients undergoing repair of proximal femoral fracture under general anaesthesia. INTERVENTIONS: Patients were randomly assigned to receive either conventional intraoperative fluid management (control patients) or additional repeated colloid fluid challenges with oesophageal Doppler ultrasonography used to maintain maximal stroke volume throughout the operative period (protocol patients). MAIN OUTCOME MEASURES: Time declared medically fit for hospital discharge, duration of hospital stay (in acute bed; in acute plus long stay bed), mortality, perioperative haemodynamic changes. RESULTS: Intraoperative intravascular fluid loading produced significantly greater changes in stroke volume (median 15 ml (95% confidence interval 10 to 21 ml)) and cardiac output (1.2 l/min (0.1 to 2.3 l/min)) than in the conventionally managed group (-5 ml (-10 to 1 ml) and -0.4 l/min (-1.0 to 0.2 l/min)) (P < 0.001 and P < 0.05, respectively). One protocol patient and two control patients died in hospital. In the survivors, postoperative recovery was significantly faster in the protocol patients, with shorter times to being declared medically fit for discharge (median 10 (9 to 15) days v 15 (11 to 40) days, P < 0.05) and a 39% reduction in hospital stay (12 (8 to 13) days v 20 (10 to 61) days, P < 0.05). CONCLUSIONS: Proximal femoral fracture repair constitutes surgery in a high risk population. Intraoperative intravascular volume loading to optimal stroke volume resulted in a more rapid postoperative recovery and a significantly reduced hospital stay.     

Variation in hospital stay after inguinal herniorrhaphy.

A study was carried out of 1086 men aged 16-65 inclusive who were admitted under nine consultants to eight hospitals in Wessex for elective repair of an inguinal hernia. The mean postoperative stay was 5.7 +/- SD 2.7 days. For different consultants operating at any one hospital the mean postoperative stays were similar, whereas for consultants who operated at more than one hospital they were significantly different. The postoperative stay was also significantly related to the size of the hospital, development of postoperative complications, time spent on the waiting list, type of repair used, bilateral herniorrhapy, and the use of convalescent facilities. The hospital therefore appears to exercise a greater influence in determining the mean postoperative stay than does the individual consultant.     

General practitioner response to elderly patients discharged from hospital.

OBJECTIVE--To determine the effect of discharge information given to general practitioners on their management of newly discharged elderly patients. DESIGN--A random sample of 133 elderly patients who had unplanned readmission to a district general hospital within 28 days of discharge was compared with a matched control sample of patients who were not readmitted. Information was gathered from the hospital, the patients, the carers, and the general practitioners about the information that the hospital had sent the general practitioner and the general practitioners'' response to this information. SETTING--All specialties in a district general hospital. PATIENTS--266 Patients aged over 65 representative in the main demographic indices of the population of elderly patients admitted to hospital. RESULTS--Ten weeks after discharge the doctors had received notice of discharge about 169 of the patients, but fewer than half the discharge notices were received within the first week. General practitioners were dissatisfied with the information in 60 cases. A general practitioner visited 174 of the patients after their discharge from hospital and three quarters of the visits took place within two weeks of the discharge. These visits were more likely to have been initiated by patients or families than by the doctor, and this was not influenced by the doctor receiving notice of the patient''s discharge. Older patients and those who had carers were the most likely to be visited. Nearly half of the carers were dissatisfied with some aspect of general practitioner care, problems with home visiting being the commonest source of complaint. CONCLUSIONS--Hospital communications to general practitioners about the discharge of elderly patients still cause concern, particularly in the time they take to arrive. Written instruction to vulnerable elderly patients asking them to inform their general practitioner of the discharge might be helpful. Carers complained of lack of support, and it is clearly important for someone (either the general practitioner or another health worker) to visit elderly people shortly after their discharge.     

Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data

Background

Avoidance of admission through provision of hospital care at home is a scheme whereby health care professionals provide active treatment in the patient''s home for a condition that would otherwise require inpatient treatment in an acute care hospital. We sought to compare the effectiveness of this method of caring for patients with that type of in-hospital care.

Methods

We searched the MEDLINE, EMBASE, CINAHL and EconLit databases and the Cochrane Effective Practice and Organisation of Care Group register from the earliest date in each database until January 2008. We included randomized controlled trials that evaluated a service providing an alternative to admission to an acute care hospital. We excluded trials in which the program did not offer a substitute for inpatient care. We performed meta-analyses for trials for which the study populations had similar characteristics and for which common outcomes had been measured.

Results

We included 10 randomized trials (with a total of 1327 patients) in our systematic review. Seven of these trials (with a total of 969 patients) were deemed eligible for meta-analysis of individual patient data, but we were able to obtain data for only 5 of these trials (with a total of 844 patients [87%]). There was no significant difference in mortality at 3 months for patients who received hospital care at home (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.54–1.09, p = 0.15). However, at 6 months, mortality was significantly lower for these patients (adjusted HR 0.62, 95% CI 0.45–0.87, p = 0.005). Admissions to hospital were greater, but not significantly so, for patients receiving hospital care at home (adjusted HR 1.49, 95% CI 0.96–2.33, p = 0.08). Patients receiving hospital care at home reported greater satisfaction than those receiving inpatient care. These programs were less expensive than admission to an acute care hospital ward when the analysis was restricted to treatment actually received and when the costs of informal care were excluded.

Interpretation

For selected patients, avoiding admission through provision of hospital care at home yielded similar outcomes to inpatient care, at a similar or lower cost.In many countries, programs in which hospital care is provided in the patient''s own home continue to be a popular response to the increasing demand for acute care hospital beds. Patients who received care through such programs, after assessment in the community by their primary care physician or in the emergency department, may avoid admission to an acute care ward. Alternatively, patients may be discharged early from hospital to receive hospital care at home. We have conducted a parallel systematic review and meta-analysis of individual patient data related to hospital care at home for patients who have received early discharge, which we will report separately. Recently, the emphasis has been on avoiding admission to hospital, which reflects the relatively limited gain from discharging patients early after a stay in hospital, given the universal trend for shorter lengths of stay in hospital.The types of patients receiving hospital care at home differ among schemes, as does the use of technology. Some schemes are designed to care for patients with specific conditions, such as chronic obstructive pulmonary disease, or to provide specific skills, such as parenteral nutrition. However, many schemes for the provision of hospital care at home lack such clear functions and have an “open door” policy covering a wide range of conditions. These schemes may build on existing community resources, or they may operate as hospital outreach services, with hospital staff making home visits. In particular, “hospital-at-home” programs are defined by the provision, in patients'' own homes and for a limited period, of a specific service that requires active participation by health care professionals. The care tends to be multidisciplinary and may include technical services, such as intravenous services.Cutting costs by avoiding admission to hospital altogether is the central goal of such schemes. Other perceived benefits include reducing the risk of adverse events associated with time in hospital¹ and the potential benefit of receiving rehabilitation in the home environment. However, it is not known if patients covered by a policy of avoiding admission through the provision of hospital care at home have health outcomes better than or equivalent to those of patients who receive inpatient hospital care. Furthermore, it is not known if the provision of hospital care at home results in a reduction or an increase in costs to the health service. We conducted a systematic review and meta-analysis, using individual patient data and published data, to determine the effectiveness and cost of managing care of patients through the provision of hospital care at home relative to inpatient hospital care. The meta-analysis of individual patient data allowed us to investigate whether the strategies were associated with key events happening after different periods of time, rather than simply whether or not those events occurred.     

Physicians' perceptions of the effect on clinical services of an alternative funding plan at an academic health sciences centre

BACKGROUND: In July 1994 an alternative funding plan for clinical services (global funding instead of fee-for-service payment) was established at the Southeastern Ontario Health Sciences Centre, Kingston, Ont. This study describes the perceptions of the referring physicians and consultants of the effects of the alternative funding plan 2.5 years after it was initiated. METHODS: A questionnaire was mailed to all physicians in the Kingston area in November 1996. Information was collected on demographics, referring physicians'' perceptions of the funding plan''s impact on their practices, consultants'' perceptions of its impact on their activities, perceptions of referring and consultant physicians of its impact on services provided by consultants, and attitudes toward alternative funding in the context of the Ontario health care system. RESULTS: Of the 772 physicians 531 (68.8%) returned a completed questionnaire (323 referring physicians and 208 consultants). A sizeable proportion of the referring physicians (126 [39.0%]) indicated that they were referring fewer patients to consultants at the study centre. They did not think that their practice volume had increased, but they did report spending more time on complex cases and on patient care after referral or hospital stay, and more time coordinating community care after hospital stay. Of the consultants 81 (38.9%) believed that their time spent on patient care had increased. No consistent impact on time spent on research or teaching activities was perceived. A total of 54 (26.0%) of the consultants were concerned about the impact of the alternative funding plan on quality of care. A significant proportion of the respondents (399 [75.1%]) believed that outpatient waiting times had increased, and 116 (35.9%) of the referring physicians believed that consultants were not as available by telephone. Most (220 [68.1%]) of the referring physicians believed that the funding change had had a negative effect on health care services in the region, and 87 (41.8%) of the consultants agreed. Nevertheless, the respondents believed that other factors such as funding cuts, hospital bed closures and staff layoffs were much more responsible than the alternative funding plan for their negative perceptions. INTERPRETATION: The alternative funding plan appears to have had an impact on the practices of individual physicians. However, it was not the focus for significant opposition or support from either consultants participating in the funding plan or referring physicians.     

Cost of achieving a balance in the anaesthetic department of a district general hospital.

In Achieving a Balance the Department of Health published requirements for medical staffing in hospitals. To review the effect that these would be likely to have a study was undertaken in the anaesthetic department of a district general hospital. The results were then validated with staffing levels in a new district general hospital with only one tier of junior staff. It was found that over the next 10 years a massive expansion in the numbers of consultants would be needed at a cost of 108,000 pounds in salaries and employer''s contributions alone.     

National survey of hospital patients.

OBJECTIVE--To survey patients'' opinions of their experiences in hospital in order to produce data that can help managers and doctors to identify and solve problems. DESIGN--Random sample of 36 NHS hospitals, stratified by size of hospital (number of beds), area (north, midlands, south east, south west), and type of hospital (teaching or non-teaching, trust or directly managed). From each hospital a random sample of, on average, 143 patients was interviewed at home or the place of discharge two to four weeks after discharge by means of a structured questionnaire about their treatment in hospital. SUBJECTS--5150 randomly chosen NHS patients recently discharged from acute hospitals in England. Subjects had been patients on medical and surgical wards apart from paediatric, maternity, psychiatric, and geriatric wards. MAIN OUTCOME MEASURES--Patients'' responses to direct questions about preadmission procedures, admission, communication with staff, physical care, tests and operations, help from staff, pain management, and discharge planning. Patients'' responses to general questions about their degree of satisfaction in hospitals. RESULTS--Problems were reported by patients, particularly with regard to communication with staff (56% (2824/5020) had not been given written or printed information); pain management (33% (1042/3162) of those suffering pain were in pain all or most of the time); and discharge planning (70% (3599/5124) had not been told about warning signs and 62% (3177/5119) had not been told when to resume normal activities). Hospitals failed to reach the standards of the Patient''s Charter--for example, in explaining the treatment proposed and giving patients the option of not taking part in student training. Answers to questions about patient satisfaction were, however, highly positive but of little use to managers. CONCLUSIONS--This survey has highlighted several problems with treatment in NHS hospitals. Asking patients direct questions about what happened rather than how satisfied they were with treatment can elucidate the problems that exist and so enable them to be solved.     

Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital

Objective To determine the efficacy of a targeted multifactorial falls prevention programme in elderly care wards with relatively short lengths of stay.Design Cluster randomised trial.Setting 24 elderly care wards in 12 hospitals in Sydney, Australia.Participants 3999 patients, mean age 79 years, with a median hospital stay of seven days.Interventions A nurse and physiotherapist each worked for 25 hours a week for three months in all intervention wards. They provided a targeted multifactorial intervention that included a risk assessment of falls, staff and patient education, drug review, modification of bedside and ward environments, an exercise programme, and alarms for selected patients.Main outcome measure Falls during hospital stay.Results Intervention and control wards were similar at baseline for previous rates of falls and individual patient characteristics. Overall, 381 falls occurred during the study. No difference was found in fall rates during follow-up between intervention and control wards: respectively, 9.26 falls per 1000 bed days and 9.20 falls per 1000 bed days (P=0.96). The incidence rate ratio adjusted for individual lengths of stay and previous fall rates in the ward was 0.96 (95% confidence interval 0.72 to 1.28).Conclusion A targeted multifactorial falls prevention programme was not effective among older people in hospital wards with relatively short lengths of stay.Trial registration Australian New Zealand Clinical Trials Registry ACTRNO 12605000467639.     

Trends and variations in length of hospital stay for childbirth in Canada

BACKGROUND: Early discharge after childbirth is widely reported. In this study the authors examined trends in maternal length of hospital stay in Canada from fiscal year 1984-85 through fiscal year 1994-95. They also examined variations in length of stay in 1994-95 in most of the Canadian provinces and the territories. METHODS: Epidemiologic analyses of the temporal and geographic variations in maternal length of hospital stay in Canada from 1984-85 to 1994-95 (even years only), based on hospital discharge data collected by the Canadian Institute for Health Information, with a total of 1,456,800 women for the 6 study years. RESULTS: Mean length of hospital stay decreased during the decade, from 5.3 days in 1984-85 to 3.0 days in 1994-95, with similar trends for both cesarean and vaginal delivery. The decrease resulted from both increasing rates of short stay (less than 2 days) and decreasing rates of long stay (more than 4 days). Substantial temporal and interprovincial variations in several medical and obstetric complications were also observed but did not explain the corresponding variations in length of stay. The reduction in length of hospital stay was not restricted to uncomplicated cases: there was an equivalent decrease in cases with complications. In 1994-95 the average length of hospital stay in Alberta was 2.6 days, 0.3 to 1.7 days shorter than in the other provinces and the territories. INTERPRETATION: Length of hospital stay for childbirth has decreased substantially in Canada in recent years, but there remain important interprovincial variations. These trends and variations are not likely due to changes or differences in patient-specific factors.     

An investigation into the management of bilateral leg amputees.

Patients with bilateral high level amputations of the legs are rarely functionally independent after their discharge from hospital. Eighty bilateral amputees were visited by a research physiotherapist, and information was obtained on their family circumstances, accommodation, mobility, and prostheses. A second questionnaire was completed by hospital staff on medical condition, assessments, rehabilitation, and total overall management. The results showed that mobility was severely restricted; out of the 80 patients visited, only 65 could manoeuvre wheelchairs and 23 use prostheses. Accommodation presented difficulties: 34 homes had steps inside and 40 had steps outside. Of the 80 patients seen, 60 could not cope in the bath while 33 were unable to use the lavatory. Assessments and rehabilitation were lacking. There appeared to be little overall management, and hospital staff made only 36 visits to the patient''s accommodation before discharge.     

Quality improvement report: The “jaundice hotline” for the rapid assessment of patients with jaundice

ProblemPatients with jaundice require rapid diagnosis and treatment, yet such patients are often subject to delay.DesignAn open referral, rapid access jaundice clinic was established by reorganisation of existing services and without the need for significant extra resources.

Background and setting

A large general hospital in a largely rural and geographically isolated area.

Key measures for improvement

Waiting times for referral, consultation, diagnosis, and treatment, length of stay in hospital, and general practitioners'' and patients'' satisfaction with the service.

Strategies for change

Referrals were made through a 24 hour telephone answering machine and fax line. Initial assessment of patients was carried out by junior staff as part of their working week. Dedicated ultrasonography appointments were made available.

Effects of change

Of 107 patients seen in the first year of the service, 62 had biliary obstruction. The mean time between referral and consultation was 2.5 days. Patients who went on to endoscopic retrograde cholangiopancreatography waited 5.7 days on average. The mean length of stay in hospital in the 69 patients who were admitted was 6.1 days, compared with 11.5 days in 1996, as shown by audit data. Nearly all the 36 general practices (95%) and the 30 consecutive patients (97%) that were surveyed rated the service as above average or excellent.

Lessons learnt

An open referral, rapid access service for patients with jaundice can shorten time to diagnosis and treatment and length of stay in hospital. These improvements can occur through the reorganisation of existing services and with minimal extra cost.     

Effects of a medical team coordinator on length of hospital stay.

OBJECTIVE: To determine the effect of a medical team coordinator (MTC) on the length of stay in a teaching hospital. DESIGN: Randomized controlled trial. SETTING: Two of four general medical clinical teaching units (CTUs). PATIENTS: Patients admitted to the CTUs between July and October 1990 except those who were admitted directly to an intensive care unit or whose death was expected within 48 hours. The 267 patients were randomly assigned to receive either standard medical care or standard medical care plus MTC services. INTERVENTION: The MTC was a baccalaureate nurse whose role was to facilitate administrative tasks such as discharge planning, to coordinate tests and procedures, and to collect and collate patient information. MAIN OUTCOME MEASURES: Length of hospital stay. A subgroup of 40 patients was asked to complete a brief survey on medical care information and satisfaction. RESULTS: The MTC intervention reduced the mean length of stay by 1.97 days (p less than or equal to 0.04, 95% confidence interval [CI] 1.02 to 2.92 days). Subanalysis by diagnostic group revealed that most of this effect was in an ill-defined group of disorders. In the survey more patients in the MTC group than in the other group reported being satisfied with their medical care (89% v. 62%; p less than or equal to 0.05, 95% CI 2% to 52%). CONCLUSIONS: The services of an MTC help to reduce the length of hospital stay for some groups of patients. Further research is necessary to examine which components of the MTC intervention are most effective and in what conditions.     

Randomised controlled trial comparing effectiveness and acceptability of an early discharge,hospital at home scheme with acute hospital care

Objective: To compare effectiveness and acceptability of early discharge to a hospital at home scheme with that of routine discharge from acute hospital. Design: Pragmatic randomised controlled trial. Setting: Acute hospital wards and community in north of Bristol, with a catchment population of about 224 000 people. Subjects: 241 hospitalised but medically stable elderly patients who fulfilled criteria for early discharge to hospital at home scheme and who consented to participate. Interventions: Patients’ received hospital at home care or routine hospital care. Main outcome measures: Patients’ quality of life, satisfaction, and physical functioning assessed at 4 weeks and 3 months after randomisation to treatment; length of stay in hospital and in hospital at home scheme after randomisation; mortality at 3 months. Results: There were no significant differences in patient mortality, quality of life, and physical functioning between the two arms of the trial at 4 weeks or 3 months. Only one of 11 measures of patient satisfaction was significantly different: hospital at home patients perceived higher levels of involvement in decisions. Length of stay for those receiving routine hospital care was 62% (95% confidence interval 51% to 75%) of length of stay in hospital at home scheme. Conclusions: The early discharge hospital at home scheme was similar to routine hospital discharge in terms of effectiveness and acceptability. Increased length of stay associated with the scheme must be interpreted with caution because of different organisational characteristics of the services.

Key messages

• Pressure on hospital beds, the increasing age of the population, and high costs associated with acute hospital care have fuelled the search for alternatives to inpatient hospital care
• There were no significant differences between early discharge to hospital at home scheme and routine hospital care in terms of patient quality of life, physical functioning, and most measures of patient satisfaction
• Length of stay for hospital patients was significantly shorter than that of hospital at home patients, but, owing to qualitative differences between the two interventions, this does not necessarily mean differences in effectiveness
• Early discharge to hospital at home provides an acceptable alternative to routine hospital care in terms of effectiveness and patient acceptability

     

Two factors that can increase the length of hospital stay of patients with dementia

ObjectivesPatients with dementia are at greater risk of a long hospital stay and this is associated with adverse outcomes. The aim of this service evaluation was to identify variables most predictive of increased length of hospital stay amongst patients with dementia.Methods/DesignWe conducted a retrospective analysis on a cross-sectional hospital dataset for the period January–December 2016. Excluding length of stay less than 24 h and readmissions, the sample comprised of 1133 patients who had a dementia diagnosis on record.ResultsThe highest incidence rate ratio for length of stay in the dementia sample was: (a) discharge to a care home (IRR: 2.443, 95% CI 1.778–3.357), (b) falls without harm (IRR: 2.486, 95% CI 2.029–3.045).ConclusionsBased on this dataset, we conclude that improvements made to falls prevention strategies in hospitals and discharge planning procedures can help to reduce the length of stay for patients with dementia.     

What do hospital consultants value about their jobs? A discrete choice experiment

Objective To examine the strength of hospital consultants'' preferences for various aspects of their work.Design Questionnaire survey including a discrete choice experiment.Setting NHS Scotland.Participants 2923 hospital consultants in Scotland.Main outcome measures Monetary valuations or prices for each job characteristic, based on consultants'' willingness to pay and willingness to accept extra income for a change in each job characteristic, calculated from regression coefficients.Results The response rate was 61% (1793 resspondents). Being on call was the most important attribute, as consultants would need to be compensated up to £18 000 (30% of their average net income) (P < 0.001) for a high on-call workload. Compensation of up to £9700 (16% of their net income) (P < 0.001) would be required for consultants to forgo opportunities to undertake non-NHS work. Consultants would be willing to accept £7000 (12% of net income) (P < 0.001) in compensation for fair rather than good working relationships with staff, and £6500 (11% of net income) (P < 0.001) to compensate them for a shortage of staff. The least important characteristic was hours of work, with £562 per year (0.9% of their net income) (P < 0.001) required to induce consultants to work one extra hour per week. These preferences also varied among specific subgroups of consultants.Conclusions Important information on consultants'' strength of preferences for characteristics of their job should be used to help to address recruitment and retention problems. Consultants would require increased payment to cover more intensive on-call commitments. Other aspects of working conditions would require smaller increases.