Family doctors and change in practice strategy since 1986

Impact of primary care funding on secondary care utilisation and patient outcomes: a retrospective cross-sectional study of English general practice

BACKGROUND

In international studies, greater investment in primary health care is associated with improved population health outcomes.

AIM

To determine whether investment in general practice is associated with secondary care utilisation, patient satisfaction, and clinical outcomes.

DESIGN AND SETTING

Retrospective cross-sectional study of general practices in England, 2014-2015.

METHOD

Practice-level data were stratified into three groups according to GP contract type: national General Medical Services (GMS) contracts, with or without the capitation supplement (mean practice income guarantee), or local Personal Medical Services (PMS) contracts. Regression models were used to explore associations between practice funding (capitation payments and capitation supplements) and secondary care usage, patient satisfaction (general practice patient survey scores), and clinical outcomes (Quality and Outcomes Framework [QOF] scores). The authors conducted financial modelling to predict secondary care cost savings associated with notional changes in primary care funding.

RESULTS

Mean capitation payments per patient were £69.82 in GMS practices in receipt of capitation supplements (n = 2784), £78.79 in GMS practices without capitation supplements (n = 1672), and £84.43 in PMS practices (n = 3022). The mean capitation supplement was £5.72 per patient. Financial modelling demonstrated little or no relationship between capitation payments and secondary care costs. In contrast, notional investment in capitation supplements was associated with modelled savings in secondary care costs. The relationship between funding and patient satisfaction was inconsistent. QOF performance was not associated with funding in any practice type.

CONCLUSION

Capitation payments appear to be broadly aligned to patient need in terms of secondary care usage. Supplements to the current capitation formula are associated with reduced secondary care costs.

Profile of General Practices in Malaysia

In this survey all practices under the headings of “Clinics”, “Medical Practitioners” and “Medical Practitioners - Registered” in the Yellow Pages telephone directories for the thirteen states of Malaysia were selected. Those excluded were clinics or medical practitioners who advertised themselves as specialists in other disciplines. A total of 2291 practices were surveyed and a response rate of 51.2% was obtained. 383(33%) of the general practitioners were trained locally for the first degree. 258(22%) had at least one postgraduate qualification. 69(6%) possessed a postgraduate qualification in primary care medicine. About 80% of general practitioners participated in continuing medical education and 4% did research in the last 3 years. 42% were involved in community activities. 75% ran solo practices. Over 90% of the practices opened six or seven days a week. The mean workload per doctor per day was 44.66. Most practices provided a comprehensive range of services including curative, preventive, dispensing services, counselling, laboratory tests, and home visits. 43% of practices had a computer.

Nutrition in primary care: scope and relevance of output from the Cochrane Collaboration

There is a lack of randomized controlled nutritional intervention studies with objective clinical endpoints conducted from primary care. Therefore, evidence-based nutritional advice is hampered by 3 factors: (1) a lack of nutritional intervention studies, (2) the difficulty of translating nutritional interventions into practice, and (3) the difficulty of translating to the setting of primary care. A search was made within the publications of the Cochrane Library with potential nutritional aspects. The key words and free text words "nutrition," "food," "foodstuff," "nonpharmacologic," "weight," "body weight," "diet," "dietitian," "general practitioner," and "family physician" were used with the Internet version of the Cochrane Library. Common clinical problems in primary care that have at least some nutritional aspects, are not currently well covered in existing Cochrane reviews. In only 6 cases was nutrition mentioned to some extent. Clinical practice could benefit from a more rigorous approach to nutritional advice. Review groups should be approached to encourage reviewers to cover these aspects in future updates. The existing "comments and criticisms" procedure available on the Cochrane website could be used for this purpose. Having a streamlined Heelsum Workshop Group, based at a university with roots within the various disciplines, linking the experience of daily practical work of the family physician is important, but a small group will need to take overall responsibility for coordination and updating Cochrane reviews on nutrition.

The process of outpatient referral and care: the experiences and views of patients, their general practitioners, and specialists

BACKGROUND

The primary care system in the United Kingdom, involving the general practitioner (GP) as gatekeeper to further services, has helped to keep health care costs down. Despite this, unexplained variation in referral rates and increasing health care costs have led to the search for methods of improving efficiency. There is relatively little recent descriptive data on the processes of care at the primary-secondary care interface. The study reported here provides information about this.

AIM

To analyse the patterns and process of care for the referral of outpatients, together with the views of patients, their GPs, and specialists.

METHOD

A questionnaire survey of outpatients, their hospital specialists, and GPs in randomly sampled district health authorities in the North Thames Region. The measures included items and scales measuring satisfaction and processes.

RESULTS

Almost all of the outpatients thought that their consultation with the specialist was 'necessary' and 'worthwhile'. Most of the GPs felt that they could not have given the study patients the care, treatment, and investigations they received in hospital, and most of the sampled patients' attendances were rated by the specialists as 'appropriate'. However, for just over one-fifth of new patients, the specialists reported that the GP could have done more tests and examinations prior to referring the study patient. Large proportions of GPs in this survey also reported having technical equipment in their practices, as well as direct access to a range of services and hospital-based facilities.

CONCLUSION

A large amount of work is carried out in general practice prior to the hospital referral of patients, and GPs have direct access to some technologies and services that can act to reduce the burden on hospitals. The discrepancy between GPs' and specialists, perceptions about the potential for further investigative work prior to patient referral merits further investigation.

Fund-holding and contracting for community nursing services: a selective review of the literature

In the context of social, political and economic pressures fund-holding has been described as the 'wild card' in the Health Care Reforms in the United Kingdom of the 1990s. Set against an international drive to reform health care and increase the efficient and effective use of resources, fund-holding by general practice is seen as one means of enhancing the contribution of a primary care led National Health Service (NHS). It is advocated that a primary care led NHS will enhance and strengthen the position of nursing in the health care context. In order to fully exploit such a position it is argued that primary care nurses must adopt a systems view, recognizing broader strategic issues upon which to base marketing approaches to the contracting process.

Management of premises for family doctors: a case for treatment

General medical practitioners (GPs) in the UK are working from increasingly sophisticated premises. UK Government consultations have highlighted that inadequate premises are currently a barrier to improvements in primary health care. Therefore the National Health Service (Primary Care) Act 1997 permits pilot schemes for primary health care which may encompass property improvements. Provision of quality buildings has implications for the willingness of patients to consult GPs, the range of services offered by family doctors and the cost‐effectiveness of primary health care delivery. The decentralized nature of primary health care raises issues about the evolution of building design knowledge to cater for technical and organizational innovations in health care. As primary health care facilities become more sophisticated, advances in construction management techniques need to be applied so that they are procured efficiently. Current real estate arrangements for the provision of primary health care facilities are causing concern. The capital investment involved is increasingly burdensome for GPs. Lack of Government finance is leading to pressures for the employment of private capital, with accompanying new opportunities for property managers.

Factors influencing audit in general practice

Since 1990, the changes introduced in UK general practice, such as fund holding and national incentives, have altered the process of care. Audit, defined as "the systematic critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for patients", is one method of monitoring change and raising standards. Presents a successful co-ordinated audit in Warwickshire, 1991-1993, involving 53 general practices. Highlights and influence of attitudes and communication within practices on the success of audit strategies. Associates aspects of practice culture, such as team working and decision-making processes with successful audit. Postulates six descriptive practice types, largely related to culture factors. Suggests that if cultural factors within practices are identified, external assistance with audit may be more focused and effective.

General practitioner fundholding: weighing the evidence

A new development in the British National Health Service is fundholding, whereby certain general practitioners are given budgets from which they purchase services for patients. Our knowledge about fundholding is rudimentary. Many important questions remain unanswered. These include: the impact of fundholding on the efficiency of overall resource utilisation; its effect on strategic planning; its effect on equity; its impact on the role of the doctor and the doctor-patient relationship; and its consequences for practice organisation and the culture of primary care. Even the scant results we do have must be interpreted cautiously. Fundholding was introduced during a period of great turbulence for general practice. Its strategic function was uncertain and its impact has been confounded by the effects of a series of earlier and concurrent policy changes. Few reliable conclusions about fundholding, either positive or negative, can be drawn from existing research.

Change in general practice and its effects on service provision in areas with different socioeconomic characteristics

OBJECTIVE

To investigate the changes in the structure and service provision of general practice in areas with different socioeconomic characteristics.

DESIGN

Interview survey; postal questionnaire.

SETTING

260 group and 80 singlehanded general practices in six family health services authorities in England.

MAIN OUTCOME MEASURES

Changes in computerisation, premises, staffing, incomes, and service provision since the introduction of the 1990 contract, including comparison with data from a study in 1987.

RESULTS

In 1993, 94% (245) of group practices were computerised compared with 38% in 1987, and 35% (90) of practices had used the cost rent scheme since 1987. Practice managers were employed in 88% (228) of group practices, and practice nurses in 96% (249) (61% and 60% respectively in 1987). Diabetes and asthma programmes were generally more common in the more affluent areas than elsewhere. A minority of practices (27% (9/33)) in the London inner city area achieved the higher target level for cervical smear testing, compared with 88% (230) overall. A similar trend was apparent for childhood immunisation. Perceived workload increased sharply between 1987 and 1993. Differences in the mean net incomes of general practitioners between areas were much lower than in 1987. Singlehanded practices generally had more problems than group practices in improving service provision.

CONCLUSIONS

Practices in all areas have shown a strong response to the new incentives. The evidence suggests, however, that generally the urban and inner city practices still lag behind practices in rural and suburban areas in terms of practice structure and service provision.