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Do minutes count? Consultation lengths in general practice

Journal of Health Services Research and Policy 1998年第4期3卷 207-214页

作者： Carr-Hill, R. Jenkins-Clarke, S. Dixon, P. Pringle, M. Centre for Health Economics University of York Heslington York YO1 5DD United Kingdom

Objective: To document the variability in consultation length and to examine the relative weight of different kinds of characteristics (of the patients, of the general practitioner (GP), or of the practice) in affecting consultation length, and, thus, to assess whether consultation length can legitimately be used as a quality marker. Design: A multilevel statistical analysis of 836 consultations across 51 GPs in ten practices. Setting and subjects: Ten general practices across four regions in England with varying list sizes, number of partners and fundholding status. Main outcome measures: Length of time face-to-face with patients in consultation measured in minutes and fractions of minutes. Results: There is substantial inter-practice variation in consultation length, from a mean of 5.7 minutes to one of 8.5 minutes. In some practices the longest average GP consultation time is about twice that of the shortest. Trainees and new partners spend, on average, about 1 minute less than their longer-serving colleagues. Consultation lengths for individual GPs range from a mean of 4.4 minutes to 11 minutes. Late middle-aged women (55-64 years) receive the longest consultations, followed by elderly people, with children receiving the shortest consultations. The number of topics raised affects the length of the consultation by about 1 minute per additional topic. When female patients consult female GPs, approximately 1 minute is added to the average consultation. A significant fraction of the variability in consultation lengths can be explained in terms of characteristics of patients, of GPs and of practices. Conclusions: The fact that there is little unexplained variation in GP consultation lengths that might be attributable to variations in quality (i.e. GP-related) throws doubt on the proposition that length of consultation can be used as a marker for quality of consultation in general practice.

关键词：家庭医学/组织和管理家庭医学/统计学和数值数据大不列颠卫生保健调查卫生服务研究医师诊疗模式医生病人关系卫生保健质量公费医疗时间和运动研究老年人儿童女(雌)性人类中年人

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Factors influencing the attendance rate at accident and emergency departments in East London: The contributions of practice organization, population characteristics and distance

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Journal of Health Services Research and Policy 1997年第1期2.0卷 6-13页

作者： Hull, S.A. Rees Jones, I. Moser, K. Department of Geography Queen Mary and Westfield College London E1 United Kingdom

Objectives: To examine the contribution of general practice organisation, population characteristics and distance to practice attendance rates at four local accident and emergency departments. Design: Practice-based study examining variations in accident and emergency department attendance rates in 105 practices, using routine data from the Family Health Services Authority (FHSA), the District Health Authority and the 1991 Census. Setting: East London and the City Health Authority, covering practices based in the inner city boroughs of Hackney, Tower Hamlets and Newham, and the City of London. Main outcome measure: Practice-based, age-standardized, adult attendance rates at accident and emergency departments in the year to 31 March 1994. Results: Annual age-standardized practice accident and emergency department attendance rates ranged from 10.3 to 29.4 per 100 population. The mean practice attendance rate was 17.6 per 100 (95% CI 16.8-18.4). No significant relationship was found between attendance rates and practice characteristics (number and sex of general practitioner (GP) principals, presence of practice manager or nurse, computerization and training status). There were strong positive relationships between attendance rates and households not owner-occupied (R = 0.55, P < 0.001) and pensioners living alone (R = 0.55, P < 0.001). There were negative correlations with Asian ethnicity (R = -0.31, P = 0.002) and residents lacking amenities (R = -0.26, P = 0.007). The distance to the nearest accident and emergency department also correlated negatively with attendance (R = -0.27, P = 0.006). A backwards multiple regression model showed that 48% of the variation in attendance rates could be accounted for by six factors: percentage of households not owner occupied, percentage living in households without a car, percentage living in households lacking amenities, percentage of pensioners living alone, percentage of Asian ethnicity, and percentage living in households wit

关键词：急诊室医院/利用人种群/统计学和数值数据家庭医学/组织和管理家庭医学/统计学和数值数据卫生服务研究伦敦模型统计学病人接受卫生保健的程度/统计学和数值数据回归分析社会阶级成年人老年人女(雌)性人类男(雄)性中年人

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The importance of care

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HEALTH CARE ANALYSIS 1997年第4期5卷 283-291页

作者： van Schie, T Seedhouse, D Westmere Physiotherapy Clin Auckland New Zealand Univ Auckland Dept Psychiat & Behav Sci Auckland 1 New Zealand

This paper is in three parts. In Part One we briefly explain that an unsophisticated form of utilitarianism-economic rationalism (ER)-has become dominant in many health systems. Its proponents argue that one of ER's most important effects is to increase consumer choice. However, evidence from New Zealand does not support this claim. Furthermore, the logic of ER requires the construction of systems which tend to restrict individual participation. In Part Two we argue that although some have advocated an 'ethic of care' in an attempt to counteract ER's utilitarianism, two decades of campaigning have had little influence on health policy. ER's pro-care adversaries have failed to make an impact because they have not developed a taxonomy of fare-they have not established a language compatible with, or as powerful as, ER's. In Part Three, in an attempt to raise the conceptual and practical status of caring in contemporary health systems, we distinguish four different forms of care. In opposition to those who believe the 'ethic of care' can adequately direct health care practice, we demonstrate that care is a secondary notion. We show that in order for a carer to decide which form of care to adopt in different situations she requires a more powerful idea. We contend further that health care ought to be governed by a theory of health, and suggest that 'the foundations theory of health' should be adopted by planners searching for a more humane alternative to ER. We conclude that ER's dominance can and must be challenged. However, only those arguments which offer detailed theoretical analyses of health care, as well as meticulously derived practical policies, have any chance of success. (C) 1997 John Wiley & Sons, Ltd.

关键词：预算卫生保健提供/经济学卫生保健提供/标准神入伦理理论伦理学伦理学医学家庭医学/经济学家庭医学/组织和管理卫生保健公平提供/经济学卫生保健公平提供/标准卫生服务研究模型理论新西兰资源分配社会价值人类

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What are the Read Codes?

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Health libraries review 1994年第3期11卷 177-182页

作者： Booth, N. Centre for Coding and Classification Loughborough United Kingdom

The Read Codes were initially developed by a general practitioner, Dr James Read from Loughborough, in the early 1980s and rapidly gained acceptance by general practitioners as a popular and useful mechanism for storing structured information about patients in individual, patient-based records, which were beginning to become popular in a few general practices at the time. This short article aims to explain the past and future development of the coding system in the National Health Service as a whole.

关键词：版权疾病/分类家庭医学/组织和管理大不列颠病案系统计算机化/分类参考书软件/标准公费医疗/组织和管理公费医疗/发展趋势人类

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Practice libraries: managing printed information and meeting the information needs of staff in general practice.

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Health libraries review 1997年第1期14.0卷 9-21页

作者： Bryant, S.L. Information Consultant 22 New Meadow Aylesbury Bucks HP21 7AN UK

Librarians and GPs share an interest in exploring different approaches to providing information to general practice and improving information management within it. Describing the aims, policy, collections, enquiries and services of three Practice Libraries in the Aylesbury area, this paper demonstrates that an information professional can make a significant impact on the management of printed information whilst facilitating access to external sources. A wealth of opportunities lie ahead for those willing to apply information handling skills to general practice. Medical librarians will need to strike a careful balance between providing direct access to sources and the development of information services tailored to meet the needs of primary health care workers.

关键词：视听设备教育继续评价研究家庭医学/组织和管理大不列颠信息管理/教育信息管理/组织和管理信息管理/标准图书馆医学出版物

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Comment: Do minutes count for quality in the general practice consultation?

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Journal of Health Services Research & Policy 1998年第4期3卷 213-214页

作者： Howie, John Department of General Practice University of Edinburgh Edinburgh EH8 9DX Levinson House 20 West Richmond Street United Kingdom

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Implementing quality: A study of the adoption and implementation of quality standards in the contracting process in a general practitioner multifund

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Journal of Health Services Research and Policy 1997年第4期2卷 205-211页

作者： Baeza, J.I. Calnan, M. Centre for Health Services Studies University of Kent Canterbury CT2 7NF United Kingdom

The increase in managerialism in the 1980s and the 1990 NHS reforms have had major implications for the regulation of providers. Purchasers of health care in the UK are now expected to specify three factors in their contracts: volume, cost and quality. This paper focuses on one of these: i.e. the quality standards purchasers now include within their health service contracts. The case study is of a general practitioner multifund and the analysis focuses on how quality standards are derived and adopted in outpatient contracts. The data were derived from in-depth face-to-face interviews with the key participants in the contracting process. The evidence shows that the standards were derived and adopted with very little participation from the providers. The impact of the quality standards on hospitals consultants' behaviour was negligible, there was very little monitoring of the standards by the multifund, and providers accepted standards which they knew they could not meet. It is concluded that this non-participatory method of developing the quality standards is likely to mean that their impact on service delivery will be limited.

关键词：门诊医疗/标准预算合同业务/标准决策评价研究循证医学家庭医学/组织和管理大不列颠卫生保健改革医院医生关系医院公立/标准卫生保健质量/标准转诊和会诊/标准公费医疗/组织和管理

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Healthcare: Integrated in the fabric of life

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Complementary Therapies in Nursing and Midwifery 2000年第1期6卷 14-18页

作者： Featherstone, Cornelia Forres IV36 3TY Caledonia Findhorn United Kingdom

Healing as a primary function of life touches all aspects of an individual as well as of the collective, be that a community or our society as a whole. Living for the last 11 years in an intentional community, the Findhorn Community in north-east Scotland, the author has the privilege to explore the relevance of healthcare for individuals and as a community service. Healthcare is much more than medical care. Mostly it is a basic aspect of daily life and relies on self-responsibility, self-care and appropriate resources/opportunities. Should medical care become necessary a wide choice of treatment approaches offered to the patient facilitates patient empowerment and involvement. The author, therefore, advocates the integration of orthodox and complementary medicine. © 2000 Harcourt Publishers Ltd.

关键词：社区网络/组织和管理补充疗法/组织和管理家庭医学/组织和管理整体保健模型组织管理苏格兰自我护理人类

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The British quasi-market in health care: A balance sheet of the evidence

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Journal of Health Services Research and Policy 2000年第1期5卷 49-58页

作者： Mays, N. Mulligan, J.-A. Goodwin, N. Social Policy Branch The Treasury Wellington 6001 PO Box 3724 New Zealand

Objectives: To summarise the findings from a comprehensive review of research on the effects of the three main elements of the quasi-market reforms of the UK National Health Service (NHS) introduced in 1991/92: - General practices becoming fundholders by volunteering to purchase elective care for their patients;- Health authorities becoming purchasers of emergency, unplanned and elective services, together with a range of alternatives to fundholding operating under their auspices;- The conversion of providers of hospital and community health services to NHS trusts separate from their local health authorities. Methods: Published and unpublished studies which included any data on the impact of the three main planks of the quasi-market changes, produced between 1991 and late 1998, were identified using a combination of electronic databases, library catalogues at the King's Fund, London, bibliographies, reference lists of individual studies, a survey of NHS directors of public health and consultations with subject area experts. Each main element of the quasi-market was assessed in relation to its impact on: efficiency (primarily productivity);equity;quality;choice and responsiveness;and accountability. Results: There was relatively little measurable change that could be related unequivocally to the core mechanisms of the quasi-market. Conclusions: The incentives were generally too weak and the constraints too strong to generate the consequences predicted by either proponents or critics of the quasi-market. On the other hand, the way in which the NHS operates was changed irrevocably by the reforms.

关键词：预算/发展趋势家庭医学/组织和管理家庭医学/发展趋势大不列颠卫生保健改革/组织和管理卫生保健改革/发展趋势卫生服务研究卫生服务使用研究/组织和管理卫生服务使用研究/发展趋势国家卫生规划/组织和管理国家卫生规划/发展趋势组织改革诊疗工作管理医学/组织和管理诊疗工作管理医学/发展趋势

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The efficiency of specialist outreach clinics in general practice: Is further evaluation needed?

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Journal of Health Services Research and Policy 1997年第3期2卷 174-179页

作者： Gosden, T. Black, M. Mead, N. Leese, B. Natl. Primary Care Res. Dev. Centre University of Manchester Williamson Building Manchester M13 9PL Oxford Road United Kingdom

Objectives: To assess the need for further evaluation of general practice-based outreach clinics in two specialties using data from a UK pilot study to model their cost-effectiveness. Methods: A pilot study was undertaken comparing one outreach and one outpatient clinic held by three dermatology specialists and three orthopaedic specialists. Information was collected on waiting times, costs to patients, casemix and resource use. Results: Only dermatology outreach clinic patients experienced significantly shorter waiting times for first appointments than their hospital counterparts. Outreach clinic patients incurred lower costs in attending appointments in either specialty but the differences were not statistically significant. Evidence of a difference in casemix between patients attending outreach and outpatient clinics meant that treatment costs incurred in both types of clinic could not be compared. Outreach clinics in both specialties were significantly more costly in terms of staff, staff travel and associated opportunity costs compared with outpatient clinics. Sensitivity analysis showed that outreach and outpatient clinics had the same marginal cost if the number of patients per outreach clinic increased greatly or attendance fell considerably at outpatient clinics. Conclusions: This study has found no evidence that outreach clinics in these two specialties are cost-effective in terms of costs and benefits. A more definitive conclusion could only be made if studies estimated other costs and benefits not accounted for in this study. Further research is required to see whether outreach clinics in other specialties or clinics with different configurations to those studied are efficient.

关键词：社区和机构的关系费用效益分析皮肤病学/经济学皮肤病学/组织和管理皮肤病学/标准效率组织家庭医学/组织和管理大不列颠卫生保健费用管理审计矫形外科学/经济学矫形外科学/组织和管理矫形外科学/标准病人满意度试点项目时间和运动研究人类

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