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This paper argues that the terms on which GPs entered the NHS, as self-employed contractors, have proved remarkably resistant to the managerial pressures which have come to dominate other sections of the National Health Service. However, this traditional mode of financing and organizing the delivery of a key element of the National Health Service has become increasingly incompatible with wider health policy objectives — the development of an integrated network of good-quality, equitable and well-coordinated primary and community health services which are responsive to local needs. Furthermore, primary health services have themselves come to play a crucially important role in securing other strategic changes in the wider health policy arena, such as securing and sustaining a shift in the traditional balance between hospital and community-based health services and controlling expenditure in a needs-led service. The paper argues that, notwithstanding the change of government, the 1997. NHS (Primary Care) Act and the White Paper "The New NHS" are both integral to the achievement of wider strategic health policy objectives, such as improving the quality and coherence of services, and increasing professional accountability for the financial consequences of clinical decisions. However, the greatest significance of these and other related measures is that they shift the emphasis of health policy from commissioning and purchasing by primary care to commissioning and contracting for primary care. They thereby extend the exposure of GP-based services to managerialist scrutiny and control. [ABSTRACT FROM AUTHOR]

The UK National Health Service (NHS) Plan has focused attention on the need to improve patient access to general practice. In trying to achieve the targets set for access, general practitioners (GPs) encounter a number of managerial dilemmas. For example, consultation times need to be limited, but the needs of individual patients for immediate care are unpredictable; continuity of care is highly valued, but GPs must be released for administration, training and other duties; delegation of tasks to other healthworkers can improve access, but dictates the need for training and the definition of legal and ethical responsibility. The management of access in general practice involves a number of constituencies including doctors, nurses, reception staff and, not least, patients themselves. Access to general practice constitutes a hybrid system, having some components that can be objectively viewed and quantified and others that remain qualitative, either because they are subjective by nature (e.g., morale and professionalism) or because data on that facet of the operation is simply not available. Hybrid management problems are amenable to treatment by qualitative systems methods and this paper describes an ex ante, real-life intervention using a qualitative system dynamics approach known as QPID (Qualitative Politicised Influence Diagrams). The method ascribes agents and actors to the connections in an influence diagram of the system under consideration. This process structures thinking about the appropriate actions (aimed at these agents and actors) for managing the system behaviour. The method is applied to the process of developing patient access policies for a large NHS practice in the South of England. It demonstrates the use of QPID to derive practical action plans for the management of this challenging aspect of general practice. Copyright © 2004 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Purpose: In the UK, ophthalmology has the highest number of outpatient appointments within the National Health Service. False‐positive referrals from primary care are one of the main factors contributing to the oversubscription of hospital eye services (HESs). We reviewed the accuracy of referrals originating from primary care optometrists and contributing factors, such as condition type and years since registration. Recent findings: Of the 31 studies included in the review, 22 were retrospective analyses of referrals and appointments at the HES. Eight were prospective studies, and one used online clinical vignettes. Seven assessed the accuracy of referrals for all ocular conditions. The remaining studies focused on glaucoma (n = 11), cataracts (n = 7), emergency conditions (n = 4), neovascular age‐related macular degeneration (n = 1) and paediatric binocular vision (n = 1). The diagnostic agreement for suspected emergency ocular conditions was the lowest, with only 21.1% of referrals considered to require urgent attention in one study. For glaucoma, the first‐visit discharge rate was high (16.7%–48%). Optometrist referral accuracy was overall 18.6% higher than General Medical Practitioners'; however, the two mainly referred different ocular conditions. Female optometrists made more false‐positive referrals than males (p = 0.008). The proportion of false positives decreased by 6.2% per year since registration (p < 0.001). Summary: There was significant variation in referral accuracy across different ocular conditions, partly due to differences when defining accurate referrals. Optometrists working in primary care are generally more limited in their resources than the HES. Thus, choosing the cautious option of referral when they are unsure could be in the patients' best interests. The possible effect of increased use of advanced imaging on referrals requires evaluation. Although interventions such as refinement schemes have been put in place, these vary across regions, and their approaches such as virtual referral triaging may reduce unnecessary HES face‐to‐face appointments and promote communication between primary and secondary care. [ABSTRACT FROM AUTHOR]

The paper reports some of the findings of a study which investigated opioid users' views on and use of available treatment services in Britain. Samples were drawn from among addicts currently receiving a prescription from a National Health Service (NHS) clinic, a general practitioner and a private practitioner and addicts who were currently dependent solely on black-market supplies. Addicts were interviewed using a combined structured and semi-structured interview schedule. There was little evidence that users dependent on black-market sources only had actively rejected available treatment services in the past. The majority of the black-market users had approached at least one type of doctor in connection with their addiction. Most of the users currently receiving a prescription from a clinic or a general or private practitioner had at some time approached other types of doctor. The main reasons given for not approaching various types of doctor concerned a belief that such doctors were unavailable locally and an expectation that they were unwilling to prescribe opioids. Given a free choice, the majority of addicts said that they would prefer to attend a GP rather than a clinic or private practitioner. [ABSTRACT FROM AUTHOR]

The article presents a study that examines the patient's confidentiality in Great Britain. It states that confidentiality is essential in doctor-patient relationship and it is stated in Great Britain National Health Services Confidentiality Code of Practice. It notes that the purpose of the article discusses the legal and regulatory framework governing confidentiality.

Rationale, aims and objectives Clinical audit informs general practitioner (GP) appraisal and will provide evidence of performance for revalidation in the UK. However, objective evidence is now required. An established peer assessment system may offer an educational solution for making objective judgements on clinical audit quality. National Health Service (NHS) clinical audit specialists could potentially support this system if their audit assessments were comparable with established medical peer assessors. The study aimed to quantify differences between clinical audit specialists and medical peer assessors in their assessments of clinical audit projects. Methods A comparison study of the assessment outcomes of clinical audit reports by two groups using appropriate assessment instruments was conducted. Mean scores were compared and 95% confidence intervals (CIs) and limits of agreement calculated. A two-point mean difference would be relevant. Results Twelve significant event analysis (SEA) reports and 12 criterion audit projects were assessed by 11 experienced GP assessors and 10 NHS audit specialist novice assessors. For SEA, the mean score difference between groups was <1.0. The 95% CI for bias was −0.1 to 0.5 ( P = 0.14). Limits of agreement ranged from −0.7 to 1.2. For criterion audit, a mean score difference of ≤1.0 was calculated for seven projects and scores between 1.1 and 1.9 for four. The 95% CI for bias was 0.8 to 1.5 ( P < 0.001). Limits of agreement ranged from −2.5 to −0.0. Conclusions The study findings suggest that a sample of NHS clinical audit specialists can give numerically accurate feedback scores to GPs on the quality of their clinical audit activity compared with established peer assessors as part of the model outlined. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives To explore stakeholder perspectives of the implementation of a new, national integrated nurse-led telephone advice and consultation service [National Health Service 24 (NHS 24)], comparing the views of stakeholders from different health care organizations. Methods Semi-structured interviews with 26 stakeholders including partner organizations located in primary and secondary unscheduled care settings [general practitioner (GP) out-of-hours cooperative; accident and emergency department; national ambulance service, members of NHS 24 and national policy makers. Attendance at key meetings, documentary review and email implementation diaries provided a contextual history of events with which interview data could be compared. Results The contextual history of events highlighted a fast-paced implementation process, with little time for reflection. Key areas of partner concern were increasing workload, the clinical safety of nurse triage and the lack of communication across the organizations. Concerns were most apparent within the GP out-of-hours cooperative, leading to calls for the dissolution of the partnership. Accident and emergency and ambulance service responses were more conciliatory, suggesting that such problems were to be expected within the developmental phase of a new organization. Further exploration of these responses highlighted the sense of ownership within the GP cooperative, with GPs having both financial and philosophical ownership of the cooperative. This was not apparent within the other two partner organizations, in particular the ambulance service, which operated on a regional model very similar to that of NHS 24. Conclusions As the delivery of unscheduled primary health care crosses professional boundaries and locations, different organizations and professional groups must develop new ways of partnership working, developing trust and confidence in each other. The results of this study highlight, for the first time, the key importance of understanding the professional ownership and identity of individual organizations, in order to facilitate the most effective mechanisms to enable that partnership working. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]