Search

The article presents the summaries of papers on dermatology presented at the main plenary sessions. The National Health Service (NHS) Plan 2000 proposed the development of specialist general practitioners (GPs) to take referrals from other GPs in specialties including dermatology. The NHS Modernization Agency Action on Dermatology program funded pilot site studies of dermatology GPwSI, services and preliminary results were encouraging. By the end of 2005, all referrals from primary care will be performed electronically using a referral template. Currently only a proportion of referrals are electronic, allowing comparison with established paper referrals.

As the first point of contact for patients, General Practitioners (GPs) play a crucial role in the National Health Service (NHS). An accurate primary diagnosis from the GP can alleviate the burden on specialists and reduce the time needed to re-confirm the patient's condition, allowing for more efficient further examinations. However, GPs have broad but less specialized knowledge, which limits the accuracy of their diagnosis. Therefore, it is imperative to introduce an intelligent system to assist GPs in making decisions. This paper introduces two data augmentation methods, the Complaint Symptoms Integration Method and Symptom Dot Separating Method, to integrate essential information into the Integration dataset. Additionally, it proposes a hybrid architecture that fuses the features of words from different representation spaces. Experiments demonstrate that, compared to commonly used pre-trained attention-based models, our hybrid architecture delivers the best classification performance for four common neurological diseases on the enhanced Integration dataset. For example, the classification accuracy of the BERT+CNN hybrid architecture is 0.897, which is a 5.1% improvement over both BERT and CNN with 0.846. Finally, this paper develops an AI diagnosis assistant web application that leverages the superior performance of this architecture to help GPs complete primary diagnosis efficiently and accurately. [ABSTRACT FROM AUTHOR]

Examines the reaction of general practitioners towards the proposals contained in the white paper 'Working for Patients' in Great Britain. Rejection of the proposals by general practitioners; Criticisms on the implementation of fixed budgets for specified surgical operations; Concerns on the cost effectiveness of the National Health Service.

Background: Primary care is an essential pillar of health systems. Many countries have implemented different policies to improve access to primary care. However, persistent challenges remain. This paper offers a critical analysis of the evolution of primary care coverage in Portugal, focusing on the number of patients without an assigned general practitioner (GP). Methods: We collected and analyzed publicly available data from 2009 to 2023 to decompose primary care coverage in three components: the number of patients enrolled in primary care units (demand-side effect), the number of GPs measured in full-time equivalent (supply-side effect), and the average number of patients on each GP's list (patient-to-GP ratio, capturing a productivity effect). We provide national and local level estimates for these three components. Results: Between 2009 and 2023, there was an overall decline in the number of patients enrolled in primary health care units. Concurrently, there was also a net decrease of GPs measured in full-time equivalent. Additionally, there was a progressive reduction in the average number of patients on each GP's list. The rise in the number of patients without an assigned GP is attributed not only to a reduction in the number of physicians, but also to a decrease in the patient load per doctor. Conclusions: Hiring additional GPs may not suffice to enhance coverage. Achieving higher coverage may imply revisiting patient load per doctor or considering alternative care models. Understanding the challenges related to GP coverage is critical for improving the efficiency of primary care. [ABSTRACT FROM AUTHOR]

Background: In 2020, Portugal had high levels of unmet health care needs. Primary Care was reported as the main source of unmet needs. Objectives: To describe face-to-face and remote access to GPs in Portugal during the COVID-19 pandemic. To discover patient experiences and attitudes to access to care. To identify determinants of access to care. Methods: A survey of a random sample of 4,286 adults registered in a group of Family Practices was conducted in 2021. Paper questionnaires were sent by post to patients who had no e-mail address registered with the practice. Patients with an e-mail address were sent a link to an online questionnaire. Outcomes were reported waiting times for face-to-face and remote contacts with GPs, dichotomized to ascertain compliance with standards. Associations between participant characteristics and outcome variables were tested using logistic regression. Results: Waiting times for face-to-face consultations with GPs during the pandemic often exceeded the maximum waiting times (MWT) set by the National Health Service. Remote contacts were mostly conducted within acceptable standards. Waiting times for speaking with the GP over the phone were rated as 'poor' by 40% and 27% reported requests for these calls as unmet. The odds of getting care over MWT increased for participants who reported poorer digital skills. Participants were less likely to get non-urgent consultations over MWT if they found it easy to use the online patient portal to book appointments (odds ratio 0.24; 99% confidence intervals 0.09–0.61), request prescriptions (0.18; 0.04–0.74) or insert personal data (0.18; 0.04–0.95). Conclusion: Patient reported access to GPs during the pandemic was uneven in Portugal. Obtaining non-urgent consultations and remote contacts over MWT affected mainly those patients with poor digital skills. Telephone access to GPs received the worse ratings. Access through traditional pathways must remain available, to prevent the widening of inequities. [ABSTRACT FROM AUTHOR]

Focuses on the publication of the working papers of the National Health Service (NHS) in Great Britain. Renegotatiation of the contracts of general practitioners; Implementation of the NHS review; Role of the Department of Health in the distribution of the working papers to general practitioners.

Focuses on the rejection of the general practitioners of the government's National Health Service (NHS) in Great Britain. Rejection of the government's proposal for general practitioners; Views regarding the white paper of the NHS; Compatibility of the concepts of the white paper with the principles of the NHS.

Migration is a core component of population change and is both a symptom and a cause of major economic and social phenomena. However, data limitations mean that gaps remain in our understanding of the patterns and processes of mobility. This is particularly the case for internal migration, which remains under-researched, despite being quantitatively much more significant than international migration. Using the Scottish Longitudinal Study, this paper evaluates the potential value of General Practitioner administrative health data from the National Health Service that can be linked into census-based longitudinal studies for advancing migration research. Issues relating to data quality are considered and, using the illustrative example of internal migration by country of birth, an argument is developed contending that such approaches can offer novel ways of comprehending internal migration, by shedding additional light on the nature of both movers and the moves that they make. [ABSTRACT FROM AUTHOR]

The author comments on the White Paper from the National Health Services (NHS) of Great Britain, titled "Equity and Excellence: Liberating the NHS," which proposes changes in the way decisions about health services are made. The author points out the lack of clarity on how the NHS Commissioning Board will promote involvement in research and the use of research evidence. The author discusses how research is funded and facilitated, topics for research, and the involvement of general practitioners (GPs).

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 author reflects on the dilemmas of general practitioners (GPs) in taking decisions for patient care in view of a new health care policy of the British National Health Service. The policy emphasizes both effectiveness and cost of patient care. However, it becomes difficult for GPs to decide what is best for patients and what is cost effective for the government. Physician Lord Horder's view on the training of general practitioners has also been considered as a solution to the problem.

The introduction of a market mechanism into the National Health service in the UK was underpinned by the belief that decentralised purchasing would both improve the quality of health care provision and restrain spiralling costs, through purchasers exercising their ability to choose between alternative providers. Focusing on budget holding General Practitioners, that is those practices responsible for purchasing hospital services for their practice populations, this paper explores the evolving purchasing behaviour of these professional intermediaries. Drawing on empirical evidence gathered as part of a broader study of the purchasing behaviour of GP Fundholders in Scotland, specifically it examines the key information sources and decisional criteria utilised by these professional intermediaries in selecting health care providers for their practice population. Utilising relational models of market behaviour, it addresses both the contextually specific issue of whether the market mechanism within the NHS is achieving the twin objectives of improving health care provision and restraining cost pressures, and the broader conceptual issue of the purchasing behaviour of professional intermediaries within a service sector environment. [ABSTRACT FROM AUTHOR]

The author argues that the National Health Service (NHS) in Great Britain needs general practitioners (GP) who are focused on patient-centered values. He emphasizes the role of GP in providing high quality care. He claims that the GP leaders needed by the NHS are those who are motivated to improve patient care and those who are committed to care for individual patients. The author also suggests ways in which GP can perform their commissioning responsibility under the British government's practice-based commissioning scheme.

Political influence on service delivery in the NHS has been significant in recent years with a drive for modernisation and service improvement. One consequence of this influence is the emergence of new roles and new ways of working. Supported by examples of three advanced practices roles (first contact care practitioner, medical care practitioner, advanced nurse practitioner), this paper will illustrate the policy drivers behind the developments and address the practice implications both for the practitioner and for the service. Healthcare practitioners undertaking these new roles will have specific learning and development needs and meeting these will be a challenge for education and health care alike. The paper will consider how work based learning models can be integral to the support infrastructure for role re-design and service improvement in the new NHS. It will also recognise the organisational development that is prerequisite to service innovation. [ABSTRACT FROM AUTHOR]

International recruitment now forms an important part of the government's policy to increase capacity in the NHS.1 By 2003, 89 general practitioners (GPs) had been recruited from countries of the European Union (EU), and in particular, Spain and France.2 The ability of the NHS to retain these GPs will, in part, depend on the support that they receive during the transition to work. In order that this can be achieved, the Department of Health recommend that all overseas doctors should participate in a thorough and comprehensive induction programme and receive support until they are fully integrated into the NHS.3 This paper describes the stages that we went through to develop an induction programme for EU GPs and reports on the programme evaluation. Evaluation of the programme has largely been positive, with most GPs suggesting that they would never have come to work in London general practice without the support of a formal programme that facilitated their transition to work in the NHS. Some components of the programme, for example facilitated peer support, provided unexpected outcomes, offering participants the opportunity to develop a supportive, cohesive team. Other aspects of the programme, for example the clinical placements, sometimes provoked an initial loss of confidence as participants found it difficult to move into a learning role, having previously been practicing ‘unwatched’ for many years. Programme evaluation also indicated that French GPs are generally not accustomed to self-directed continuing education or professional development. In order to maximize learning from the induction programme, therefore, participants tend to require clear direction regarding private study. At the time of writing this paper, 33 GPs have attended the programme, 26 (79%) of whom have taken up employment in London general practice. [ABSTRACT FROM AUTHOR]

The NHS 111 service triages over 16,650,745 calls per year and approximately 48% of callers are triaged to a primary care disposition, such as a telephone appointment with a general practitioner (GP). However, there has been little assessment of the ability of primary care services to meet this demand. If a timely service cannot be provided to patients, it could result in patients calling 999 or attending emergency departments (ED) instead. This study aimed to explore the patient journey for callers who were triaged to a primary care disposition, and the ability of primary care services to meet this demand. We obtained routine, retrospective data from the Connected Yorkshire research database, and identified all 111 calls between the 1st January 2021 and 31st December 2021 for callers registered with a GP in the Bradford or Airedale region of West Yorkshire, who were triaged to a primary care disposition. Subsequent healthcare system access (111, 999, primary and secondary care) in the 72 hours following the index 111 call was identified, and a descriptive analysis of the healthcare trajectory of patients was undertaken. There were 56,102 index 111 calls, and a primary care service was the first interaction in 26,690/56,102 (47.6%) of cases, with 15,470/26,690 (58%) commenced within the specified triage time frame. Calls to 999 were higher in the cohort who had no prior contact with primary care (58% vs 42%) as were ED attendances (58.2% vs 41.8), although the proportion of avoidable ED attendances was similar (10.5% vs 11.8%). Less than half of 111 callers triaged to a primary care disposition make contact with a primary care service, and even when they do, call triage time frames are frequently not met, suggesting that current primary care provision cannot meet the demand from 111. [ABSTRACT FROM AUTHOR]

AbstractA number of policy initiatives over the last few years have encouraged general practitioners (GPs) to participate in commissioning, as opposed to simply purchasing, health care. This role was reinforced in the white paper, The New NHS. A qualitative study of GPs in two health authorities uncovered not only concerns about the reforms which have since emerged in the medical and general press, but other issues which have been less frequently articulated. There was also evidence of goodwill towards professional colleagues, including those in social services departments. The preference for professional, as opposed to market relationships may help to secure the collaborative ethos desired by government. However, if the concerns the study uncovered are indicative of a more widespread response to the white paper, they suggest the need for careful support of developing Primary Care Groups (PCGs). [ABSTRACT FROM AUTHOR]

This paper considers the micro-econometric analysis of patients' hospital choice for elective medical procedures when their choice set is pre-selected by a general practitioner (GP). GPs have a dual role with regard to elective referrals in the English NHS, advising patients and at the same time taking account of the financial implications of referral decisions on local health budgets. The paper proposes a two-stage choice model that encompasses both patient and GP level optimization. It demonstrates that estimators that do not take account of strategic pre-selection of choice sets may be biased and inconsistent. We find that GPs as patients' agents select choice options based on quality, but as agents of health authorities also consider financial implications of referrals. When considering these choice options, patients focus on tangible hospital attributes, like amenities. [ABSTRACT FROM AUTHOR]

The article reports that the government of Great Britain has launched the White Paper, Equity and Excellence: Liberating the National Health Services (NHS) of Great Britain, to focus on healthcare management and quality of care. It states that the government wants to reduce the management costs of NHS by 45 percent. It mentions that the funding of services, that general practitioners (GPs) refer to patients will now be undertaken by GP commissioning consortia along with local authorities.

The paper compares two separate studies on GP appraisal and consultant appraisal in the British National Health Service (NHS). Both found potential for appraisal to be a developmental process, which enabled clinicians to reflect on and improve their practice, or to become a ‘tick box exercise’. We explain the contextual factors leading to appraisal outcomes and suggest that clinical ownership is critical to the success of appraisal. It seems, however, that more often importance is placed upon ‘ticking the boxes’ so that clinicians and NHS organisations are seen to have conducted appraisals, regardless of effectiveness in practice. [ABSTRACT FROM AUTHOR]

This paper outlines the processes of quality assurance of GP appraisal in Wales. These processes demonstrate the application of national guidance for quality assurance of medical appraisal as recommended by the National Clinical Governance Support Team (NCGST). The paper describes how defined standards of practice in the context of GP appraisal have, on a relatively large scale, been developed and demonstrated through robust internal and external quality assurance mechanisms. These quality assurance mechanisms reveal positive feedback from the vast majority of participants in the process. Both GPs and appraisers report that they benefited from their involvement in appraisal. The study demonstrates that the outputs of appraisal (summary and personal development plan) accurately reflect the content of the appraisal and help doctors to plan their learning, although further work is required with respect to specifying action plans. [ABSTRACT FROM AUTHOR]

This paper explores the relations between management discourse and employee subjectivity in the process of organizational change, drawing on a new empirical study of doctors and nurses working in the British National Health Service (NHS). It builds on recent critiques of more muscular accounts of discourse to examine the manoeuvres made by working subjects in response to managerialist discourses of the entrepreneurial self. While others have shown that alternative discourses including gender, age and profession are important here, this paper argues that we must pay attention to the spatial and temporal contexts within which such generic discourses are received and understood in order to interpret the practices of subjectivity and power in organizational life. We suggest that this approach allows new insights to policy concerns in the NHS; to our understanding of the nature of work subjectivities; and to sociological understandings of organizational power. [ABSTRACT FROM AUTHOR]

Violence against doctors provides an illuminating context for studying medicalisation and its limits in the management of deviance. The paper examines the emergence of such violence as a policy issue in England, with particular reference to general practitioners (GPs) in the National Health Service. Recent guidance exhorts doctors to exercise ‘zero tolerance’ with respect to acts of violence. The emphasis is on risk management and protecting victims rather than on resolving the perpetrators’ problems. The paper argues that this policy frame is consistent with recent claims from criminologists that there is a new ‘turn’ in penal policy, away from rehabilitation and addressing the needs of individual offenders. However, responses of individual GPs, obtained through a postal questionnaire sent to c.1000 GPs and in–depth interviews with a sub–sample, suggest that doctors are not ‘zero tolerant’ in responding to attacks. But nor are they medical imperialists seeking to include all perpetrators within their professional jurisdiction. Rather, they exercise professional discretion about behaviours which often fall into a ‘grey area’ between ‘illness’ and ‘crime’, and about individuals who are not clearly categorisable as either ‘sick’ or ‘bad’. [ABSTRACT FROM AUTHOR]

The article focuses on the purchasing power and polarized professionalism in British medicine. The inception of fund holding, the opportunity to hold a budget at practice level, for general practitioners (GPs) has constituted a critical, formative moment for intra-professional relations in British medicine. Fund holding conferred purchasing power on GPs. This paper argues that they are using this financial leverage to enhance their influence within the British National Health Service (NHS). The mechanisms of fund holding have enabled GPs to accommodate their latent desire to shift the balance of power between themselves and the hospital consultants. This desire had remained latent as any overt intraprofessional challenge would have threatened public perceptions of all medical experts as exemplars of rationality, impartiality and civility. Societies rationalize socially significant but unclear domains, such as medicine, by professionalizing them and handing over decisions to licensed practitioners.

Background: Temporary doctors, known as locums, are a key component of the medical workforce in the NHS but evidence on differences in quality and safety between locum and permanent doctors is limited. We aimed to examine differences in the clinical practice, and prescribing safety for locum and permanent doctors working in primary care in England. Methods: We accessed electronic health care records (EHRs) for 3.5 million patients from the CPRD GOLD database with linkage to Hospital Episode Statistics from 1st April 2010 to 31st March 2022. We used multi-level mixed effects logistic regression to compare consultations with locum and permanent GPs for several patient outcomes including general practice revisits; prescribing of antibiotics; strong opioids; hypnotics; A&E visits; emergency hospital admissions; admissions for ambulatory care sensitive conditions; test ordering; referrals; and prescribing safety indicators while controlling for patient and practice characteristics. Results: Consultations with locum GPs were 22% more likely to involve a prescription for an antibiotic (OR = 1.22 (1.21 to 1.22)), 8% more likely to involve a prescription for a strong opioid (OR = 1.08 (1.06 to 1.09)), 4% more likely to be followed by an A&E visit on the same day (OR = 1.04 (1.01 to 1.08)) and 5% more likely to be followed by an A&E visit within 1 to 7 days (OR = 1.05 (1.02 to 1.08)). Consultations with a locum were 12% less likely to lead to a practice revisit within 7 days (OR = 0.88 (0.87 to 0.88)), 4% less likely to involve a prescription for a hypnotic (OR = 0.96 (0.94 to 0.98)), 15% less likely to involve a referral (OR = 0.85 (0.84 to 0.86)) and 19% less likely to involve a test (OR = 0.81 (0.80 to 0.82)). We found no evidence that emergency admissions, ACSC admissions and eight out of the eleven prescribing safety indicators were different if patients were seen by a locum or a permanent GP. Conclusions: Despite existing concerns, the clinical practice and performance of locum GPs did not appear to be systematically different from that of permanent GPs. The practice and performance of both locum and permanent GPs is likely shaped by the organisational setting and systems within which they work. [ABSTRACT FROM AUTHOR]

Background There is an insufficient number of medical students intending to pursue general practitioner ( GP) careers. The undergraduate curriculum has traditionally prioritised teaching in large hospital settings despite most National Health Service patient contact occurring in primary care. Primary care is faced with providing health care for an ageing population with high levels of co-morbidities. Patients who live in deprived areas suffer many disadvantages affecting their health and additionally tend to be underserved. Globally, there has been an initiative to provide medical students with extended clinical placements in rural and remote areas. These placements have identified many beneficial outcomes; however, little is known about placements in other underserved, deprived areas. This paper describes an innovative pilot programme to address these issues. Context The North East of England has a large proportion of the most deprived communities and worst health care outcomes in England. In Teesside, Phase 1 Medicine at Durham University provides the pre-clinical curriculum. Durham students then join Newcastle University for Phase 2 Medicine, the clinical years. Innovation The Difficult and Deprived Areas Programme ( DDAP) places fourth-year students in general practice and community settings in post-industrial, deprived areas for 14 weeks, thus adopting and applying principles from rural initiatives (continuity and immersion) to other deprived settings. The DDAP allows students to learn about psychosocial determinants of health and to pursue community interests whilst gaining an excellent clinical grounding. Implications The DDAP provides a model for educators seeking to implement initiatives in similar underserved, deprived settings, which may potentially alleviate GP workforce shortages. [ABSTRACT FROM AUTHOR]

Clinical commissioning groups (CCGs), part of the UK's National Health Service (NHS) since April 2013, are complex organizations requiring buy-in by GPs for strategic success. CCG budgetary deficits and lack of sustained engagement by GPs are a problem. This paper utilizes evidence of GP experience in commissioning models to determine the factors that may influence engagement in the governance of CCGs by GPs, which is crucial if clinically-led commissioning is to be part of a financially sustainable NHS. [ABSTRACT FROM AUTHOR]

Background: During the COVID-19 pandemic, clinical services were severely disrupted, restricted, or withdrawn across the country. People living with Inflammatory Bowel Disease (IBD) – an auto-immune disorder for which medical treatment often results in immunosuppression, thus requiring regular monitoring—may have struggled to access clinical support. As part of a larger qualitative study, we investigated experiences of access to clinical services during the pandemic, and patient concerns about and preferences for services in the future. Methods: This exploratory qualitative study used semi-structured interviews to explore participants' experiences of clinical services across the UK during the pandemic. All data were collected remotely (March – May 2021) using online video-calling platforms or by telephone. Audio files were transcribed professionally and anonymised for analysis. Data were analysed using thematic analysis. Results: Of the eight themes found across all data, four related specifically to accessing GP, local (district) hospital, and specialist (tertiary) referral services for IBD: 1) The Risk of Attending Hospital; 2) Missing Routine Monitoring or Treatment; 3) Accessing Care as Needed, and 4) Remote Access and The Future. Conclusions: Our findings support other studies reporting changes in use of health services, and concerns about future remote access methods. Maintenance of IBD services in some form is essential throughout crisis periods; newly diagnosed patients need additional support; future dependence on IBD services could be reduced through use of treatment / self-management plans. As the NHS digitalises it's future services, the mode of appointment—remote (telephone, video call), or in-person – needs to be flexible and suit the patient. [ABSTRACT FROM AUTHOR]

Our second paper in the series is from the talk by Professor Paul Corrigan CBE. He was special advisor to Secretary of State for Health Alan Milburn and his successor Dr John Reid and (according to his Wikipedia entry) is credited as the man behind the Labour government's policy on foundation hospitals. In 2006 he became policy adviser to then PM Tony Blair. Until the latest NHS reorganisation, when strategic health authority and primary care trusts were abolished, he was Director of Strategy and Commissioning of the NHS London HSA. www.pauldcorrigan.com It is reactionary to imagine turning the clock back to a time when medicine was a cottage industry served by individual craftsmen. The NHS had to industrialise to cope with the demand, but it need not become a faceless production line if we can build in state-ofthe- art approaches for feedback, quality control and customer engagement, and educate staff in genuine customer-centredness. [ABSTRACT FROM AUTHOR]

The paper discusses the issue of family involvement in the process of obtaining consent to treatment. Legally, doctors have a duty to inform the patient, and the patient has a right to be informed before making a decision. In this context, however, there is no requirement to involve relatives or to take into account their interests or requests. Yet, findings from in-depth interviews with NHS general practitioners presented in the paper indicate that in reality relatives have a substantial impact on the process of informed consent. Their presence may lead the doctor to provide more information to the patient and help the patient better understand the information conveyed by the doctor. Ultimately, the relatives' involvement enhances the patient's ability to make an informed decision, even though in some cases - when the relative is dominant - this may have a negative impact on the channel of communication between doctor and patient. These findings reflect a relational approach to patient autonomy. They lead the author to suggest that the current doctor-patient partnership model in English medical law would benefit by the addition of relatives as an integral component of the decision making team. Such a significant shift in the legal approach requires changes in the type of information conveyed by the doctor to the patient; in the means to increase the patient's understanding; and lastly at the point when decisions are actually made. [ABSTRACT FROM AUTHOR]

Purpose - The purpose of this paper is to discuss the impact of contracts on general practise in the UK National Health Service. In particular, it is concerned with the response of practitioners to the apparent flexibilities offered in the new contract with its focus on outcomes rather than processes. Design/methodology/approach - Ethnographic studies of two general practices, using non-participant observation, documents and interviews with staff over a five-month period. Findings - Conclusions suggest that the new contracts, far from encouraging flexibility and responsiveness from general practitioners, have tended to strengthen bureaucratic forms in the way the contract is implemented. Originality/value - The new contract has introduced greater clarity regarding roles and responsibilities within practises. At the same time, when operating in financially tight conditions, the contract can make rationing more explicit. Decisions are made not in accordance with the targets but in light of local pressures and constraints, causing tensions between primary and tertiary care. [ABSTRACT FROM AUTHOR]

Background: Leaders who have the capability to deliver service improvement in healthcare are much sought after at this time of structural change. This paper describes a leadership programme trialled in the UK in the medical specialty of general practice, which gave participants the opportunity to learn about the principles of leadership in healthcare, and approaches to service improvement. In their own practices, participants used the skills and knowledge that they had gained from the programme to identify, implement and evaluate a change in healthcare service provision. Method: A total of 13 general practitioners and one practice business manager participated in the one-year programme, supported by a faculty team of three. Participants and faculty met as a learning set for one day a week over three terms, first to focus on the knowledge and skills needed to lead change, secondly to support the projects as they developed, and thirdly to review and evaluate them. Results: The outcomes of the programme were evaluated using a number of data sources, including the Medical Leadership Competency Framework (a self-assessment rating scale). Participants completed the scale at the start and end of the programme. Statistical analysis (Wilcoxon signed-rank test) of the scores demonstrated statistical significance across 60 (75%) of the 80 items. Further data about the impact of the programme on their personal and professional development arose from their service improvement project reports and reflective accounts of the programme. Conclusions: The Practice Leaders Programme (PLP) was found to be effective in developing competent and capable improvement leaders in NHS general practice. It supported the participants in developing new skills and confidence to make changes to healthcare services, and also provided insight into their learning and interaction with other practice team members. [ABSTRACT FROM AUTHOR]

Is the British National Health Service (NHS) equitable? This paper considers one part of the answer to this: the utilization of the NHS by different socioeconomic groups (SEGs). It reviews recent evidence from studies on NHS utilization as a whole based on household surveys (macro-studies) and from studies of the utilization of particular services in particular areas (micro-studies). The principal conclusion from the majority of these studies is that, while the distribution of use of general practitioners (GPs) is broadly equitable, that for specialist treatment is pro-rich. Recent micro-studies of cardiac surgery, elective surgery, cancer care, preventive care and chronic care support the findings of an earlier review that use of services was higher relative to need among higher SEGs. [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]

There is concern that the UK general practitioner (GP) workforce has declined relative to the expanding needs of a primary care-led NHS. Much of the debate about possible solutions within the profession and amongst medical workforce planners has focused on the need to raise medical school intakes and recruit more new GPs. However, other evidence shows that, as with medicine in general, a differential relation ship exists in the GP labour market based upon socially ascribed characteristics. It follows that many already qualified GPs (e.g. women, ethnic minority and older doctors) are under-used in the context of generally accepted career structures. Hence, we would argue, part of the solution to workforce shortages lies in better retention and management of existing human resources. This paper first suggests a simple re-conceptualisation, which will help to frame a more sophisticated analysis than so far used for workforce planning of the nature of GP demand and supply. The framework is then used to explore the findings of the first ever national survey (n = 621) and follow-up interviews (n = 32) with a cohort of GP principal leavers. These showed that a variety of more flexible employment arrangements are needed in order to improve both GP recruitment and retention. In taking this approach, the paper also explores the potential implications of changing social trends for the structure of the GP profession. [ABSTRACT FROM AUTHOR]

Background. This paper describes a study to develop and test an instrument to measure the level of appropriate admissions and days of care in the paediatric hospital population. [ABSTRACT FROM PUBLISHER]

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]

Background: Lack of access to documentation is a key barrier to GP registration, despite NHS England guidance stating that documents are not required. Staff attitudes and practice regarding registration of those without documentation are under- researched. Aim: To understand the processes through which registration might be refused for those without documents, and the factors operating to influence this. Design and setting: Qualitative study conducted in general practice across three clinical commissioning groups in North East London. Method: In total, 33 participants (GP staff involved in registering new patients) were recruited through email invitation. Semi-structured interviews and focus groups were conducted. Data were analysed using Braun and Clarke's reflexive thematic analysis. Two social theories informed this analysis: Lipsky's street-level bureaucracy and Bourdieu's theory of practice. Results: Despite good knowledge of guidance, most participants expressed reluctance to register those without documentation, often introducing additional hurdles or requirements in their everyday practice. Two explanatory themes were generated: that those without documents were perceived as burdensome, and/or that moral judgements were made about their deservedness to finite resources. Participants described a context of high workload and insufficient funding. Some felt that GP services should be restricted by immigration status, as is widespread in secondary care. Conclusion: Improving inclusive registration practice requires addressing staff concerns, supporting navigation of high workloads, tackling financial disincentives to registering transient groups, and challenging narratives that undocumented migrants represent a 'threat' to NHS resources. Furthermore, it is imperative to acknowledge and address upstream drivers, in this instance the Hostile Environment. [ABSTRACT FROM AUTHOR]