Objective— To determine referral rates and intermediate and long‐term outcomes for patients consulting for menstrual disorders and referred by their general practitioner to gynaecology outpatient clinics. Design— General practitioners' records of referrals to outpatient clinics and retrospective audit of general practice notes to determine outcomes. Setting— General practices in the Oxford Regional Health Authority area referring to 19 gynaecology outpatient clinics. Subjects— 205 patients aged 15–59, referred in 1983/4 and follow up in 1988/9. Main outcome measures— Immediate outcomes: the initiation by hospital specialists of investigation, treatment or advice. Five year outcomes: general practice consultation rates and symptom prevalence. Results— Of 18 754 index referrals recorded by 33 practices over a period of 6 months, 2513 (13%) went to gynaecology clinics. Menstrual disorders constituted 21% (n = 539) of the gynaecology referrals; there was more than three‐fold variation between the practices in referral rates. In the 5 years following the index referral, of the 205 audited patients 167 (81%) had been admitted to hospital, 91 (44%) had had a hysterectomy (including 87 (60%) of the 145 patients referred for menorrhagia), 98 (48%) had dilatation and curettage; 25 (12%) received only drug therapy; and 10 (5%) had no active treatment for these symptoms from either the specialist or the general practitioner. Only 29 (14%) had consulted their general practitioners about menstrual problems in the 12 months preceding the audit. Conclusions— Guidelines are needed to assist referral decision‐making. If audit is to be used to promote good practice these guidelines should consider the patients' anxieties and preferences, as well as the most appropriate use of investigations and treatments.
Objective-To compare general practitioners' prescribing costs in fundholding and non-fundholding practices before and after implementation of the NHS reforms in April 1991.Design-Analysis ofprescribing and cost information (PACT data; levels 2 and 3) over two six month periods in 1991 and 1992.Setting-Oxford region. Fundholders' drugs budgets were calculated on the same basis as indicative precribing amounts, with additional adjustments for discounts and container costs to convert the indicative amount into a cash budget. The budgets were cash limited and any savings made could either be transferred into another budget category-for example, hospital services-or spent on improving patient care in the next financial year. These budgets offered a more direct incentive to general practitioners to save money.The effects of these two initiatives need to be properly compared and evaluated. In this paper we report some results from a study designed to evaluate the impact of the NHS reforms on general practices in the Oxford region. We have collected data from first wave fundholding practices and non-fundholding practices in the year before and the year after the 1991 reorganisation to measure the effect of the NHS reforms on outpatient referral rates, inpatient admissions, prescribing patterns, and practice based facilities. This paper reports the general practitioners' prescribing patterns and costs.
Objective-To compare outpatient referral patterns in fundholding and non-fundholding practices before and after the implementation of the NHS reforms in April 1991.
Objective-To compare outpatient referral patterns in fundholding and non-fundholding practices before and after the NHS reforms in April 1991.
Objectives-To observe changes in prescribing practice that occurred after the introduction of fundholding in first wave practices and to contrast these with changes occurring in similar nonfundholding practices.Design-Prospective observational study. Setting-Oxford region fundholding study. Subjects-Eight first wave fundholding practices and five practices that were not interested in fundholding in 1990-1, which were similar in terms of practice size, training status, locality, and urban rural mix. Three of the fundholding and none of the non-fundholding practices were dispensing practices.Main outcome measures-Changes in prescribing practice as measured by net cost per prescribing unit, cost per item, number of items prescribed, and substitution rates for generic drugs three years after the introduction of fundholding. Data for fundholding practices were analysed separately according to whether they were dispensing or nondispensing practices.Results-Prescribing costs rose by a third or more in all types of practice. The patterns of change observed in this cohort after one year offundholding were reversed. No evidence existed that fundholding had controlled prescribing costs among nondispensing fundholders; costs among dispensing fimdholders rose least, but the differences were small compared with the overall increase in costs.Conclusions-Early reports of the effectiveness of fundholding in curbing prescribing costs have not been confirmed in this longer term study. IntroductionThe 1991 NHS reforms were introduced to address the problem of escalating NHS costs; prescribing costs constituted an important component of this problem.' In the reforms, general practice fundholders were
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