The cornerstone of Labour's 'New NHS': reforming primary care

Two remarkable aspects of the Thatcher ‘internal market’ reforms of the NHS were the focus on creating a market for hospital services and the way in which primary care was treated almost peripherally in the 1989 White Paper (Department of Health 1989a). The 1991 NHS reforms introduced general practitioner (GP) fundholding almost as an afterthought, and the revision of the GP contract in 1990 Paper (Department of Health 1989b) was conducted separately from the implementation of other health care reforms. In contrast the principal focus of Labour’s ‘new NHS’ reform is primary care (Department of Health 1997). The intention of the government is both to improve the efficiency and equity of primary care provision and to develop Primary Care Groups and Primary Care Trusts which both provide care efficiently and act as agents who purchase secondary and tertiary care on behalf of patients. This is an ambitious agenda. This paper explores the policy context of Primary Care Groups in sections 1 and 2, describes and appraises the government proposals in section 3, and identifies major issues involved in the implementation of change in section 4.fundholding, rationing

From the Shadow of Reagan: George Bush and the End of the Cold War.

George Bush entered the presidency constantly compared and contrasted with his predecessor, Ronald Reagan. Lacking Reagan\u27s eloquence and adept use of the media, Bush was lambasted by the press as Reagan\u27s lapdog and labeled a wimp. The press pushed Bush to establish themes to match policy goals and to use the bully pulpit to lead the national debate on issues. His refusal prompted journalists to characterize the Bush presidency as lacking an agenda. Reagan\u27s success with the media and Bush\u27s failure have produced a misconception about the successes and failures of each president\u27s policies. Thus, the period usually is referred to as the Reagan-Bush years, indicating that Bush\u27s term can best be explained as Reagan\u27s third term. This distinction is partly a result of the misconception that the Cold War was basically over by the end of the Reagan administration and that Bush merely signed agreements Reagan had already negotiated. This ignores the instability of the Soviet Union, as well as the potentially explosive situation in Central and Eastern Europe, that still existed when Reagan left office. This dissertation explores how differences between Ronald Reagan and George Bush affected the end of the Cold War, examining Bush\u27s use of the media, the restructuring of the National Security Council, the subsequent fundamental shift in foreign policy approach to the Soviet Union, and the use of personal diplomacy in the reunification of Germany and the breakup of the Soviet Union. Bush led a transition: a transition from the Cold War to a post-Cold War world. Bush\u27s diplomatic strengths proved as great as his media skills and domestic agenda were weak. Bush and his advisors managed the end of the Cold War, helping it end not with a bang, but a peaceful whimper. This dissertation is funded by a Peter and Edith O\u27Donnell Grant from the George Bush Presidential Library Foundation and is based on interviews with Bush administration officials such as Brent Scowcroft, James Baker, Colin Powell, Marlin Fitzwater, and Jack Matlock, plus many recently declassified documents

Non-steroidal anti-inflammatory drugs: a suitable case for treatment?

Non-steroidal anti-inflammatory drugs (NSAIDs) are used widely throughout the world to relieve the symptoms of musculoskeletal disorders, in particular osteoarthritis and rheumatoid arthritis. These drugs produce significant side effects, including gastro-intestinal ulceration and the associated complications of perforation and bleeding. The relative toxicity of competing forms of branded and generic NSAID scary considerably. Their cost also varies considerably, often with the relatively more toxic formulations being more expensive. These characteristics, differing toxicity and cost, offer the possibility of reducing both adverse effects to patients and pharmaceutical expenditure if doctors’ behaviour can be changed. A tentative exploration of alternative patterns of NSAID use demonstrates that it may be possible to reduce expenditure below the 1994 level of around £175 million and reduce adverse events. An illustrative model shows that if prescribing was reduced by 25%, average dose reduced by 10% and patients switched to less toxic NSAIDS, up to £86 million could be saved, the number of serious adverse events per year reduced by 189 and the number of gastrointestinal complications reduced by 127. Such results may be achieved without reductions in the quality of life of patients using these drugs. Available clinical and economic information about NSAIDs is limited, with numerous published studies of poor quality which corrupt the knowledge base. Despite these problems there appears to be enough evidence to indicate that expenditure on NSAIDs could be considerably reduced and significant adverse effects could be avoided if general practitioners can be persuaded to change their prescribing behaviour. Inefficient and inappropriate prescribing of these often beneficial but sometimes dangerous drugs appears to be wasting scarce NHS resources and harming patients.NSAIDs, prophylaxis

Will the new GP contract lead to cost effective medical practice?

Since the mid 1980s the imprecise nature of the GPs’ contract and the lack of knowledge about what services were provided by general practitioners has created much argument and radical changes in the terms and conditions in the GPs’ contract. The old contract required a general practitioner to render those services to her patients which were normally provided by GPs. This “John Wayne contract” – a GP’s got to do what a GP’s got to do – permitted much discretion which some policy makers welcomed as it enabled them to “advise” the extension of GP practice and regard that as a “normal” service. However the lack of precision such Departmental advice and general ignorance about what GPs did was inevitably challenged by demands for greater accountability and “value for money”. Furthermore some research results – for instance a survey of GP working hours in Manchester and Salford – implied that some GPs might be interpreting discretion as an invitation to consume leisure and apparently work quite short working weeks. Against this background of ignorance about what GPs do and rhetoric from the British Medical Association that asserted, in the absence of appropriate knowledge, that general practice was cost effective, the Government formulated a new contract for GPs which it imposed on the profession from April 1 1990. The purpose of the new GP contract is to identify “core services” which must be provided by all practices and to reward performance by financial incentives. The purpose of this paper is to describe the new contract and analyse critically the cost effectiveness of the core services it requires GPs to offer their patients. The contract requires GPs to provide for remuneration: i) health checks within 28 days of joining a GP’s list for all new patients ii) health checks for all patients aged 16 to 74 who have not seen their general practitioner in the last 3 years or have not had a health check in the last 12 months iii) an annual consultation and a domiciliary visit for all patients aged over 75 years iv) cervical cytology every 5 ½ years for women aged 25 to 64 years of age v) immunisation and vaccination services for children vi) health promotion clinics In addition GPs can provide child health surveillance and minor surgery for additional fees. Is it cost effective to provide these services? This paper reviews the available scientific evidence and concludes that the cost effectiveness of many of the services which GPs are now required to provide is unproven. It is possible that GPs are being induced to practice inefficiently. Such an assertion needs to be tested by careful evaluation of these services. Indeed it would have been judicious to develop the core services of the GPs contract in the light of careful evaluation rather than system-wide reform of unknown efficiency. However, given the contract is in place it is essential to evaluate these new services to determine their effects on patients’ health. Such evaluation is complex and produces new knowledge slowly but it will at least facilities the adjustment of the new contract in a way which is demonstrably cost effective. Like many of the Government’s health care reforms, the new GP contract is an attempt to address problems, such as the imprecise nature of the GPs terms and conditions of employment, with a radical and unproven new policy. Such “shots in the dark” should be recognised as such and evaluated to inform future policy choices. Without such evaluation the “next” reform of the GP contract may be based on hope rather than knowledge in the formulation of health care reforms aimed at using scarce NHS resources more efficiently.General practice, GP contract

Economic aspects of addiction control policies

This is a follow-up paper arising from a World Health Organisation meeting which was held in Disley (near Manchester) in England in September 1984. The original paper for that conference (Maynard (1984)) was revised as a result of comments perceived at the Disley meeting and circulated to participants in a revised form (Maynard (1986)). As a result of comments received at Disley and subsequently this paper has been written to provide the present overview of the economic aspects of addiction control policies.tobacco, alcohol, drugs, addiction

Economic aspects of hospital acquired infection

Despite the decline in rates of hospital acquired infections (HAI) since the 1950s, the level remains high and a significant proportion of them are unavoidable. International studies show that between 5.9 and 13.5 patients in every hundred are affected by hospital acquired infections, most frequently of the urinary tract, of the lower respiratory tract and in surgical wounds. The evidence from the UK is similar to that from the rest of the world e.g. one study (Meers et al, 1981) found a UK prevalence rate of 9.2 infections per hundred patients. These rates appear to have been largely unchanged for two decades despite evidence that perhaps as many as 1 in 3 infections could be avoided. To reduce the costs and impaired quality of life associated with these infections it is necessary to improve surveillance methods, in particular add an economic (cost) component to identify the resource consequences of increased length of stay and increased medication, and identify cost effective methods of reducing HAIs. It is estimated that hospital acquired infections in England cost the NHS nearly £115 million in 1987. With improved policies of demonstrated cost effectiveness, such as better hygiene and the selective use of prophylactic drugs, perhaps as much as £36 million of these costs to the NHS count be avoided. This would “free up” NHS resources for other patients wishing for beneficial care and would avoid much misery and reduced quality of life for patients unfortunate enough to acquire infections in hospitals.hospital acquired infections

Functional dyspepsia: a review of scientific and policy issues

Functional dyspepsia can be defined as chronic or recurrent upper abdominal pain or discomfort, for which no focal lesion or systemic disease can be found. It is a common complaint seen by physicians and, although it does not cause death or severe disability in the majority of cases, represents an important and costly health problem. It is estimated that each year the total pharmaceutical cost for function dyspepsia ranges from £4.88 million to £41.84 million in England and Wales. The effect of treatment with various agents for function dyspepsia has not been convincingly evaluated, mainly because of lack of validated outcome measures and heterogeneity in patients. However, evidence from clinical trials suggests that prokinetic agents may help to improve symptoms in the short term among patients with dysmotility-like dyspepsia. The role of anti-secretory agents and treatment of Helicobacter pylori is less clear. Antacids do not relieve symptoms of functional dyspepsia more effectively than placebo. Due to great heterogeneity in patients with functional dyspepsia and the uncertainty of treatment effects, a variation in clinical management of dyspepsia is to be expected. Because there is a large pool of patients with dyspepsia, the potential growth of demand for investigation and treatment services for dyspepsia is great.dyspepsia, pharmaceuticals

Equity in primary care

The allocation of funding and the distribution of the workforce in primary care is very unequal in England. Whilst hospital resources have been allocated in relation to a weighted capitation formula in each of the component parts of the United Kingdom since the late 1970s, there have been minimal efforts to equalise the distribution of general practitioners and the budgets which finance them and the services they provide. The purpose of this paper is to illustrate both the existing inequalities in the distribution of primary care funding and the impact of alternative, simplistic but illustrative formulae which could be used as a basis for achieving more equitable funding of primary care in England. These calculations show hat a weighted capitation formula would have a significant impact on the old fourteen regions of the English NHS with major losses in funding and staffing levels in the South, particularly the South West, and major gains in the North of England. For example, using one of the models, the South West would have lost 14 per cent and the Northern region gained over 9% of FHSA expenditure with ‘RAWPed’ primary care budgets in 1990-91. The pursuit of greater equity in primary care funding may require a radical change in the GP contract, perhaps with it being replaced by franchises for primary care which are let to multi-disciplinary teams of providers. Such change requires careful evaluation to ensure that the hospital gatekeeper role of the GP is maintained and the incentives to ensure efficient use of scarce primary care resources are improved.RAWP, weighting, FHSA