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Biomedical subjects

B Leese

Publications and source records attributed to B Leese.

At least 19 recordsLinked to original sources
PubMed1999

The information requirements of total purchasing projects. Implications for primary care groups.

To successfully purchase, commission and manage health services at the primary care level requires accurate, reliable, up-to-date and appropriate information for use by trusts, health authorities, and by the soon to be operational primary care groups. The national total purchasing evaluation has provided evidence which will be relevant to primary care groups, particularly in the areas of information technology (IT) and access to information. Progress in developing independent purchasing by total purchasers was slower than anticipated because of the large number of factors which had to be taken into account, of which IT and information were just two. Accurate and timely information will be crucial for primary care groups if they are to move from level 1 to level 4 without undue delay.

Budgets↗
PubMed1998

Cost-effectiveness of a new treatment for somatized mental disorder taught to GPs.

BACKGROUND: Patients with mental disorder presenting with medically unexplained symptoms (somatized mental disorder) are difficult to treat and consume a lot of health care. OBJECTIVES: The aim of the study was to examine the cost-effectiveness of a training package for somatized mental disorder delivered by GPs. METHODS: The study design was a prospective, before- and after-training study of different cohorts of patients attending eight GPs, acting as their own controls. Cost-effectiveness analysis was estimated using changes in case level on a self-rated psychiatric symptom questionnaire (GHQ-12) and direct health costs between the index consultation and 3 months later. RESULTS: There were 103 and 112 patients with somatized mental disorder in the before and after training cohorts, respectively. After training, costs of referrals outside the primary care team decreased significantly by 23%, with little overall change in primary care costs. Total direct health care costs, including training, were reduced by 15%. After training, an extra 17 patients were successfully treated (no longer GHQ-12 cases) at 3 months. The marginal cost-effectiveness per extra successfully treated patient was pound sterling 325 and the cost per successfully treated case was 69% of the cost of the GP's usual treatment. CONCLUSIONS: Training GPs with the reattribution training package appears to be extremely cost-effective.

Cost-Benefit Analysis↗
PubMed1998

General practitioner turnover and migration in England 1990-94.

BACKGROUND: In tandem with fears about a GP workforce crisis, increasing attention is being focused on the supply and distribution of primary care services: on general practitioners in particular. Differential turnover and migration across health authority boundaries could lead to a maldistribution of GPs, yet comprehensive studies of GP turnover are non-existent. AIM: To quantify general practitioner (GP) turnover and migration in England from 1990 to 1994. METHOD: Yearly data from 1 October 1990 to 1 October 1994 were collected on GPs in England practising full time, including average yearly turnover, rates of entry to and exit from general practice, and net migration among GPs. All were calculated at the family health service authority (now the new health authorities) level. RESULTS: Average yearly GP turnover ranges from 2.9% in Shropshire to 7.8% in Kensington, Chelsea and Westminster; turnover is associated with deprivation and high-need areas. Migration of GPs across health authority borders was rare. Entry and exit rates were also positively related to measures of deprivation and need. Relatively underprovided health authorities lost 23 GPs over the study period as a result of migration; relatively overprovided ones gained three. CONCLUSION: Turnover is driven primarily by exits from general practice and is related to deprivation and high need. Retention appears to be the main problem in ensuring an adequate GP supply in relatively deprived and underprovided health authorities.

England↗
PubMed1997

Primary care. Burden of proof.

Evidence that the shift of services from secondary to primary care is creating extra work for GPs is limited. A study showed that it is possible to quantify additional workload for GPs, but that certain aspects, such as measuring the time input, remain problematic. Future research needs to agree workload definitions, employ sensitive measures other than consultation rates, and distinguish between workload in practices and that of individual practitioners.

England↗
PubMed1997

Recruitment, retention, and time commitment change of general practitioners in England and Wales, 1990-4: a retrospective study.

OBJECTIVES: To describe the recruitment and retention of general practitioners and changes in their time commitment from 1 October 1990 to 1 October 1994. DESIGN: Retrospective analysis of yearly data. SETTING: England and Wales. SUBJECTS: General practitioners in unrestricted practice. MAIN OUTCOME MEASURES: Numbers of general practitioners moving into and out of general practice; proportion of general practitioners practising less than full time; proportion of general practitioners having unchanged time commitment over the study period; and proportion of general practitioners leaving general practice in 1991 who were subsequently practising in 1994. RESULTS: Numbers of general practitioners entering general practice (1565 in 1990, 1400 in 1994) fell over the study period as did the numbers leaving general practice (1488 in 1990, 1115 in 1994). The net effect was an increase in both the total and full time equivalent general practitioners practising from 1 October 1990 (26,757 full time equivalents) to 1 October 1994 (27,063 full time equivalents). Numbers of general practitioners practising full time were decreasing whereas part time practice was increasing; women were more likely to practise part time. 35.5% (43/121) of women practising full time and 17.8% (24/135) of men practising full time who left practice in 1991 were practising again in 1994. CONCLUSION: Simply using total numbers of general practitioners or net increase to describe workforce trends masks much movement in and out of general practice and between differing time commitments. Recruitment and retention issues need to be separated if reasonable policies are to be developed to assure the necessary general practitioner workforce for a primary care led NHS.

Adult↗
PubMed1997

What will a primary care led NHS mean for GP workload? The problem of the lack of an evidence base.

Ongoing negotiations on the general practitioner contract raise the question of remunerating general practitioners for increased workload resulting from the shift from secondary to primary care. A review of the literature shows that there is little evidence on whether a shift of services from secondary to primary care is responsible for general practitioners' increased workload, and scope for making generalisations is limited. The implication is that general practitioners have little more than anecdotal evidence to support their claims of greatly increased workloads, and there is insufficient evidence to make informed decisions about remunerating general practitioners for the extra work resulting from the changes. Lack of evidence does not, however, mean that there is no problem with workload. It will be increasingly important to identify mechanisms for ensuring that resources follow workload.

Family Practice↗
PubMed1997

Partnership changes in English general practice from 1990 to 1994.

BACKGROUND: The objective of this study was to quantify the rate of partnership change among general practitioners (GPs) in the National Health Service (NHS) in England from 1990 to 1994. METHODS: Time series data on English GPs were analysed on 1 October for the years 1990-1994. The main outcome measures include: (1) proportion of GPs practising in an unchanged partnership from 1 October 1990 to 1 October 1994; (2) proportion of partnerships that were unchanged over the study period; (3) the average yearly rate of partnership changes for England and per Family Health Service Authority (FHSA), calculated using both the individual GP and the practice as the unit of analysis. RESULTS: A total of 6532 (27.1 per cent) of the 24,107 unrestricted GPs practising full time on 1 October 1990 were still practising in the identical partnership on 1 October 1994; 3539 (35.7 per cent) of the 9918 practices in England were unchanged over the same period. The average yearly partnership change rate for all England was 23.1 per cent when calculated using the individual GP as the unit of analysis, and 23.4 per cent when calculated using the practice as the unit of analysis. There is threefold variation found in the average yearly partnership change rate by FHSA, with similar rank ordering of health authorities when using either the individual GP or practice as unit of analysis. CONCLUSIONS: Changes in partnerships are commonplace. The possible influence of such changes on primary care in the NHS should be further investigated.

England↗
PubMed1997

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

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.

Ambulatory Care Facilities↗
PubMed1997

Specialist outreach clinics in general practice: what do they offer?

BACKGROUND: Specialist outreach clinics in general practice, in which hospital-based specialists hold outpatient clinics in general practitioners' (GPs) surgeries, are one example of a shift in services from secondary to primary care. AIM: To describe specialist outreach clinics held in fundholding general practices in two specialties from the perspective of patients, GPs, and consultants, and to estimate the comparative costs of these outreach clinics and equivalent hospital outpatient clinics. METHOD: Data were collected from single outreach sessions in fundholding practices and single outpatient clinics held by three dermatologists and three orthopaedic surgeons. Patients attending the outreach and outpatient clinics, GPs from practices in which the outreach clinics were held, and the consultants all completed questionnaires. Managers in general practice and hospital finance departments supplied data for the estimation of costs. RESULTS: Initial patient questionnaires were completed by 83 (86%) outreach patients and 81 (75%) outpatients. The specialist outreach clinics sampled provided few opportunities for increased interaction between specialists and GPs. Specialists were concerned about the travelling time resulting from their involvement in outreach clinics. Waiting times for first appointments were shorter in some outreach clinics than in outpatient clinics. However, patients were less concerned about the location of their consultation with the specialist than they were about the interpersonal aspects of the consultation. There was some evidence of a difference in casemix between the dermatology patients seen at outreach and those seen at outpatient clinics, which confounded the comparison of total costs associated with the two types of clinic. However, when treatment and overhead costs were excluded, the marginal cost per patient was greater in outreach clinics than in hospital clinics for both specialties studied. CONCLUSION: The study suggests that a cautious approach should be taken to further development of outreach clinics in the two specialties studied because the benefits of outreach clinics to patients, GPs and consultants may be modest, and their higher cost means that they are unlikely to be cost-effective.

Ambulatory Care Facilities↗
PubMed1996

Changes in general practice organization: survey of general practitioners' views on the 1990 contract and fundholding.

BACKGROUND: General practitioners' views on two major changes in the organization of general practice--the 1990 contract for general practitioners and fundholding, introduced in 1991--have not been researched in any great detail. AIM: A study in 1993 sought to investigate the views of general practitioners from group practices and of single-handed general practitioners, in family health services authority areas with different socioeconomic characteristics, on the 1990 contract for general practitioners, fundholding and the effects of these two changes in general practice organization. METHOD: One general practitioner partner from each of 323 group practices in six family health services authority areas of England was invited for interview and 142 single-handed general practitioners in the study areas were sent a postal questionnaire. The interview and questionnaire sought general practitioners' views on the 1990 contract and fundholding, reasons for their opinions, and views on the effects of these reforms on workload and the quality of service. Other information was recorded on fundholding status, workload pressures, outreach clinics, budget surpluses, retirement plans, and opinions on a salaried service. RESULTS: A total of 260 group practice general practitioners (80%) participated in the study and 80 single-handed general practitioners (56%) returned questionnaires, 78 of which could be analysed. Over half of all respondents were opposed or strongly opposed to both the 1990 contract and fundholding. However, despite this opposition, a sizeable minority of group practice practitioners (38%) agreed that the quality of services provided had improved or considerably improved since the 1990 contract. Workload appeared to have increased, with the proportion of respondents who reported being always under pressure increasing from 12% in 1987 to 41% in 1993. All but one respondent considered administration to have increased. Some respondents were considering early retirement. One of the solutions proposed to alleviate problems in inner city general practice, a salaried service, received little support, even from those general practitioners working in areas which might be expected to benefit. CONCLUSION: Dissatisfaction of general practitioners with the National Health Service reforms was expressed in continued opposition, in concerns about workload and levels of administration, and in a desire to retire early. Suitable ways of improving general practitioner morale must be sought.

Attitude of Health Personnel↗
PubMed1995

Change in general practice and its effects on service provision in areas with different socioeconomic characteristics.

OBJECTIVE: To investigate the changes in the structure and service provision of general practice in areas with different socioeconomic characteristics. DESIGN: Interview survey; postal questionnaire. SETTING: 260 group and 80 singlehanded general practices in six family health services authorities in England. MAIN OUTCOME MEASURES: Changes in computerisation, premises, staffing, incomes, and service provision since the introduction of the 1990 contract, including comparison with data from a study in 1987. RESULTS: In 1993, 94% (245) of group practices were computerised compared with 38% in 1987, and 35% (90) of practices had used the cost rent scheme since 1987. Practice managers were employed in 88% (228) of group practices, and practice nurses in 96% (249) (61% and 60% respectively in 1987). Diabetes and asthma programmes were generally more common in the more affluent areas than elsewhere. A minority of practices (27% (9/33)) in the London inner city area achieved the higher target level for cervical smear testing, compared with 88% (230) overall. A similar trend was apparent for childhood immunisation. Perceived workload increased sharply between 1987 and 1993. Differences in the mean net incomes of general practitioners between areas were much lower than in 1987. Singlehanded practices generally had more problems than group practices in improving service provision. CONCLUSIONS: Practices in all areas have shown a strong response to the new incentives. The evidence suggests, however, that generally the urban and inner city practices still lag behind practices in rural and suburban areas in terms of practice structure and service provision.

Contract Services↗
PubMed1995

Family doctors and change in practice strategy since 1986.

OBJECTIVES: To investigate the changes in practice strategy that have taken place since 1986. DESIGN: Comparison of practices in 1986 and 1992. SETTING: 93% of group practices (26 practices) in a single family health services authority. MAIN OUTCOME MEASURES: Changes in staffing, premises, equipment, clinic services, and incomes between 1986 and 1992. RESULTS: In 1986, 28% of practices employed a nurse; in 1992, 92% did so. Between 1986 and 1992, 14 cost-rent schemes costing more than 10,000 pounds had been started. Certain practices, designated innovators, were more likely to possess specified items of equipment than other practices. Computer ownership was widespread: 77% of practices had a computer, compared with 36% in 1986. In 1992, 16 practices had a manager, compared with 10 in 1986. Clinic services provided by more than half of practices were well established services (antenatal, for example), new services for which a payment had been introduced (such as diabetes, asthma, minor surgery), or the more readily provided "new" clinic services (diet, smoking cessation). Gross income increased, but so did practice costs, especially for innovators. Practices in the more affluent area of the family health services authority were still more likely to invest in their premises and staff, and to provide more services than those in the declining area. In the more affluent area, practices had higher costs but also higher incomes. CONCLUSION: Between 1986 and 1992, practices in this area invested heavily in equipment and services, but differences remain, depending on the location of the practice. Investment has increased, particularly in the more deprived part of the area, so that the inconsistency in standards has been much reduced. Practice incomes have risen, but so also have workload and costs.

Aged↗
PubMed1995

Communication aids for the speech impaired. Cost and quality-of-life outcomes of assessment programs provided by specialist Communication Aids Centers in the United Kingdom.

An evaluation was conducted of the approaches, costs, and quality-of-life outcomes associated with communication aid assessment programs for the speech-impaired provided by specialist Communication Aids Centres (CACs) in the United Kingdom. The average costs of CAC assessment programs was 410 pounds per client, which is not excessive. There was evidence of moderate quality-of-life benefits from clients' use of the recommended aids.

Adolescent↗
PubMed1995

Economic evaluations of type II diabetes.

Economic analyses, which can be either descriptive or evaluative, can help to ensure that healthcare resources are used effectively. Most studies of diabetes mellitus have been descriptive and have used the cost-of-illness methodology, which estimates the burden of a disease to society. This method provides an estimate of the direct, indirect and intangible costs of a disease or illness. Methodological problems are mainly related to the measurement of indirect costs and even to whether they should be included at all. Existing studies that have measured the direct costs of non-insulin-dependent diabetes mellitus (NIDDM, type II diabetes) serve to highlight the difficulties involved in comparing costs between countries with different healthcare systems, and the importance of defining the study population and the sources of the costs. There is a lack of recent data on the costs of treating people who have diabetes.

Diabetes Mellitus, Type 2↗
PubMed1995

Diabetes mellitus and the St Vincent Declaration. The economic implications.

Diabetes mellitus imposes significant costs both on individuals and on healthcare delivery systems. Chronic diseases such as diabetes mellitus have lifetime costs, and so resources spent on interventions now may not bring benefits, in terms of reduced complications, for many years. In Europe, the St Vincent Declaration, which includes targets for the reduction of diabetes mellitus-related complications, is an important initiative set up to address quality and education issues relevant to people with diabetes mellitus. The Declaration is to be welcomed as focusing attention on diabetes mellitus, and its implementation may lead to a reduction in healthcare expenditure on complications in future years. The aims of the St Vincent Declaration are to set goals and 5-year targets to improve quality of life and life expectancy for people with diabetes mellitus and to reduce the serious complications associated with the disease. Achievement of these targets will depend on good organisation and management of services to people with diabetes mellitus, but the aims are a clear signal that the importance of prevention and education have been recognised. A major barrier to the implementation of the Declaration is financial. If more people are diagnosed and treated, more services will be required. This will incur costs, although future benefits will be gained in terms of a reduction in complications.

Age Factors↗
PubMed1994

The costs of managing severe cancer pain and potential savings from transdermal administration.

The economic evaluation of any new or existing therapy should include a comprehensive appraisal of costs. When evaluating pharmaceutical interventions, it is inappropriate to identify the purchase price alone. Other relevant costs include the costs of time of doctors, nurses and other personnel in administering and monitoring the effects of the therapy, and the costs of treating any side-effects. This study estimates direct National Health Service (NHS) costs in the U.K. of current medical practice in managing severe cancer pain, using a review of the published literature and constructing a cost analysis for four 'typical' patients. Costs are estimated for patients with severe cancer pain in a hospital and an ambulatory setting, with oral and subcutaneous routes of drug administration. The study includes costs of drugs, supplies, equipment and personnel time. The results demonstrate the importance of personnel time costs, and potential cost savings which could result from the use of transdermally administered opioid analgesics.

Administration, Cutaneous↗