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PubMed1999

Barriers to improving endodontic care: the views of NHS practitioners.

AIMS: Concerns have been expressed about the technical quality of NHS endodontic treatment. Bringing performance into line with guidelines for good practice needs to be underpinned by an understanding of barriers to compliance. To this end, our research involved an exploratory investigation of the factors influencing the behaviour of general dental practitioners in their practice of endodontics. MATERIALS AND METHODS: Subjects 12 dental practitioners, representative of varying levels of professional experience and status, and of compliance with good practice guidelines. Data collection In-depth interviews, following a topic guide. Analysis Identification, abstraction and charting of major themes. FINDINGS: Informants' responses suggested that general dental practitioners' endodontic practice is influenced by a complex web of factors. A key barrier to high quality treatment is the NHS remuneration scheme. Undergraduate and postgraduate education and training are also highly influential on practice. Dentists reported employing a range of strategies to manage the time-cost tensions imposed by the remuneration system. Perceived deficiencies in the content and delivery of postgraduate training were highlighted by our informants. CONCLUSIONS: There was a perception among our informants that the NHS fee structure needs to be revised. Their views suggest that a system which rewards quality rather than volume may be more appropriate, but, we believe, such a system would need to take into account efficiency as well as effectiveness. Modification of the current system of postgraduate training in endodontics is also indicated by the views expressed in the interviews. From the diversity of views and from a critical review of the literature, we conclude that flexibility is the key note in changing practice, with no single strategy likely to be universally appropriate.

Attitude of Health Personnel↗
PubMed2005

Management of dental trauma in primary care: a postal survey of general dental practitioners.

OBJECTIVES: To determine the self-perceived knowledge and attitudes of general dental practitioners (GDPs) concerning management of dental trauma in primary care. To identify potential barriers to the management of dental trauma in primary care. DESIGN AND SETTING: A self-completion postal questionnaire survey of 417 GDPs in six local health authority districts in northeast England. MAIN OUTCOME MEASURES: Likert scale responses to 20 statements designed to test self-perceived knowledge and attitudes. Following descriptive statistical analysis. Factor analysis with principle components analysis was undertaken to identify areas of correlation in questionnaire responses, followed by Chi squared test, Spearman's Rank Correlation and analysis of variance (ANOVA) to measure association between variables. RESULTS: The response rate was 74%. Enamel and dentine fractures were the most common injury, with 45% of GDPs responding seeing more than 10 cases of dental trauma in the preceding year and 53% of respondents seeing one to three cases of complicated crown fracture. Seventy-eight per cent believed that NHS remuneration was inadequate, but only 8% would refer patients with dental trauma to secondary care for this reason. Half of the GDPs believed that trauma could be treated more effectively in practice if NHS payments were greater. GDPs were significantly more likely to agree with this statement if they had previously undertaken a postgraduate course in the treatment of dental trauma (p=0.002). Single handed GDPs were statistically significantly more likely to agree with the statements 'I would not treat dental trauma cases at my practice because the NHS payment is inadequate' (p=0.008) and 'Treating dental trauma at my practice requires too much of my clinical time to be worthwhile' (p=0.002). Ninety-six per cent of GDPs disagreed that treatment of dental trauma rested solely within secondary care. Ninety-six per cent of GDPs agreed that they had a responsibility to provide initial emergency treatment for trauma patients prior to referral. Eighty-eight per cent of GDPs felt that aids to management would be useful. CONCLUSIONS: Although GDPs believed that financial remuneration was inadequate, this did not prevent them treating trauma cases. They strongly agreed that they had responsibility for the management of dental trauma in primary care and that they believed trauma could be treated more effectively in practice if payment was greater. Time constraints were perceived as a barrier to long-term management of complex trauma cases in primary care. GDPs would welcome the use of management aids.

Analysis of Variance↗
PubMed2006

Smoking cessation as a dental intervention--views of the profession.

OBJECTIVE: To undertake a questionnaire-based survey to determine the attitudes and activities of dental professionals in primary care in the Northern Deanery of the UK in relation to providing smoking cessation advice. METHODS: Questionnaires for dentists, hygienists and dental nurses were sent to hygienists to distribute to other members of the team. The information collected included: smoking status of the professionals and the practice; roles of the dental team in giving smoking cessation advice; levels of training received; and potential barriers to giving this brief intervention. RESULTS: Over 90% of practices were smoke-free environments and significantly more dental nurses (23%) were smokers compared to dentists (10%) and hygienists (7%) (p<0.01). The majority of dentists and hygienists enquired about smoking status of their patients and all three groups believed that hygienists and dentists should offer brief smoking cessation advice. Potential barriers to delivering smoking cessation advice were identified: lack of remuneration; lack of time; and lack of training. CONCLUSION: Dental teams in primary care are aware of the importance of offering smoking cessation advice and, with further training and appropriate remuneration, could guide many of their patients who smoke to successful quit attempts.

Analysis of Variance↗
PubMed2001

Medical specialists servicing the New England Health Area of New South Wales.

There is increasing emphasis on research, policy and program activity to recruit and retain rural general practitioners in Australia. In contrast, until recently, there has been less attention paid to specific policies and programs relating to rural medical specialists. The New England Area Health Service experiences a shortage of general practitioners and specialists. This study surveyed this region's specialist workforce in 1998 and aimed to identify recruitment and retention issues affecting specialist rural workforce planning in north-west New South Wales. All 91 medical specialists practising in this rural area were surveyed. Seventy-one completed survey forms were received, representing a response rate of 78%. Positive features of rural specialist practice included the rural lifestyle, professional autonomy and available medical infrastructure. Negative features included professional isolation, long working hours, lack of locum relief and inadequate remuneration. Almost all surveyed specialists believe that there is a shortage of specialists servicing the New England Health Area. The major deficits in specialty areas identified relate to: dermatology; ear, nose and throat; obstetrics and gynaecology; orthopaedics; paediatrics; and urology. Recruiting and retaining medical specialists would be facilitated by improvements in the following areas: specialist resources and facilities, specialist locum scheme, remuneration and professional support. Effective strategies need to take account of local circumstances and be based on discussions involving all local key stakeholders.

Female↗
PubMed2003

Operative experience in the Victorian general surgical training programme.

BACKGROUND: The Royal Australasian College of Surgeons recommends minimum operative and endoscopy training requirements for advanced trainees in general surgery. This study examines the influences of trainee seniority, geographical location of surgical rotation, and surgeons' remuneration arrangements on the operative and endoscopy experiences of general surgical trainees in Victoria. METHODS: Trainee log books covering two 6-month training periods in the year 2001 were analysed for depth and breadth of reported operative and endoscopy experience. RESULTS: A total of 81 trainee log books was reviewed. Senior trainees were significantly more likely to have a higher primary operator experience. Total operative caseload and primary operator experience, in terms of major operative cases, were greater in rural rotations. Endoscopy experience was significantly greater in rural rotations. Operative exposure to gynaecological, laparoscopic, orthopaedic, paediatric and plastic surgical procedures was significantly greater in rural rotations. Surgeons' remuneration arrangements were not significantly related to trainee operative experience. CONCLUSIONS: Rural surgical rotations enhance the depth and breadth of operative experience of Victorian general surgical registrars, allowing greater exposure to subspecialty surgical procedures.

Australia↗
PubMed1999

Determination of reasons for cessation of participation in serial plasmapheresis programs.

BACKGROUND: An earlier retrospective review of records of over 500 remunerated donors participating in plasmapheresis programs at various levels of frequency for 10 or more years showed that there were no significant differences in mean values for total protein, microhematocrit, body weight, and individual serum proteins, regardless of the number of annualized donations for each of four frequency groups. Although these data demonstrated that donors undergoing serial plasmapheresis for 10 or more years were able to successfully continue in such programs, the review did not include information relative to individuals who had discontinued their participation. The current study investigated reasons that donors drop out of plasmapheresis programs. STUDY DESIGN AND METHODS: Donors who had successfully undergone plasmapheresis at least 20 times within a recent 6-month period but who had failed to appear for at least 30 days subsequent to their last donation were defined as potential subjects for the study. Staff members at the participating center contacted the donors, inviting them to return to the center to participate in a survey. Donors were also asked for a blood sample upon their arrival at the plasma center; samples were tested for total and various serum proteins. RESULTS: A total of 409 eligible subjects appeared at the centers for the survey, and 375 blood samples were analyzed for proteins. Survey responses indicated that the predominant reasons for an end to participation were socioeconomic in nature. Serum protein findings were compared to the most recent results obtained while the donors were active in the plasmapheresis program. Slightly higher mean serum protein findings were seen for samples collected on the survey date. CONCLUSION: A review of the aggregate responses obtained in the survey indicates that the predominant reasons that donors ceased to participate were not health-related: the remuneration was no longer needed, and work schedule conflicts, time constraints, and relocation were frequently cited.

Adult↗
PubMed1998

Treatment of toxic nodular goitres: Comparative costing of radioiodine therapy and surgery.

Cost accounting has shown that the volume of tissue to be treated is the decisive factor in determining the cost of radioiodine therapy (RAITh). In the case of large goitres, the costs of excision (5.185 DM) and radioiodine therapy (5.562 DM) are, to a large extent, equivalent. Under the 1993 regulations for radiation protection, RAITh was cost-effective for treatment of toxic multinodular goitres up to volumes of 57 ml. However, new maximum permissible levels of radioactivity on discharge from hospital (250 MBq iodine-131 residual activity) have raised this threshold volume to 90 ml. In Germany, remuneration for a goitre resection is calculated from standard charges for total treatment without any consideration of the size and spectrum of medical services offered by different clinics, while remuneration for RAITh comes from payments for basic and specific, departmental medical services. University clinics with departments of nuclear medicine have relatively high basic costs. In the first quarter of 1998, the length of hospitalisation after RAITh (for all indications combined) was 4.6 days in university hospitals in Germany. Owing to this shorter length of hospitalisation, the payments received in some clinics fell far short of the total costs of this treatment calculated by cost accounting.

Cost Control↗
PubMed2002

[Preparing for the G-DRG system: portfolio analysis of the hospitals in Saxony-Anhalt, Germany].

Diagnosis-Related Groups are scheduled for step-by-step introduction into the German hospital system. Initially DRG base rates will be specific to each hospital (i. e. in keeping with the present budget), but eventually (by 2007) a common base rate will be reached in each federal state. This development may have grave financial consequences for some hospitals where initial base rates are above average and hence likely to be reduced. Therefore, we grouped the remunerations paid by the AOK Saxony-Anhalt (i. e. the largest statutory health insurance company in this federal state) for a total of 308,495 hospital cases in fiscal year 2000 according to hospital and diagnoses, expressed them as a percentage difference from the average remuneration, and analysed them jointly with the average length of stay (LOS). We found considerable differences between hospitals in terms of the payments per case and the LOS, independent of the stratification of the cases. For example, Magdeburg University Clinical Centre registered hospitalisations that were short (below average) but expensive (well above average), hence there is less scope for further rationalization of the LOS in this hospital compared to others. Considerable adjustments will become necessary in due course when switching over from hospital-specific base rates to a common regional base rate.

Budgets↗
PubMedDate not supplied

[Bottom-up analysis of the case costs of stem cell transplantation and selected chemotherapies].

BACKGROUND: Up to now, reliable data has not been available on the actual costs of treating oncological patients. However, such data material is urgently required in view of the institution of the health service reform with the concomitant introduction of the G-DRG remuneration system. PATIENTS: The medical services and their costs for 66 patients comprising several stays in hospital, part-time hospitalization and outpatient visits to the clinic categorized "establishment of the diagnosis", "stem cell therapy (SCT)" and "chemotherapy" were recorded in parallel to treatment over a time period of three months. It was thus possible to relate a cost volume of 2.7 million euro to more than 2800 nursing days (full and partial hospitalization) and more than 500 outpatient visits. METHODS: All pertinent costs were collated with the various stays/movements of the patients over 100 calendar days. This was very largely possible thanks to a sophisticated costing and setting off of payments within the hospital on the part of the service providers in the hospital in direct allocation to patients and the third-party payers. Additionally, partial and full surveys as well as questionnaires enabling allocation to the individual case as far as possible, especially the staff requirement, were used. A breakdown of the costs in terms of the patient nursing days was only effected in marginal areas such as the "hotel function" or the general administrative costs. A further subdivision of the stays and movements as well as the phases of the stays applied to the service or the treatment progress above and beyond the areas of treatment. In the case of chemotherapy, a distinction was therefore made between "protocol blocks" and "stays due to complications" and in the case of SCT inter alia even individual phases such as "conditioning". RESULTS AND CONCLUSIONS: It is problematical to represent these patients within an DRG case flat rate system because of frequent and very divergent residence periods with regard to services and costs. The multiplicity of treatment sessions is manifested in the compact "establishment of the diagnosis" to determine a therapy protocol which entails very elaborate inpatient measures under hospitalization, in the expensive and individual "stays due to complications" which usually take place between the "chemotherapy blocks", and the expensive long-term care of the SCT patients after the end of the residence limit (GVD). Owing to the small and divergent numbers of cases in Germany (2000 new patients in 50 centers and 330 SCT per year) and per center, this problem cannot be dealt with by means of a quantity compensation argumentation, as is doubtless justified elsewhere. The actual individual case costs of oncological patients would be 166,72 euro; per outpatient contact and covered by 459,30 euro; per day of hospital care and 808,20 euro; per inpatient treatment day (admission plus discharge day calculated separately and comprised stem cell transplantation patients beyond the residence limit) is covered. The level of the currently applicable case flat rate payments for stem cell transplantations and heterologous donors, mismatched heterologous donors and family donors appear appropriate in relation to the GVD. (The true costs of all oncological patients would indeed be even higher if the GOA payment of the ILV did not only relate to a house-internal low pricing of the GOA scoring value, but would also relate to HLA typing, unpaid physician overtime and the costs of the study centers to the individual cases. From 2002, there will be changes consequent on the judgment of the European Court that stand-by is working time, so that more physicians must be employed and there are expensive changes in the infrastructure owing to the need for a GMP clean area laboratory to process stem cells according to the medical products law.) The indeterminate bound-aries between the three treatment categories place in question the dual financing by the Panel Doctor's Association and the health insurance funds and indicate that a total-sum remuneration appears appropriate.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2000

Relationship between achievement goal orientations and the perceived purposes of playing rugby union for professional and amateur players.

The recent professionalization of rugby union makes it an excellent achievement context in which to examine the relationship between achievement goal orientations and the perceived purposes of sport as a function of competitive standard. During the 1996-97 season, 73 professional and 106 amateur rugby players in England completed a series of questionnaires assessing their achievement goal orientations, beliefs about the purposes of rugby and demographic information. The results of a canonical correlation analysis revealed a conceptually coherent relationship between achievement goal orientations and purposes of rugby. Specifically, a high ego/moderate task orientation was positively related to fitness, aggression and financial remuneration as significant purposes of rugby. Professional players scored higher on those purposes of rugby related to aggression, financial remuneration and fitness, but lower on sportspersonship than amateur players. Professional players also reported higher task and ego goal orientations than amateur players. The findings are discussed in terms of the differences in lifestyle and motivation of professional and amateur rugby union players.

Achievement↗
PubMed1978

How much is Jack worth? A study of the work of anaesthetists' in the S.E. Thames Region.

A study of anaesthetists' work in the S.E. Thames Region has indicated that about three-quarters of actual working time is spent giving anaesthetics, the rest of the time being spent on activities outside the operating theatre. In addition, however, equal amounts of time to that spent working is committed to being on call, so that the average total amount of time committed to the N.H.S. by the four grades of staff studied is 75.8 hours. While current maximum salary scales may (arguably) bear a resonable relationship to a 38.5 hour week, calculations of remuneration based on the data elicited from the study in respect of the amount of time actually committed and equivalent rates paid to junior staff or doctors in Europe suggest a considerable shortfall in consultant remuneration.

Anesthesiology↗
PubMed2004

Comparative analysis of national regulations concerning blood safety across Europe.

In October 2001, representatives of 17 European countries (Albania, Bosnia-Herzegovina, Bulgaria, Croatia, Czech Republic, Federal Republic of Yugoslavia, Finland, France, Germany, Greece, Italy, Macedonia, Romania, Slovenia, Spain, Turkey and UK) met in Sarajevo at a course organized by the European School of Transfusion Medicine to discuss their countries' regulations concerning different aspects of the safety of blood transfusion. Results are summarized in tables to facilitate comparisons. Most countries (13/17) have specific transfusion laws and 9/17 have hospital-based systems as opposed to national organizations. Quality assurance is common among investigated countries (14/17). Voluntary associations are responsible for donor promotion in the majority of countries (13/17). Exclusively, voluntary non-remunerated donors are found in 5/17 countries, whereas in the remaining ones, incentives, family replacement and remuneration are mechanisms stimulating blood donation. Medical doctors using official selection criteria are checking donor suitability in virtually all countries, which also perform main microbiological testing. Regulations on good clinical use of blood and derivatives are present in most countries but applied only in some. Although the data presented need to be interpreted with some caution, this preliminary analysis shows that, although some significant differences still exist, the majority of countries studied are moving in the same direction to ensure safety of their blood supply.

Blood Banks↗
PubMed1987

Role and responsibilities of general practitioner organisers of continuing medical education.

A total of 359 general practitioner organisers of continuing medical education in England and Wales were sent a questionnaire on their role and responsibilities in 1985; 206 with relevant duties replied. The results of the survey showed that they were playing an effective part in planning, organising, and evaluating educational activities at district level, that many were highly qualified and experienced general practitioners, and that many had previously been concerned in vocational training. Less than half had undergone formal training for their continuing education role. Only 105 (51%) were appointed district general practitioner tutors. They were more active in postgraduate centres than in practice based education. Almost a quarter (49) spent three to five hours a week on their educational duties, but 111 (54%) spent fewer hours. Although well provided with educational resources, few had any control over district educational funds, and over half lacked office space. As to remuneration, 161 (78%) received 500 pounds or less a year and almost two thirds received no reimbursement for expenses. Most had no job description. Attention is drawn to the case for appointing general practitioner organisers of continuing medical education ("district general practice tutors") in all districts of England and Wales, to their role in improving the participation of general practitioners in continuing medical education, and to the urgent need for a national agreement on their job description, preparation, support, and remuneration.

Education, Medical, Continuing↗
PubMed1996

Vocational training for general practice in inner London. Is there a dearth? And if so what's to be done?

OBJECTIVE: To identify the nature and extent of any vocational training deficit within the London initiative zone and investigate the reasons. DESIGN: Collation of statistics and postal questionnaire surveys. SETTING: Thames regions inside and outside the London initiative zone. SUBJECTS: General practice registrars, trainers, principals from non-training practices, and vocational training course organisers. MAIN OUTCOME MEASURES: Trends in numbers of general practice registrars, proportions of trainers, views on current vocational training in inner London. RESULTS: Numbers of general practice registrars fell significantly between 1988 and 1993 within the London initiative zone and in England overall. The number of registrars within the zone fell by more than in the rest of the Thames regions, where the decline was not statistically significant. A lower proportion of principals were approved as trainers within the zone than in the rest of the Thames regions and England overall. In their responses to the survey (88% of inner London registrars responded and 81% of outer Thames registrars) registrars suggested that improving remuneration and personal safety would make training in London more attractive. Trainers and non-trainers (response rates 89% and 66% respectively) also suggested increasing remuneration for trainers together with more protected time for training. CONCLUSIONS: Less vocational training takes place within the London initiative zone than in the rest of the Thames regions and England overall, although there are discrepancies in official statistics. As well as specific recommendations for improving recruitment to vocational training in inner London, measures to tackle inner city deprivation should also remain high on the political agenda.

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↗
PubMedDate not supplied

[Developments in the Scandinavian countries' nurses' salaries and employment conditions in the 80s].

This article is based on a report published by the Northern Nurses' Federation (NNF) as background material for a conference on Nordic Nurses' Remuneration and Employment Conditions 22-24 October 1991, Denmark. The report contains an overview and analysis of data on nurses' remuneration and employment conditions obtained from the five Nordic nurses' associations: the Swedish Federation of Health Officers, the Danish Nurses' Organization, the Norwegian Nurses' Association, the Finnish Federation of Nurses and the Islandic Nurses' Association comprising the NNF. To make the report accessible for international use, English summaries have been added at the end of each chapter, and the headings of tables and figures are translated into English.

Economics, Nursing↗
PubMed2004

Traumatic-event headaches.

BACKGROUND: Chronic headaches from head trauma and whiplash injury are well-known and common, but chronic headaches from other sorts of physical traumas are not recognized. METHODS: Specific information was obtained from the medical records of 15 consecutive patients with chronic headaches related to physically injurious traumatic events that did not include either head trauma or whiplash injury. The events and the physical injuries produced by them were noted. The headaches' development, characteristics, duration, frequency, and accompaniments were recorded, as were the patients' use of pain-alleviative drugs. From this latter information, the headaches were classified by the diagnostic criteria of the International Headache Society as though they were naturally-occurring headaches. The presence of other post-traumatic symptoms and litigation were also recorded. RESULTS: The intervals between the events and the onset of the headaches resembled those between head traumas or whiplash injuries and their subsequent headaches. The headaches themselves were, as a group, similar to those after head trauma and whiplash injury. Thirteen of the patients had chronic tension-type headache, two had migraine. The sustained bodily injuries were trivial or unidentifiable in nine patients. Fabrication of symptoms for financial remuneration was not evident in these patients of whom seven were not even seeking payments of any kind. CONCLUSIONS: This study suggests that these hitherto unrecognized post-traumatic headaches constitute a class of headaches characterized by a relation to traumatic events affecting the body but not including head or whiplash traumas. The bodily injuries per se can be discounted as the cause of the headaches. So can fabrication of symptoms for financial remuneration. Altered mental states, not systematically evaluated here, were a possible cause of the headaches. The overall resemblance of these headaches to the headaches after head or whiplash traumas implies that these latter two headache types may likewise not be products of structural injuries.

Adult↗
PubMed2006

How are health professionals earning their living in Malawi?

BACKGROUND: The migration of health professionals from southern Africa to developed nations is negatively affecting the delivery of health care services in the source countries. Oftentimes however, it is the reasons for the out-migration that have been described in the literature. The work and domestic situations of those health professionals continuing to serve in their posts have not been adequately studied. METHODS: The present study utilized a qualitative data collection and analysis method. This was achieved through focus group discussions and in-depth interviews with health professionals and administrators to determine the challenges they face and the coping systems they resort to and the perceptions towards those coping methods. RESULTS: Health professionals identified the following as some of the challenges there faced: inequitable and poor remuneration, overwhelming responsibilities with limited resources, lack of a stimulating work environment, inadequate supervision, poor access to continued professionals training, limited career progression, lack of transparent recruitment and discriminatory remuneration. When asked what kept them still working in Malawi when the pressures to emigrate were there, the following were some of the ways the health professionals mentioned as useful for earning extra income to support their families: working in rural areas where life was perceived to be cheaper, working closer to home village so as to run farms, stealing drugs from health facilities, having more than one job, running small to medium scale businesses. Health professionals would also minimize expenditure by missing meals and walking to work. CONCLUSION: Many health professionals in Malawi experience overly challenging environments. In order to survive some are involved in ethically and legally questionable activities such as receiving "gifts" from patients and pilfering drugs. The efforts by the Malawi government and the international community to retain health workers in Malawi are recognized. There is however need to evaluate of these human resources-retaining measures are having the desired effects.

Attitude of Health Personnel↗