Community medicine最新文献

In late 1987, as part of the response to an overspend of pounds 3.2 million, the health authority of an inner London teaching district, Paddington and North Kensington, proposed to close urgently 16 of the 56 gynaecology beds at the Samaritan hospital. They did so on the assumption that the hospital often served women who were neither local nor required the special expertise of a teaching hospital. To test this assumption, we reviewed the functions and funding of the hospital, how its activity level and size compared with other districts, and the nature of the workload, i.e. the extent to which the patients were local or non-local, or needed routine or specialist care. It was agreed that non-local routine patients are the district's lowest priority, and we demonstrated that such patients account for no more than six to 11 beds. This information helped to resolve negotiations over the bed numbers. This study demonstrates that it was possible to defuse a potential confrontation by using routinely available and additional survey data to inform the debate.

This paper describes one of the first attempts at an economic evaluation of a community care initiative for elderly mentally infirm people and their carers. It is demonstrated that community support provided mainly through an innovative Family Support Unit (FSU) is almost three times more costly than that which would otherwise be provided. However, FSU support results in prolonged life at home for elderly mentally infirm people, thus saving costly long-term care beds. If life at home is preferable to long-term care, FSU care can be judged cost effective. However, regarding implementation of such schemes, cash-limited local authorities appear to be forced to take on schemes which, despite being cost effective when taking a broad range of resources into account, cost more than they save as far as the local authority itself is concerned.

A comparison of information obtained from a postal screen of people on the electoral register about attendance at outpatient clinics with data extracted from hospital records found agreement between the two sources for 87 per cent of people. This rose to 90 per cent after an interview follow-up of those whose replies were unclear. Given the complexities of defining outpatient attendances clearly, these levels of agreement seemed good. Fewer consultations were omitted by people when a three rather than a 12-month study period was used, but the particular three-month period used (January-March) may have contributed to this difference.

Both the true incidence of meningococcal disease and the proportion of cases of meningococcal meningitis notified in England and Wales are not known. A comprehensive search for cases of meningococcal disease within a defined boundary, that of Greater Manchester, was made using various sources of information, for 1985. Sixty-seven per cent of cases of meningococcal meningitis and 63 per cent of meningococcal disease were notified. Fifty-seven percent of cases were referred for further tests to the United Kingdom meningococcal reference laboratory. Only 79 per cent of cases were identifiable on Hospital Activity Analysis (HAA) data. Information was also sought on sources of notification, notification delay, delay in laboratory diagnosis and length of stay. There is considerable potential in reducing notification delay, after comparing dates of laboratory diagnosis and notification. Notification should be more complete. In the absence of this ideal, surveillance of meningococcal disease needs to rely on various sources of information to gain a complete picture of the disease. Management of contacts of cases and of outbreaks is impossible without prompt and complete notification.

To monitor the effectiveness of a breast cancer screening service accurate information is necessary on the incidence of breast cancer before and after screening is introduced. The Wessex Cancer Register has been used to provide data on the incidence prior to screening and arrangements are being made for the exchange of information between the Register and each screening service in Wessex in order that future registrations can be divided into screen-detected and symptomatically-detected cases. Since changes in mortality will not be apparent for some years and are not detectable in small populations, other indicators of effectiveness are required. Stage at presentation predicts mortality; a change in stage distribution as a result of screening would indicate future changes in mortality. The Cancer Register has been used to analyse stage distribution before the advent of screening. Procedures have been adopted for collecting staging data on all breast cancers diagnosed in the future, both within and without the screening service. In this way stage distribution will be compared before and after the implementation of the service and predictions made on the effect on mortality in the future. In addition, information on the incidence of interval cancers will be analysed using the Cancer Register so that, in the long term, an assessment can be made of the appropriate length of the interval between screens. These cancers will be notified to the screening office for review. A Cancer Register can provide the population base from which to measure the true effectiveness of a breast screening service on the community it serves.

This paper considers management options for limiting general practitioner use of open access radiology - a service for which there is increasing demand which is difficult to meet. In the current climate of cost containment, restriction of general practitioner access to these expensive diagnostic facilities has management appeal. However, it is difficult to justify blanket restriction of access to radiology services as there is no evidence that it would be economically or clinically sensible. An explicit quota system is unlikely to be feasible because of the small number of referrals made by general practitioners and the element of chance which will inevitably enter into the referral process. Managers should examine more closely the manipulation of incentives and costs which are used, often implicitly, to balance the conflicting desires of clinicians and managers. The best management option would appear to involve a re-evaluation of the role of the radiologist to include responsibility for managing the service. This should include assessment of appropriateness of referral by reference to guidelines for investigation and the behaviour of acknowledged good practitioners.