Health trends最新文献

There is little information on referrals between consultants (cross-referrals), and they are difficult to identify within current information systems which may affect the development of efficient services, and erode the traditional role of the general practitioner (GP) as the gatekeeper to secondary care. For one month in 1994, the source and outcome for all outpatient attendances was recorded in medical, paediatric and orthopaedic clinics in a teaching hospital and in a district general hospital. Detailed interviews were also held with consultants to increase understanding of reasons for cross-referral, and their appropriateness. Referrals from hospital doctors were more frequent in the teaching hospital and in the more specialised clinics. Cross-referral as an outcome of a clinic attendance was more common in the teaching hospital, and among patients seen in the general clinics. These findings support the view that cross-referrals are likely to increase as specialisation among consultants increases. Interviews with consultants showed that they did not believe that there was a need to reduce cross-referrals, which were regarded as an integral part of an effective service for patients. However, the development of GP fundholding may impose new constraints on specialists' ability to refer within the hospital system.

Population-based epidemiological surveys of deliberate self harm (DSH) exclude homeless people and do not represent them in their conclusions. However, DSH in the homeless is commonly seen in inner city hospitals and the homeless are probably at higher risk of eventual suicide. We examined the demographic characteristics of all patients who presented to an inner London hospital after an episode of DSH over a period of three years and found that 15% of patients were of no fixed abode. Alternative methods of studying DSH need to be explored if suicide is to be prevented in this group of people.

A short postal questionnaire was sent to all practising orthopaedic surgeons in the United Kingdom, to determine the current pattern of post-operative care for patients with a fracture of the proximal femur, and to determine the current contribution to care being undertaken by geriatricians. This paper presents the responses of 616 orthopaedic surgeons who are actively involved in the care of patients with a fracture of the proximal femur. For the patient who had been partially dependent on family and social services before injury, and thus had most to benefit from an effective rehabilitation, there was a diversity of care on offer. Sixty-three per cent of surgeons stated that this category of patient was routinely cared for on an acute orthopaedic ward; 36% regularly transferred such patients to rehabilitation units, which were geriatric units in 18% of cases, 'second line' orthopaedic beds in 9% of cases and orthogeriatric units in a further 9% of cases. Surgeons who regularly transferred patients to designated rehabilitation units were more satisfied than those whose patient care took place in the environment of the acute orthopaedic ward. Eighty per cent of surgeons were satisfied with orthogeriatric units, and 62% were satisfied with transfer of patients to units supervised by geriatricians. By contrast, only 17% of surgeons were satisfied with a system of care in which geriatricians were available for consultation by written request only. The specialties of orthopaedic surgery and geriatric medicine have a vital role to play in the post-operative care of patients, and a combined effort to address this issue should be made.

We investigated the resource available for public health doctors to carry out statutory responsibilities out-of-hours by a postal questionnaire survey of consultants in communicable disease control (CsCDC) in England and Wales. The questionnaire requested details of local District Health Authority (DHA) population profile, major incident and outbreak policies, the background of the CCDC, out-of-hours communication, access and resources, reference materials and medical equipment carried by the public health doctor on duty. The CsCDC from 96% (121/126) DHAs in England and Wales responded. Whilst 85% (101/119) of public health doctors carried policies on infectious disease when on duty, only 28% (32/116) carried policies on dealing with chemical incidents and 25% (28/111) carried the District policy to deal with radiation hazards. Twenty-six per cent (32/121) of public health physicians had no access to their District headquarters. There is a wide variation in the standard of resources available to on-call public health doctors in England and Wales; following Department of Health and Department of the Environment guidance, Health Authorities need to ensure that they have adequate arrangements in the event of any major incident or outbreak.

A postal questionnaire was sent to the 213 National Health Service maternity units in England and Wales to identify their current involvement with drug misusers. The response rate was 89.5%. Data indicated that only 29% had formal links with their local drug agency. Child protection case conferences were automatically convened in 52%, and 57% routinely admitted babies to high dependency areas. Twenty-seven per cent of the units did not offer hepatitis B screening to pregnant women, and 32% did not offer hepatitis B prophylaxis to babies whose mothers were infected. Local Health purchasing authorities should ensure that their providers are offering appropriate services to pregnant drug misusers in order to encourage such women to seek help without fear of discrimination. Liaison between health care agencies should be encouraged and areas with low levels of drug misuse should receive help with formulating policies, and training, from units with more experience.

Commissioners of health care require rapid, accurate and usable information on health technology effectiveness to help them to decide on the content of contracts. Despite major strides in the national initiatives in health technology assessment, such information is still in short supply at the local level. In 1991 the former Wessex region (now in the new South and West Region) established a mechanism which continues to provide carefully established recommendations on new technologies. Its features include: identification of locally important topics for evaluation by the purchasers and the providers; an evaluation team, working to a well-defined format in a service-led academic institute; an arbitration committee to deliver recommendations to purchasers on the basis of both the cost-utility of proposals and the quality of the evidence; and implicit obligations for purchasers to respond to strong recommendations.

There is a dearth of information on the health needs of Vietnamese refugees in Britain. In May 1993, a structured interview survey was undertaken to determine the health care experiences and health-related behaviour of Vietnamese adults living in Nottingham Health District. One hundred and thirty-five adults (66 women) were successfully interviewed in Vietnamese or Cantonese, from 71 to 77 eligible households. Levels of English usage were extremely low, and between 27% and 69% of respondents reported considerable difficulty during the various stages of a consultation with their general practitioner. Data on breast screening services suggested a pattern of low uptake, and the prevalence of male smoking was estimated to be 47%. These results suggest that Vietnamese communities suffer high levels of disadvantage in their use of primary care services; remedial action is required.

Highly trained, dedicated assistants with relevant occupational skills are essential for safe medical practice. A vocational qualification has been introduced as a potential common training for non-medical personnel wishing to pursue a career in operating department practice. Approval of extended role options gives an opportunity for specialist support, and may also be of use in relieving some of the problems associated with the reduction of the hours of trainee doctors. This paper briefly traces the evolution of theatre training and reviews current developments.

This study investigated the effect of education and audit on the identification and management of medical inpatients with excessive alcohol consumptions by use of a cross-sectional survey of medical and nursing notes, compared with historical controls. We report the proportion of medical and nursing notes containing qualitative and quantitative drinking histories, the use of the CAGE questionnaire, and notification of alcohol consumption in discharge summaries. A total of 1,979 out of 2,680 (74%) notes of eligible patients were examined. The number of medical notes containing quantitative alcohol histories rose from 175/792 (22%) among historical controls, to 242/690 (35%) after training of junior medical and nursing staff, and to 241/497 (48%) after feedback of results in a clinical audit meeting. The number of medical notes with no recorded alcohol history changed from 309/792 (39%) to 287/690 (42%) to 152/497 (31%), respectively (chi 2 for trend = 97.2, p < 0.0001). The number of nursing notes containing quantified alcohol histories rose from 31/792 (4%) among historical controls, to 123/690 (18%) after training, and to 237/497 (48%) after feedback of results in a clinical audit meeting. The number of nursing notes with no recorded alcohol history fell from 309/792 (90%), to 512/690 (74%), to 205/497 (41%) respectively (chi 2 for trend = 353.7, p < 0.0001). The proportion of patients found to be drinking excessively rose from 40/792 (5.1%) to 57/690 (8.3%) to 45/497 (9.1%) (chi 2 for trend = 8.25, p = 0.004). There was little worthwhile improvement in use of the CAGE questionnaire and in discharge summaries. Education and audit are effective ways of improving the identification of excessive drinkers by both junior doctors and nurses alike. Other aspects of management are less responsive.