The role of community pharmacists in prescribing medication for the treatment of head lice.

BACKGROUND: The aim of the study was to discover whether the use of community pharmacy, rather than general practice, as the first port of call for suspected head lice infestation would represent an acceptable, effective and cost-reducing means of management in the community. METHODS: A before-and-after study was carried out of a new system of care delivery. Between September and November 1997, pharmacists in Nottingham City West recorded details of all patients attending with prescriptions for head lice treatment or those purchasing over-the-counter medication. The new system of care delivery began in January 1998, during which, pharmacists were providing advice and treatment for head lice, in the absence of a referral from general practice. Changes in prescribing behaviour were assessed from Prescribing Analysis and Cost (PACT) data. Acceptability and subjective assessment of the scheme (patients and professionals) was gauged from questionnaires. RESULTS: Referral patterns were altered drastically (away from general practice and towards self-referral) by the project, and the changes were apparent within the first month. This trend continued throughout and beyond the formal evaluation period. Cost analysis suggests that the community pharmacy scheme generates resource savings, largely driven by the lower cost of a pharmacy consultation, as opposed to a GP consultation. Questionnaire evidence suggests that both patients and health care professionals viewed the new arrangement as at least as acceptable as the old. CONCLUSION: With respect to the original objective, the new delivery system appears to provide no evidence of ineffectiveness; evidence of acceptability on the part of the majority of patients and professionals; and evidence of improved cost-effectiveness.

What problems do patients present with outside normal general practice surgery hours? A prospective study of the use of general practice and accident and emergency services.

BACKGROUND: This study was designed to address some current issues concerning the use of general practice and accident and emergency (A & E) services outside normal surgery hours. METHOD: Six general practices in Nottingham (with a combined population of 46,698 patients) were recruited to take part in the study. Over a six month period, data were collected on patient contacts with general practice services and the local A & E department outside normal surgery hours. RESULTS: General practice services dealt with 63 per cent of first contacts over the course of the study. There were 3181 (136 per 1000 patients per year) contacts with general practitioners and deputizing service doctors (of which 1009 (31.7 per cent) were dealt with by telephone alone) and 1876 (80 per 1000 patients per year) attendances at the A & E department. There were marked differences in the distribution of problems that patients presented to the two types of service. The proportion of presentations dealt with by telephone alone by general practice services varied with the type of presentation. However, the use of the telephone was not particularly high, even for problems such as a sore throat. CONCLUSIONS: Given the differences in presentations to both general practice and A & E services there may be limited scope for altering patients' consulting patterns without making significant changes to service provision. However, there may be scope for increasing the proportion of general practice contacts dealt with by telephone alone.

Relation of out of hours activity by general practice and accident and emergency services with deprivation in Nottingham: longitudinal survey.

OBJECTIVES: To investigate the relation between out of hours activity of general practice and accident and emergency services with deprivation and distance from accident and emergency department. DESIGN: Six month longitudinal study. SETTING: Six general practices and the sole accident and emergency department in Nottingham. SUBJECTS: 4745 out of hours contacts generated by 45,182 patients from 23 electoral wards registered with six practices. MAIN OUTCOME MEASURES: Rates of out of hours contacts for general practice and accident and emergency services calculated by electoral ward; Jarman and Townsend deprivation scores and distance from accident and emergency department of electoral wards. RESULTS: Distances of wards from accident and emergency department ranged from 0.8 to 9 km, and Jarman deprivation scores ranged from -23.4 to 51.8. Out of hours contacts varied by ward from 110 to 350 events/1000 patients/year, and 58% of this variation was explained by the Jarman score. General practice and accident and emergency rates were positively correlated (Pearson coefficient 0.50, P = 0.015). Proximity to accident and emergency department was not significantly associated with increased activity when deprivation was included in regression analysis. One practice had substantially higher out of hours activity (B coefficient 124 (95% confidence interval 67 to 181)) even when deprivation was included in regression analysis. CONCLUSIONS: A disproportionate amount of out of hours workload fell on deprived inner city practices. High general practice and high accident and emergency activity occurred in the same areas rather than one service substituting for the other.

General practitioners' referral thresholds and choices of referral destination: an experimental study.

General practitioners (GPs) exert a major impact on NHS resource use, both as providers of primary care and as referrers to secondary care. Referral rates are subject to wide variations, leading to the conjecture that certain GPs may have different 'referral thresholds' from those of others. In this paper, the authors describe an experiment designed both to test the referral threshold hypothesis and to illuminate the GP's decision process with respect to choice over referral destination. Nottinghamshire GPs were provided with hypothetical case histories and a list of possible referral destinations, specifying a range of consultants, their specialist interests, plus the expected waiting times and costs for both out-patient investigation and in-patient treatment. For each case, respondents were requested to indicate whether or not they would refer the patient, and to whom. Respondents were also asked to indicate the extent to which their choices of consultants generally were governed by the specialist interest, the waiting time and the cost information. The responses of the sample support the referral threshold conjecture, with specialist interests and waiting time appearing to be far more important than cost in influencing choice of referral destination. The possibilities of influencing GPs' referral behaviour are discussed, in the light of recent initiatives with respect to prescribing.