Biomedical subjects
Publications and source records attributed to B Kirkup.
This is the seventh paper in a series on the consequences for public health of the conflict in the Balkans. It describes the state of the hospital sevices in Pristina after the cease fire in June 1999 and the subsequent reconstruction programme.
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The history of public health began with the investigation of communicable diseases. Improved epidemiological methods have subsequently illuminated the causes and management of a wide range of health problems. The day-to-day challenges facing today's public health practitioners must be tackled rapidly and with limited resources, but must still subject to sound epidemiological principles.
Through the reforms to the National Health Service in 1990 an internal market for public health care provision in the United Kingdom was introduced. As part of this new system of care, responsibility for purchasing of health care was separated from that for its provision. The new purchasing function, undertaken by district health authorities and fundholding general practices, has created the opportunity for improvements in health and higher standards of care to be achieved through new and explicit mechanisms. However, the purchasing function has not yet realized its full potential to achieve beneficial change, partly because traditional behaviours have not yet adapted to the new system of care and partly because specific aspects of the internal market are creating barriers and perverse incentives. This paper discusses these issues and identifies the important barriers which have still to be overcome if purchasing is to be the driving force for change in the new National Health Service.
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Perinatal mortality remains an important topic, with wide ranging coverage in the literature. I have considered three main themes: preexisting risk factors, clinical management, and perinatal mortality reviews. Three major studies have identified a wide range of risk factors for perinatal death. Different inclusion criteria may be responsible for some of the apparent inconsistencies between study findings, but unravelling the complex web of interrelated factors remains a major epidemiologic challenge. Recent studies of clinical management highlight the role of the delivery of health care in determining outcome. However, they also underline the difficulties of assessing contrasting approaches to clinical management in this field. There is a welcome continuing impetus to develop the systematic review of perinatal death as an indicator of effectiveness in the delivery of maternity care.
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Under the proposals in Working for Patients, Health Authorities will need to assess health needs in the populations for which they will become responsible, in order to ensure that optimal contracts are placed for hospital care. It seems inevitable that this process will have to be based at least in part on previous utilization data. Utilization data are known to be strongly influenced by the supply of facilities, particularly beds; unless this can be taken into account there is a likelihood that historical patterns will simply be perpetuated whether justified or not. We have used multiple regression analysis with nationally available data to investigate the effects of supply as well as of need and demand indicators on variations in hospital utilization rates. We describe how the approach may be taken by Health Authorities as the basis for a staged assessment of local levels of utilization, so that they may target further and more detailed investigation more efficiently.
The case notes relating to 75 of the 91 perinatal deaths of nonmalformed babies of birthweight greater than or equal to 2.5 kg born in the Northern Region in 1983 were examined. The major groups involved antepartum deaths of unknown cause (40%), and deaths due to intrapartum anoxia or trauma (35%). A case-control study compared each of the 75 cases with two controls matched for place of birth, obtained by taking the next two babies born in the same maternity unit (excluding perinatal deaths, birthweight less than 2.5 kg, and malformations). Four factors were found to be significantly associated with risk of perinatal death in this group: primigravidity, parity greater than or equal to 3, not booked for antenatal care by 20 weeks, and corrected birthweight less than 3.2 kg (adjusted for gestation). Two further factors were related only to the risk of perinatal death consequent upon intrapartum events: labour post-term and malpresentation in labour. All four factors relevant to the whole group remained independently associated with risk of perinatal death after multivariate analysis by two techniques. Adjusted odds ratios (95% CI) were estimated as: primigravidity 2.1 (1.1 to 4.1); parity three or more 5.7 (1.9 to 17); not booked for antenatal care by 20 weeks 15.7 (3.0 to 81); and corrected birthweight less than 3.25 kg 2.5 (1.3 to 4.6). An avoidable factor, as defined, was detected in 50% of deaths. In 30% of deaths there was an avoidable factor (grade 2) such that absence may have been expected to lead to a different outcome had all other factors remained equal. Of the avoidable factors detected, 61% related to intrapartum management, as did 76% of the grade 2 factors. Most of these involved failure to respond to evidence of fetal distress in labour. The defined group constituted 21% of all perinatal deaths, suggesting that this is an important category, particularly as their potential for normal survival should otherwise have been high.
The identification of problem waiting lists is important in effectively targeting scarce resources. This paper discusses the data available on waiting lists, and develops an information profile which can be used as a screening device to construct a short list of the 'worst' waiting lists. This profile was tested using the waiting experience of one specialty in the Northern region, and the results are presented here. Further developments to the profile are largely dependent upon improvements to the information currently collected on waiting lists.
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Explore the source record for details and available documents.