From black bag to black box: will computers improve the NHS?
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Computer Systems↗
Biomedical subjects
L J Donaldson
Publications and source records attributed to L J Donaldson.
The reporting of in-patient suicides: identifying the problem.
Fifty in-patient suicides occurring in an English health region over the five-year period 1987-91 were identified from two data sources: the Regional Health Authority's records of untoward incident reports and coroners' records. An analysis of the quality of incident investigations conducted locally was carried out. The people who committed suicide were more often men, with a similar sex distribution in the study population to suicides in the community. Male in-patient suicides (mean age, 40 years) were younger than females (mean age 58 years). There was a high incidence of violent methods and around a third of the deaths occurred in the week after admission. More than half the deaths had occurred outside hospital. The health service's untoward incident reporting system seriously under-enumerated cases of in-patient suicide. Even when notifications were made, they appeared to be of variable quality and few demonstrated a comprehensive investigation and action plan.
Adult↗
The doctor's dilemma.
The close relationship between expenditure on health care and the countless individual judgements made by doctors for their patients means that any discussion about rationing must involve the process of clinical decision-making. Increasingly, doctors are being drawn into rationing by two powerful forces. Firstly, through the corporate responsibilities of those working within a managed health care system in which organisational objectives and budgetary constraints are agreed and specified in a much more explicit way than ever before. Secondly, by the professionally-led movement towards more clinically effective practice. These, in combination, are leading towards a fundamental review of the nature and ethical basis of clinical practice in which the duty of doctors to individual patients must be balanced against the wider considerations.
Cost-Benefit Analysis↗
Limb reduction defects in the northern region of England 1985-92.
STUDY OBJECTIVE: To test the hypothesis that children born to mothers living near the sea are at increased risk of limb reduction defects. DESIGN: Descriptive data analysis. SETTING: The northern health region of England. PATIENTS: All children born between 1 January 1985 and 31 December 1992 in the northern region of England with isolated limb reduction defects. MAIN RESULTS: The birth prevalence of isolated limb reduction defects was not affected by the distance the mother lived from the sea. There was some evidence of space-time clustering, but there was no evidence of statistically significant variation in the occurrence of the condition with sex, time of birth (monthly or yearly), or county of birth. CONCLUSIONS: There is no evidence that children born to mothers living near the sea are at increased risk of limb reduction defects.
Cluster Analysis↗
Press coverage of the Cleveland child sexual abuse enquiry: a source of public enlightenment?
BACKGROUND: The objective of this study was to assess national and local newspaper reporting of events considered by a Public Enquiry which investigated a major crisis involving child protection services. The Judicial Enquiry, held in Cleveland, North East England, examined the actions of statutory bodies and the professionals working within them following the diagnosis of suspected sexual abuse in 121 children. METHODS: This is a descriptive study using analysis of legal transcripts and newspaper reports. The data involved a total of 216,360 lines of transcript evidence given by 111 witnesses and lawyers representing them at the Judicial Enquiry which lasted 74 days; together with 344,899 words in reports covering 17 newspapers (seven local and ten national). The main outcome measures were based on the volume and type of newspaper coverage including that for each witness' and lawyer's evidence. A coverage index related the amount of newspaper reporting to the extent of evidence given. RESULTS: The highest coverage of any single day of the Enquiry in both local and national newspapers occurred when Dr Marietta Higgs (one of the two principal paediatricians involved) made her first appearance. However, the highest interest (coverage index) was shown in evidence given by lawyers for the parents and the least in evidence given by public bodies. The evidence of witnesses was used very selectively by the press in emotive headlines to imply blame or support for the main protagonists or their actions. This sustained several lines of reporting: criticism of the doctors and social workers, inter-professional conflicts, damage and wrong-doing to the families and the search for someone to blame. CONCLUSIONS: The Cleveland crisis occupied newspaper headlines in the United Kingdom for more than a year. Much of the newspaper coverage took an adversarial approach which sought to apportion blame and take sides. The press appeared to report negative issues which were newsworthy and did not give a balanced view. Broader policy issues, which formed an important part of the Enquiry report's influence on subsequent child protection legislation, were largely ignored.
Child↗
Is it possible to catch leukaemia from a cat?
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Animals↗
Doctors with problems in an NHS workforce.
OBJECTIVES: To describe the incidence, nature, and implications of serious disciplinary problems among the medical staff of a large NHS hospital workforce. DESIGN: Descriptive study with analysis of case records. SETTING: Northern Health Region, an administrative area within the NHS covering a population of three million. SUBJECTS: Forty nine hospital doctors: 46 consultants and three associate specialists. MAIN OUTCOME MEASURES: The nature of the problems encountered within the doctors' practice, and the types of action taken by the employing authority. RESULTS: Over a five year period concerns serious enough to warrant the consideration of disciplinary action were raised about 6% of all senior medical staff (49/850). Ninety six types of problem were encountered, and were categorised as poor attitude and disruptive or irresponsible behaviour (32), lack of commitment to duties (21), poor skills and inadequate knowledge (19), dishonesty (11), sexual matters (seven), disorganised practice and poor communication with colleagues (five), and other problems (one). Twenty five of the 49 doctors retired or left the employer's service, whereas 21 remained in employment after counselling or under supervision. CONCLUSIONS: Existing procedures for hospital doctors within the NHS are inadequate to deal with serious problems. Dealing with such problems requires experience, objectivity, and a willingness to tolerate unpleasantness and criticism. Because most consultants' contracts are now held by NHS trust hospitals, however, those who had developed skill over the years in handling these complex issues are now no longer involved.
Adult↗
Lanterns in the jungle: is the NHS driven by the wrong kind of efficiency?
The performance of the National Health Service is assessed in part by an Efficiency Index (EI) which is applied to the service as a whole as well as to individual health authorities. The EI relates increases in the amount of patient care activity to increases in total expenditure. The index can give a misleading impression of performance, creates perverse incentives and is at odds with the overall strategy of the health service which is to place greater emphasis on the promotion of health and to provide more care in primary and community-based settings. The philosophy, validity and appropriateness of the EI are discussed.
Community Health Services↗
Is health care a commodity: how will purchasing improve the National Health Service?
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.
Contract Services↗
Maintaining excellence: the preservation and development of specialised services.
The advent of the Tomlinson inquiry draws attention to the need to strike a balance between market led and planned approaches to health care delivery. This is important not just for hospital rationalisation but also for the preservation and development of services which are provided in a smaller number of hospitals. Specialised services are often in the forefront of raising standards of care and introducing new developments and innovations. They are the only option for a small number of patients with serious illnesses. In the internal market for health care provision created by the 1990 NHS reforms more sophisticated and flexible mechanisms must be found to provide stability for specialised services while at the same time enabling the benefits of purchaser choice and provider competition to be realised.
Delivery of Health Care↗
Eight years' experience of clinical activity in an outpatient fracture clinic.
Major changes to the method of planning and provision of health care in Britain have led to the introduction of contracts as the main means through which services are procured. Never before has the need for accurate and comprehensive clinical information been greater. Yet comprehensive outpatient information, though planned, is not yet available, and there is relatively little experience of such systems which have been introduced in individual localities. Fracture clinic patients are an important group of outpatient, not least because interventions are often undertaken as an integral part of the outpatient episode. This is relevant for estimating resource use and for pricing, but until now has been 'hidden' work as far as conventional information systems are concerned. This study describes the establishment and manifestation of a clinical information system based on a fracture clinic serving the majority of a population of 850,000. Information was gathered over 8 years on 61,635 patients, who had 72,984 diagnoses and received 93,878 treatments. An information system of the type described in this study can be of great value as part of the contracting process (for both purchasers and providers of orthopaedic services), as a basis for clinical audit and research, and to facilitate undergraduate and postgraduate teaching.
Adolescent↗
The domiciliary consultation service: time to take stock.
OBJECTIVE: To review the use of the domiciliary consultation service in modern clinical practice in the Northern region. DESIGN: Retrospective study of data on domiciliary consultations from claim forms for payment submitted to the regional health authority by consultants during 1984-5 and prospective study during 1985-9. Peer review of patterns of practice by consultants. SETTING: 15 Of the 16 health districts in the Northern region, comprising a mixed urban and rural population of about 2.8 million. PARTICIPANTS: 760 Consultants in 28 specialties and 1666 general practitioners who were eligible to perform or request domiciliary consultations. MAIN OUTCOME MEASURES: Numbers of domiciliary consultations, general practitioners' requests for consultations, and consultants performing consultations and expenditure on the service by the region. RESULTS: Use of the domiciliary consultation service in the Northern region declined by 53% between 1984-5 and 1988-9, considerably in excess of the national rate of decline of 27%, and expenditure on the service was reduced, after allowing for inflation, by 604,000 pounds, or 38%, in real terms. Most consultants and general practitioners used the service sparingly whereas a small proportion used it heavily; a few specific consultants and general practitioners were responsible for a relatively high rate of domiciliary consultations. Contrary to the original definition of domiciliary consultation, the general practitioner accompanied the consultant on only one occasion in 17 and, in one specialty examined (paediatrics) patients who received domiciliary consultations seemed to have minor medical problems. CONCLUSIONS: Peer review examination of the pattern of practice in the domiciliary consultation service proved effective in rationalising use of the service, although a substantial minority of consultants and general practitioners continued to use the service heavily. The place of the service in modern clinical practice would benefit from a national review.
Consultants↗
Variations in clinical decisions: a study of orthopaedic patients.
Three groups of patients were clinically reviewed within a new orthopaedics department: patients who were on an inpatient waiting list for surgery; new referrals from general practitioners; and patients who had been referred earlier and were awaiting an appointment for outpatient consultation. Approximately two-fifths of patients who were already on the inpatient waiting list, and who had confirmed their wish to remain on it, were considered on clinical review not to require inpatient treatment. A third of patients attending for first outpatient consultations were immediately returned to the continuing care of their general practitioner and this proportion was higher (47%) amongst patients who were waiting for outpatient appointments and who had not been referred to a named hospital consultant. These findings draw attention to the possible inappropriate use of specialist hospital facilities because of clinical decisions taken by some general practitioners and also to variations in the threshold for surgical intervention used by hospital consultants. It is important that the medical profession develops a consensus approach to the clinical management of patients with common conditions. It is also important that clinical review of patients on inpatient waiting lists, especially those who have been waiting a long time, becomes a routine part of waiting list management. Under the new British health care system, it is likely that purchasers of health care will seek to ensure that these issues are being dealt with by hospitals with which they are considering placing contracts.
Decision Making, Organizational↗
Travelling for earlier surgical treatment: the patient's view.
As part of the northern region's programme within the national waiting list initiative, schemes have been funded to test the feasibility and acceptability of offering patients the opportunity to travel further afield in order to receive earlier treatment. A total of 484 patients experiencing a long wait for routine surgical operations in the northern region were offered the opportunity to receive earlier treatment outside their local health district; 74% of the patients accepted the offer. The initiative was well received by the participating patients and the majority stated that if the need arose on a future occasion they would prefer to travel for treatment rather than have to wait for lengthy periods for treatment at their local hospital. These findings, interpreted in the light of the National Health Service reforms introduced in April 1991, suggest that for some types of care, patients would welcome greater flexibility in the placing of contracts, not merely reinforcement of historical patterns of referral.
Adolescent↗
Medical audit and the wider quality debate.
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Medical Audit↗
Incidence of fractures in a geographically defined population.
STUDY OBJECTIVE: The aim was to describe the population based age and sex specific incidence of fractures at different sites in a large English health district. DESIGN: Recording of fractures was accomplished by a specially constructed outpatient index and by record linkage to hospital inpatient information, for the three years surrounding the 1981 census. SETTING: The fracture index was held by the Department of Community Health in Leicester using data from the fracture clinic at the central large district general hospital, supplemented by hospital inpatient data from Trent Region and the two adjoining regions. PARTICIPANTS: The denominator population was the Leicestershire Health Authority resident population. In the three years, 12,711 fractures amongst males and 10,565 amongst females were recorded. MEASUREMENTS AND MAIN RESULTS: The overall estimated annual incidence of fractures was 100 per 10,000 population for males and 81 per 10,000 population for females. Below the age of 55 years all fractures showed a higher incidence amongst males but amongst the over 55s, there was a consistent fall in the male:female incidence ratio with some sites showing a striking female preponderance. The results also show an apparent age specific temporal increase in incidence at certain fracture sites compared with earlier British data, but fracture incidence figures still suggest lower rates in this country than in North America and some Scandinavian countries. CONCLUSIONS: These findings provide population based incidence data on a major public health problem and are consistent with the major determinants of osteoporosis and increase in falls in postmenopausal women. The temporal and geographical variation in fracture incidence remain to be explained.
Age Factors↗
Death certification in fractured neck of femur.
Fracture of the neck of the femur is a major public health problem within the elderly population of most industrialised countries whose health services are increasingly being taken up with its management. Moreover, within Britain, there is evidence of a real increase in its incidence even allowing for the ageing of the population. A condition whose aetiology is still far from clear (and where no strategy for prevention can therefore be formulated), and which is of such importance to the planning and provision of services demands detailed investigation and careful monitoring. Mortality data are an important part of epidemiological studies of disease problems and, in Britain, in resource allocation through the Resource Allocation Working Party (RAWP) formula. In this study, a cohort of 2,631 elderly patients, resident in the largest health district in the country, and admitted to hospitals over a seven year period with the diagnosis of fractured neck of femur, was assembled. Hospital records were linked to national mortality data to determine whether patients had died and, where this was so, to record underlying cause of death. A total of 930 deaths occurred within the study cohort but only 52 were certified as dying from fractured neck of femur; even amongst those who died in the hospital to which they were admitted with the fracture, less than a fifth of deaths were attributed to the fracture as underlying cause. Diseases of the circulatory system accounted for almost half of all underlying causes of death and bronchopneumonia a further 20%. These findings suggest a gross undercertification of fractured neck of femur as a cause of death in the elderly and are consistent with other studies. They may be explained by a failure of junior hospital doctors to understand the importance of accurate certification of cause of death and a misguided attempt to reduce the burden to coroners of having to consider each death from this cause.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗