Primary care tomorrow

Shared care

Problem: The combination of a computer-based patient record and a decision-support system (DSS) may give physicians the decisive push they need to accept such systems. In the PropeR-project we determine the requirements for a generic interface between both these systems and evaluate its potential impact on patient care. This article reports results from the first year in one of the domains under study. It also provides background information about the project, including design considerations and experimental approach of forthcoming years. Purpose: The objectives of the first year were to determine bottlenecks of the current situation and to determine expected improvements and conditions for implementation of a future situation with computer support. Methods: These topics were investigated in general by literature review and in the local situation by a requirements analysis. For the analysis we used a combination of observation, interviews, and patient record study. For the literature survey we searched for reviews, meta-analyses and original studies concerning experiences with computer-based patient records and DSSs in conventional settings and in integrated care. Results: Main bottleneck was the poor use of shared patient record and paper guidelines. Expected improvements were better protocol adherence and communication. Conditions for implementation of computer support were a proper system interface and adoption by the user. Conclusion: Our main conclusion was that the aspect of cooperation needs more decision support than the clinical work itself.

The management of patients within shared care programmes would seem to have significant benefits in terms of individuals' convenience, addressing resource needs and expanding professional horizons. To date, these schemes have typically concentrated on the monitoring of patients with diabetes and glaucoma. At Moorfields Eye Hospital, we attempted to develop the role of the hospital optometrist by establishing a study to evaluate the clinical appraisal of new referrals in a busy out-patient clinic. The results showed a high level of diagnostic accuracy which suggests that the role of hospital optometrists may be successfully extended to include some aspects of patient evaluation not typically undertaken.

The management of cancer services for children and their families at one regional paediatric oncology centre has changed recently to involve the paediatric department of the child's local District General Hospital (DGH). This system has been named shared care. A philosophy of shared care has been identified whereby the concept of holistic care is promoted across health-care boundaries, moving away from the traditional medical model of care where the patient is delivered to the care system, to a holistic one, where the system is delivered to the patient. This paper discusses the development of such a practice within a regional paediatric oncology centre where 36 DGHs currently purchase oncology services. It focuses on the changes in practice and attitudes that were required by all the staff at the regional oncology centre and the dissemination of specialist skills and knowledge to the health-care teams participating in shared care. The transition period and ongoing changes in practice will be identified with recommendations for further developments required to meet the ever-changing needs of children with cancer and their families.

A new development in the British National Health Service is fundholding, whereby certain general practitioners are given budgets from which they purchase services for patients. Our knowledge about fundholding is rudimentary. Many important questions remain unanswered. These include: the impact of fundholding on the efficiency of overall resource utilisation; its effect on strategic planning; its effect on equity; its impact on the role of the doctor and the doctor-patient relationship; and its consequences for practice organisation and the culture of primary care. Even the scant results we do have must be interpreted cautiously. Fundholding was introduced during a period of great turbulence for general practice. Its strategic function was uncertain and its impact has been confounded by the effects of a series of earlier and concurrent policy changes. Few reliable conclusions about fundholding, either positive or negative, can be drawn from existing research.