Andrew Gilliland

Consultation charges in Ireland deter a large proportion of patients from seeing the GP: results of a cross-sectional survey

Objective: To estimate the effect of a consultation charge on the health-seeking behaviour of patients. Methods: Cross-sectional survey of patients carried out in Northern Ireland, where services are free at the point of delivery, and the Republic of Ireland, where 70% of the population are charged a consultation fee to see the general practitioner (GP). Results: There were 11 870 respondents to the survey (response rate 52%). In the Republic of Ireland, 18.9% of patients (4.4% of non-paying patients and 26.3% of paying patients) had a medical problem in the previous year but had not consulted the doctor because of cost; this compares with only 1.8% of patients in Northern Ireland. Because those in the Republic of Ireland on low income are entitled to free care, the effects of the consultation charge were most marked in the middle of the income distribution, with such patients being over four times as likely to have been deterred as those in the most affluent group. However, amongst paying patients, it was the poorest and those with the worst health who were most affected. Compared to the most affluent patients and those without depression, the likelihood of not having seen the GP due to cost was 6.75 (95% confidence interval [CI] 3.79, 11.09) for the poorest patients and 2.01 (95% CI 1.53, 2.52) for those with depression. Conclusion: Even in countries with exemptions for the poor and more vulnerable, a consultation charge can deter a large proportion of poorer and less healthy patients from seeing their GP.

Repeat prescribing of non-steroidal anti-inflammatory drugs excluding aspirin: how careful are we?

About 5% of all National Health Service prescriptions in Britain and a quarter of reports of suspected adverse reactions are accounted for by non-steroidal anti-inflammatory drugs. Their prescription was investigated in two computerised group practices serving 11850 patients. Altogether 198 patients receiving repeat prescriptions of non-steroidal anti-inflammatory drugs were identified and relevant clinical details extracted from their notes. Of these patients, 119 were over 65 years old; 172 were receiving one of six different non-steroidal anti-inflammatory drugs; and 76 were taking drugs that can interact with non-steroidal anti-inflammatory drugs. Ninety one patients had one or more medical conditions that may be aggravated by non-steroidal anti-inflammatory drugs, and 36 had experienced side effects important enough for their treatment to be changed. A questionnaire to assess opinions and knowledge of non-steroidal anti-inflammatory drugs was given to 42 general practitioners and 26 rheumatologists. Although the two groups showed a comparable knowledge of the properties and costs of non-steroidal anti-inflammatory drugs, they differed significantly in their views on the circumstances under which these drugs should be used. Clear guidelines on the prescription of these drugs would indicate when careful monitoring is essential for patients to benefit from them safely.

Socio-economic gradients in self-reported health in Ireland and Northern Ireland

BackgroundResearch and policy related to reducing health inequalities has progressed separately within Ireland and Northern Ireland. This paper describes the first exploration of the socio-economic influences on health on the island of Ireland since 1922.MethodsPostal survey.ResultsThe response rate was 52%; 11,870 respondents. Men reported more long-standing illness (LLTI) or poor general health (PGH); depression was more common amongst women. Socio-economic gradients in health were evident in both jurisdictions, with the effects of household income being particularly marked. Overall, morbidity levels were significantly better in Ireland than in Northern Ireland: adjusted odds ratio of 0.79 (95% Cl 0.71–0.88) for LLTI; 0.64 (0.57 – 0.72) for PGH; 0.90 (0.82 – 0.99) for depression.ConclusionsThere is evidence of strong and similar socio-economic gradients in health throughout the island of Ireland. This would suggest joint policy approaches or at least further comparative evaluation of the initiatives in each jurisdiction.

Do all outpatients need a face-to-face consultation in rheumatology?

We have explored the diagnostic accuracy and acceptability of a video-consultation in an outpatient rheumatology setting and compared it with a telephone consultation and the ‘gold standard’ face-to-face interview. One hundred patients referred to a consultant rheumatologist were selected using information in the referral letter from the general practitioner (GP). Each patient was seen by a study GP to obtain a medical history. There then followed a three-way telephone consultation between the patient, GP and specialist rheumatologist, who was in another building. The patient and specialist then took part in a teleconsultation using a desktop videoconferencing unit (VC7000, BT) connected by ISDN at 128kbit/s. A second video-camera with a zoom lens (KY-F55B, JVC) was used for close-up pictures. Finally the specialist met the patient for a face-toface consultation. The rheumatologist formulated a diagnosis after each consultation. Questionnaires were completed after each consultation by the patients and doctors. Each consultation lasted 10 min. The age range of the 100 patients was 20–87 years (mean 48). The male–female ratio was 1–3. The cases included fibromyalgia (30%), degenerative arthritis (26%), soft-tissue rheumatism (27%), rheumatoid arthritis (5%), connective tissue disease (3%) and psoriatic arthritis (3%). Compared with the face-toface consultation, the diagnostic accuracy from the telephone alone was 69% and from the video-consultation was 97%. GP satisfaction with the telephone was 51% and with the videoconsultation was 99%. Patient satisfaction ratings were 56% and 90%, respectively. However, 42% of patients still wished to see the specialist face to face. Telerheumatology is diagnostically accurate and highly acceptable to the patient, specialist and GP.