Mike Pringle

The effect of deprivation on variations in general practitioners' referral rates: a cross sectional study of computerised data on new medical and surgical outpatient referrals in Nottinghamshire.

Abstract Objective: To determine the effect of deprivation on variations in general practitioners referral rates using the Jarman underprivileged area (UPA(8)) score as a proxy measure. Design: Cross sectional survey of new medical and surgical referrals from general practices to hospitals (determined from hospital activity data). Setting: All of the 183 general practices in Nottinghamshire and all of the 19 hospitals in Trent region. Main outcome measures: The relation between the referral rates per 1000 registered patients and the practice populations UPA(8) score (calculated on the basis of electoral ward), with adjustment for the number of partners, percentage of patients aged over 65 years, and fundholding status of each practice. Results: There was a significant independent association between deprivation, as measured by the UPA(8) score, and high total referral rates and high medical referral rates (P<0.0001). The UPA(8) score alone explained 23% of the total variation in total referral rates and 32% of the variation in medical referral rates. On multivariate analysis, where partnership size, fundholding status, and percentage of men and women aged over 65 years were included, the UPA(8) score explained 29% and 35% of the variation in total and medical referral rates respectively. Conclusion: Of the variables studied, the UPA(8) score was the strongest predictor of variations in referral rates. This association is most likely to be through a link with morbidity, although it could reflect differences in patients perceptions, doctors behaviour, or the use and provision of services. Key messages Significant associations exist between deprivation as measured by the UPA(8) score and high total and medical referral rates On multivariate analysis, where partnership size, fundholding status, percentage of men and women aged over 65 years were included, the UPA(8) score explained 29% and 35% of the variation in total and medical referral rates respectively Of the variables studied, the UPA(8) score is the strongest predictor of variations in medical referral rates Studies of general practitioners workload and activity need to include deprivation scores such as the UPA(8) score

Association between teenage pregnancy rates and the age and sex of general practitioners: cross sectional survey in Trent 1994-7

Abstract Objective: To examine variations in teenage pregnancy rates in Trent region and to determine possible associations with local general practice characteristics such as the age and sex of the doctors. Design: Cross sectional survey. Setting: All 826 general practices in Trent region in existence between 1994 and 1997. Subjects: All pregnancies of teenagers aged 13 to 19 between 1994 and 1997 that resulted in an admission to an NHS hospital. Main outcome measures: Pregnancy rates for teenagers aged 13 to 19 and general practice characteristics: presence of a female or young doctor (under 36 years old), number of whole time equivalent practice nurses, Townsend score, vocational training status, list size per whole time equivalent doctor, fundholding status, and partnership size. Results: On multivariate analysis, lower teenage pregnancy rates were associated with the presence of a female or young doctor and more nurse time. Practices in deprived areas had higher teenage pregnancy rates. Conclusion: General practices with female doctors, young doctors, or more nurse time had lower teenage pregnancy rates. The findings may have implications for the mix of health professionals within primary care.

Dispensing by Physicians and Pharmacists

Over the years, the relationship between general practitioners and pharmacists has fluctuated, with periods of peace contrasting with times of overxad lapping interests and responsibilities. All prescripxad tions which are dispensed by a physician or a pharmacist in the UK are sent to the Prescription Pricing Authority which reimburses the cost plus profit margin of the drug or dressing, with addixad tional fees for the cost of containers and the exxad pense of dispensing. Thus, more expensive prodxad ucts are more profitable, and multiple prescriptions are more profitable than a single longterm prexad scription. Whereas a pharmacist has dedicate premises and staff, dispensing physicians use their usual premises (for which the National Health Service already reimburses the rent) and employ few extra staff. For patients who are liable for payment, the fixed prescription charges are collected by the pharmacist or physician for passing on to the Government.

Commentary: interesting idea, but case not proved.

B W Lloyd has produced a paper of interest and originality. If his evidence were compelling–or indeed if it were confirmed by others in a more rigorous study–then a small but important behavioural shift in doctor behaviour might follow. A more open consultation in which the patient feels respected as a full partner may benefit both parties. All my intuition (and my personal experience, for I too dictate many letters in front of patients) tells me that his conclusions are right. But intuition is clearly insufficient evidence especially in such an emotive area.nnBefore I can be …