Roland Petchey

'The last resort would be to go to the GP'. Understanding the perceptions and use of general practitioner services among people with HIV/AIDS

In England and Wales, departments of Genito-Urinary Medicine have led the clinical response to HIV infection and AIDS (HIV/AIDS). They provide an open-access self-referral service on a basis of strict confidentiality. People with HIV/AIDS have been found to be reluctant to involve their general practitioner (GP) in their care. Previous research has not investigated their decisions about service use in the context of their broader strategies for coping with the multiple psychological and social challenges, which are posed by HIV/AIDS as a chronic, stigmatised condition. We report a depth-interview study of twenty people with HIV/AIDS in a low-prevalence nonmetropolitan urban area of England. Their health care choices were products of complex judgements. Five concerns predominated: expertise, security, rights to care, confidentiality and the maintenance of normality. Transfer to GP care signified a transition from essential wellness to essential illness and represented a loss of biographical continuity. Their other concerns express problems of information management, which are universal features of stigmatising conditions. These may be heightened in the case of locally provided services, where any leakage of discrediting information is likely to impact directly on everyday life. These concerns should be understood and respected in policy initiatives to develop services.

A prescription for improvement? An observational study to identify how general practices vary in their growth in prescribing costs

Abstract Objective: To identify how some general practices have low growth in prescribing costs relative to other practices. Design: Observational study. Setting: Trent region of England. Participants: 162 general practices: 54 with low growth in prescribing costs, 54 with average increases in costs, and 54 with large increases in costs. Main outcome measures: Changes in prescribing costs in therapeutic categories in which it has been suggested that savings can be made. Results: There were significant differences between the three groups of practices in terms of their changes in prescribing costs for almost all the variables studied. For the group of practices with lowest growth in costs the most important factors were reducing numbers of prescription items and costs per item; relatively low growth in the costs of “new and expensive” drugs; increasing generic prescribing; and reducing costs for modified release products. This group of practices did not increase costs as much as the others for lipid lowering drugs (P=0.012) and hormone replacement therapy (P=0.007). The practices with the greatest increases in costs had particularly large increases for proton pump inhibitors, selective serotonin reuptake inhibitors, and modified release products. Compared with the other groups these practices had larger increases in costs for “expensive hospital initiated drugs” (P=0.009). Conclusion: General practices vary in their growth in prescribing costs in many ways, with growth in costs for “new and expensive” drugs being particularly important.

A tale of two (low prevalence) cities: social movement organisations and the local policy response to HIV/AIDS

In the field of HIV/AIDS, social movement organisations (SMOs) have been identified as powerful potential catalysts for change through their impact on formal organisational structures and the policy process. In addition, they have the capacity to be important providers of services in their own right, through the community resources they are capable of mobilising. In the United Kingdom, however, their role in policy formation is disputed. Previous studies have concluded that they have been most influential at national policy and ward level. At the level of local policy making, their influence has been found to be patchy and confined largely to securing recognition of HIV as an issue. Most previous research has, however, been conducted in high prevalence, metropolitan settings with functional SMOs. This paper presents the results of a comparative case study of two neighbouring provincial low prevalence district health authorities (HAs) in England. We describe the changing national policy context from 1986 to 1995 and use a strategic change model to analyse the local development of care and treatment services for people with HIV/AIDS, in particular the relationship between SMOs and HAs. Despite being demographically, socioeconomically and epidemiologically similar, and sharing an identical national policy framework, the two districts demonstrate completely divergent organisational responses to the HIV/AIDS epidemic. We conclude that the level of prior social movement mobilisation and the degree of receptivity for change within the HA are the key variables for explaining variations in the scale of strategic change observed in the two districts.

NHS internal market 1991-2: towards a balance sheet.

The first year of the internal market in the NHS has been claimed to have resulted in increased efficiency. These claims, however, are hard to substantiate because the systems for operating the market are not fully in place. Examination of data on tax relief for private health insurance premiums for over 60s, general practice fundholding, and implementation and transaction costs suggest that much of the increased efficiency is not due to the reforms but to increased funding. Furthermore, some of the changes seem to be decreasing market forces and reducing efficiency.

Specialist Outreach Clinics in General Practice

Ed Martin Roland, Jonathan Shapiro Radcliffe Medical Press, £15, pp 120 ISBN 1 85775 218 X Specialist outreach clinics in general practice are not new, but their numbers have increased substantially since the introduction of general practitioner fundholding. Their character has probably altered also. Earlier schemes largely followed the “liaison-attachment” model, aimed at improving patient care through collaboration between general practitioners and specialists. Recent schemes mostly follow the “shifted outpatient” model: the location of care moves from hospital to the general practice surgery, but otherwise it remains …