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Disease management has been marketed by healthcare industry providers as a way of improving resource allocation in healthcare and containing costs. However, to achieve improved efficiency in healthcare requires the guidelines and protocols in the disease management process to be based on sound evidence of effectiveness and cost effectiveness. This has not always been the case. The approach itself has an inadequate evidence base in terms of randomised controlled trials, other rigorous methods of evaluation and the results of economic evaluation. Disease management can be viewed as an attempt by pharmaceutical companies to undertake forward vertical integration into other parts of the healthcare process. This could reduce uncertainty for purchasers and reduce transaction costs, thereby potentially facilitating both healthcare expenditure control and efficiency. However, such cost savings may be outweighed by a concentration of power in disease management (pharmaceutical) companies, and the exploitation of such power to inflate expenditure and misallocate resources. Disease management must be appraised with care.

Two remarkable aspects of the Thatcher ‘internal market’ reforms of the NHS were the focus on creating a market for hospital services and the way in which primary care was treated almost peripherally in the 1989 White Paper (Department of Health 1989a). The 1991 NHS reforms introduced general practitioner (GP) fundholding almost as an afterthought, and the revision of the GP contract in 1990 Paper (Department of Health 1989b) was conducted separately from the implementation of other health care reforms. In contrast the principal focus of Labour’s ‘new NHS’ reform is primary care (Department of Health 1997). The intention of the government is both to improve the efficiency and equity of primary care provision and to develop Primary Care Groups and Primary Care Trusts which both provide care efficiently and act as agents who purchase secondary and tertiary care on behalf of patients. This is an ambitious agenda. This paper explores the policy context of Primary Care Groups in sections 1 and 2, describes and appraises the government proposals in section 3, and identifies major issues involved in the implementation of change in section 4.

Pharmaceutical prescribing currently represents around 10% of total National Health Service expenditure, and is one of the most inflationary elements of spending (Parliamentary Office of Science and Technology 1993). Between 1980 and 1990, the overall cost of a prescription increased by 19%. Pharmaceuticals are one of the most commonly used and important interventions available to doctors in clinical practice, and their appropriate use can reduce mortality, morbidity and costs falling on other parts of the health care system. However, evidence from systematic reviews demonstrates that current prescribing may not always be effective or cost-effective (Effective Health Care, 1993). A number of policy initiatives have been introduced which attempt to contain prescribing costs. These include provision of Prescribing Analysis and Cost (PACT) data; the limited list; the indicative prescribing scheme and GP fundholding. However, these schemes have had limited impact and tend to focus on cost containment rather than cost-effectiveness in prescribing. Confusion remains concerning current knowledge and good practice in cost-effective prescribing. This confusion could be reduced with appropriate research making use, where possible, of the valid and reliable routinely collected activity data available on prescribing in the UK. In other countries, particularly Australia and Canada, policies have been introduced to limit the introduction of new drugs to those which demonstrate cost-effectiveness. Other countries, including European countries and the United States, are encouraging provision of economic evaluations of pharmaceuticals and have introduced varying initiatives to control prescribing costs and increase cost-effectiveness. UK policy initiatives should be informed by the experience of other countries. There is a considerable inertia in prescribing habits, and evidence of effectiveness and cost-effectiveness, when it exists, is not always used. A number of organisations are attempting to improve this situation. The NHS Centre for Reviews and Dissemination, at The University of York, produces and commissions systematic reviews of specific health-related questions, and disseminates these findings throughout the NHS. The Cochrane Collaboration, at the UK Cochrane Centre in Oxford and around the world, aims to produce systematic reviews of randomised controlled trials. The Cochrane Collaboration for Effective Professional Practice, an international collaboration with an editorial office at The University of York, conducts systematic reviews of initiatives aimed at changing professional behaviour. These and other organisations all attempt to improve the process of getting good evidence about health care interventions (including prescribing) into practice.

This is the third of three papers that review international policies to control spending on drugs and to improve the efficiency of drug use. This paper reviews policies regulating the supply of drugs, particularly licensing and reimbursement controls, price and profit regulation. Price and profit controls contain few incentives for improving cost effective use of drugs, and focus on cost containment and profitability of domestic industry. Carefully monitored economic evaluation could lead to improvements in efficiency and benefits to patients and the health care system.

The United Kingdom's National Health Service (NHS), created in 1948, is a publicly financed system that provides universal access to health care within a moderate and fixed budget. Reforms introduced in 1991 by the government led by Prime Minister Margaret Thatcher sought to contain costs, maintain equity, and at the same time make the allocation of resources more efficient by introducing some features of a market, constrained by the overall budget and the principle of universal access. These reforms created what is known as an “internal market” in health care, in which providers are permitted a degree of competition. Publicly . . .

The allocation of funding and the distribution of the workforce in primary care is very unequal in England. Whilst hospital resources have been allocated in relation to a weighted capitation formula in each of the component parts of the United Kingdom since the late 1970s, there have been minimal efforts to equalise the distribution of general practitioners and the budgets which finance them and the services they provide. The purpose of this paper is to illustrate both the existing inequalities in the distribution of primary care funding and the impact of alternative, simplistic but illustrative formulae which could be used as a basis for achieving more equitable funding of primary care in England. These calculations show hat a weighted capitation formula would have a significant impact on the old fourteen regions of the English NHS with major losses in funding and staffing levels in the South, particularly the South West, and major gains in the North of England. For example, using one of the models, the South West would have lost 14 per cent and the Northern region gained over 9% of FHSA expenditure with ‘RAWPed’ primary care budgets in 1990-91. The pursuit of greater equity in primary care funding may require a radical change in the GP contract, perhaps with it being replaced by franchises for primary care which are let to multi-disciplinary teams of providers. Such change requires careful evaluation to ensure that the hospital gatekeeper role of the GP is maintained and the incentives to ensure efficient use of scarce primary care resources are improved.

Non-steroidal anti-inflammatory drugs (NSAIDs) are used widely throughout the world to relieve the symptoms of musculoskeletal disorders, in particular osteoarthritis and rheumatoid arthritis. These drugs produce significant side effects, including gastro-intestinal ulceration and the associated complications of perforation and bleeding. The relative toxicity of competing forms of branded and generic NSAID scary considerably. Their cost also varies considerably, often with the relatively more toxic formulations being more expensive. These characteristics, differing toxicity and cost, offer the possibility of reducing both adverse effects to patients and pharmaceutical expenditure if doctors’ behaviour can be changed. A tentative exploration of alternative patterns of NSAID use demonstrates that it may be possible to reduce expenditure below the 1994 level of around £175 million and reduce adverse events. An illustrative model shows that if prescribing was reduced by 25%, average dose reduced by 10% and patients switched to less toxic NSAIDS, up to £86 million could be saved, the number of serious adverse events per year reduced by 189 and the number of gastrointestinal complications reduced by 127. Such results may be achieved without reductions in the quality of life of patients using these drugs. Available clinical and economic information about NSAIDs is limited, with numerous published studies of poor quality which corrupt the knowledge base. Despite these problems there appears to be enough evidence to indicate that expenditure on NSAIDs could be considerably reduced and significant adverse effects could be avoided if general practitioners can be persuaded to change their prescribing behaviour. Inefficient and inappropriate prescribing of these often beneficial but sometimes dangerous drugs appears to be wasting scarce NHS resources and harming patients.

Introduction Born in Bradford is a large multi-ethnic birth cohort drawn from the North of England. As background to comparing mental health across our sample we conducted a confirmatory factor analysis (CFA) and invariance testing for each of the four-factor seven-item subscales of the GHQ-28 for a bi-ethnic subpopulation. Methods We examined data from White (N=2011) and Pakistani-origin (N=1516) women who responded to the GHQ-28 in English. We fitted a single factor model to data from each subscale to the White subpopulation and tested for invariance against the Pakistani women9s data. Where configural invariance was indicated for a proposed factor we followed a model generation strategy for each subpopulation and tested for invariance on this reduced item set. Results In general, the models gave poor fit. Fit was acceptable when we reduced the number of items from seven to four for the Somatic, Anxiety/Insomnia and Severe Depression subscales. The unmodified Social Dysfunction subscale fitted both groups adequately. After correcting for differential item functioning (Item 4, Felt ill) we found Pakistani women were more likely to have worse scores on the reduced Somatic subscale (d=0.10, p Conclusion The unmodified GHQ -28 subscales did not fit a CFA model well and modifications were needed to ensure measurement equivalence. Pakistani women in this preliminary dataset fared significantly worse on all measureable subscales than White women.

Introduction Born in Bradford is a large multi-ethnic birth cohort drawn from the North of England. We describe the risk factors associated with poor mental health in pregnancy for White and Pakistani-origin women. Methods We examined data from White (N=1901) and Pakistani (N=1360) women who completed the GHQ-28 in English. We used univariate and multivariate logistic regression to examine socio-demographic risk factors associated with scoring above the conventional threshold for poor mental health. We conducted a sensitivity analysis on the threshold method by comparing the highest and lowest scoring quintile within each ethnic group. Results 43% of White and 47% of Pakistani women scored above the threshold. For White women univariate risk factors were not living with a partner, self-reported financial worries and less education. For Pakistani women not being in a relationship and having financial worries were associated with poor mental health. Significant variables remaining in the multivariate models for both groups were financial worries (White OR 2.4, 95% CI 2.0 to 3.0; Pakistani 2.7, 2.1 to 3.5) and not being in a relationship (White 1.4, 1.0 to 2.1; Pakistani 2.6, 1.0 to 6.5). Sensitivity analyses indicated the same significant risk factors with the addition of cohabitation and younger age in the univariate analyses for White women. Pakistani women had worse within-quintile scores than White women (highest quintile difference 5.6 points, t=8.8, p Conclusion Prevalence and severity of poor mental health varies by ethnicity but consistency in the associated risk factors underline patterns of social disadvantage in both groups.

Has government expenditure on the National Health and Personal Social Services increased significantly in real terms over the past decade? If so, where has this growth in expenditure been utilised? This paper investigates claims of real increases in expenditure by examining trends in total expenditure on the NHS between 1979 and 1992, and disaggregating these trends to concentrate on different sectors, the influence of changes in NHS personnel, the revenue/capital split and the geographical distribution of expenditure increases. The total cost of the UK NHS has increased from approximately £9.2 billion in 1978/79 to £37.4 billion in 1991/92. Adjusting this figure to account for general inflation shows a real increase of 50.4% over this period. This gives a reflection of the increased cost of the NHS to the economy. However, adjusting the increases to account for changes in NHS pay and prices shows a smaller increase, of about 22% over the period, an average annual increase of around 1.5%. As NHS costs are taken into account, this measures what the NHS is able to buy with the increased resources. Increases in expenditure have not been evenly distributed between different sectors. The smallest relative increases have been in the hospital sector, which have absorbed a decreasing proportion of overall NHS and PSS expenditure over the period. The relative restriction on hospital budgets during the 1980s contributes greatly to the public perception of a parsimoniously funded health service. Expenditure on community health services has increased by the greatest proportion over the period, but this is still a small, though increasing, proportion of overall expenditure. The family health services budget (which funds primary care) has remained relatively stable as a proportion of overall expenditure over the 1980s. This means that significant real increases have taken place. This is due largely to increases in general practitioner and other staffing. Between 1980 and 1991, the number of GPs increased by around 19%, with average list sizes decreasing from 2,247 to 1,918. In addition, GPs have increasingly employed nursing and other support staff. There has also been increasing expenditure on pharmaceutical services (the government’s net expenditure on pharmaceuticals has increased by around 47% over the period 1778-79 to 1991-92). Finally, expenditure on personal social services has increased at around the same rate as overall health and PSS expenditure. The NHS is a labour intensive service, and this means that changes in personnel have major expenditure implications. Over the period studied, numbers of whole-time equivalent medical (particularly senior medical) and nursing staff increased steadily, and these staff received significant real increases in salary levels. There were also increases in the number of professional and technical staff and administrative and managerial staff. Numbers of whole-time equivalent administrative and clerical staff increased from 105,430 in 1980 to 129,716 in 1990, i.e. by around 23%. There were, however, significant reductions in numbers of directly employed works professional, maintenance and ancillary staff, due to government policies of contracting out these services. The resource consequences of the apparent shift towards relatively high paid staff are substantial, and if these trends continue the overall wage bill for the NHS will continue to increase considerably even if staff numbers do not. The majority of NHS expenditure is current expenditure, primarily on salaries and wages, with capital expenditure representing around 5-6% of total NHS expenditure in England over this period. Geographical distribution of hospital and community health services expenditure has also changed relatively little, despite the implementation of the RAWP formula for HCHS in England and similar formulae subsequently and elsewhere in the UK. No attempt has yet been made to equalise primary care spending using a RAWP-type allocation formula. This is surprising given the government’s emphasis on the integration of primary and secondary care and the primacy given to the services managed by general practitioners. The ‘Waiting List Initiative’ and more recent government pledges in the ‘Patients’ Charter’ were aimed at reducing waiting times, particularly the number of long waits, with guarantees that no one should wait more than two years for a procedure. This goal has been achieved but, as ever, supply creates demand in the absence of agreed clinical practice guidelines and the number waiting have, as a consequence, grown to over one million. This policy concentrates on activity, which is an unsuitable goal and an unusable measure of success. In allocating resources to the NHS, as in all other policy areas, the appropriate target should be efficiency. Increasing activity, where this activity is often of unproven effectiveness is inefficient and inappropriate. The level of public expenditure devoted to the National Health Service is largely a political decision – the overall budget, as in all other departments, is determined by the political bargaining of the annual public expenditure round. The settlement for 1994-95 includes a real funding increase and meets the 1992 Conservative election pledge, provided the Treasury estimates of inflation are correct (which is rare!) However, to achieve efficiency in the NHS, expenditure increases must be directed to areas of proven cost-effectiveness. This goal would be assisted by publication of more detailed breakdowns of NHS expenditure increases and more economic evaluation of new and existing health care programmes. In future there will be increasing pressure on limited NHS resources due to demographic change and technological advance. The vague ways in which NHS expenditure is monitored and “value for money” determined will have to be replaced by more sophisticated monitoring of spending and the provision of cost effectiveness data to ensure society’s scarce health care resources are used effectively. There is evidence of considerable scope to improve the efficiency of resource allocation in the NHS and this may be best achieved by the ‘leverage’ of parsimonious funding.

Value based pricing does not remove the need for rigorous analysis of the cost effectiveness of new drugs

Objective Most women who stop smoking during their pregnancy will relapse within the first 6 months after birth, with health risks to the mother and family. There have been few UK-specific studies identifying factors associated with relapse. Such information would help health care providers identify those most at risk so that extra support and resources can be targeted. We examined whether a small set of factors that are potentially readily measured or observable in routine health care settings were associated with women at risk for relapse postpartum. Design and setting Analysis of the first wave of the Millennium Cohort Study. Variables in the final model were selected using backwards logistic regression weighted to account for the complex survey design. Participants 2353 natural mothers who reported quitting smoking during their pregnancy. Main outcome measure Postpartum smoking relapse. Results 58% of mothers who quit during pregnancy were smoking again at 9 months. Only 16.2% of smoking couples quit together. The strongest risk factors were related to postnatal partner smoking status and single parenthood. Compared to mothers with a non-smoking partner, the risk of relapse was higher for those with a partner who smoked at 9 months (OR 3.2, 95% CI 2.6 to 3.9), a partner who smoked antenatally (1.2, 1.4 to 2.1), and those who had no live-in partner postnatally (3.2, 2.2 to 4.8) or antenatally (2.3, 1.5 to 3.4). Other significant risk factors remaining in the models were the mother having no-one to share her feelings with, drinking 1–2 times a month or 1–2 times a week, having fewer educational qualifications and more children in the household. Factors that did not appear to be influential in the final models were age, ethnicity, change in marital status from birth to 9 months, depression history, financial status, timing of entry into ante-natal care, feelings about the pregnancy or breastfeeding. Conclusion Pragmatic variables can be used to identify women at higher risk for relapse. The validity of these findings are potentially limited by the inability to measure antenatal intent to relapse, the smoking cessation and relapse prevention interventions actually received, and timing/sequence of relapse for partner-mother pairs in this data set. Both partner smoking habits and single marital status are strongly associated with relapse and can be readily identified both antenatally and postnatally by healthcare providers.

It is essential that excellence in the performance of doctors in the National Health Service is rewarded explicitly and efficiently. Unfortunately the existing system of Distinction Awards which, for the select few, can double a doctor’s public sector pay is both secretive and of unproven efficiency. Distinction awards have existed since 1948 and at present 34% of consultants receive them. They are payable at four levels: A+ at £46,500 per year, A at £34,260 p.a., B at £19,580 p.a. and C at £9,790 p.a. Since 1989 a few managers have been involved in the allocation of ‘C’ awards but all the other awards are determined by committees of consultants who meet in secret to decide who deserves rewards for “distinction”. The costs of these awards, in excess of about £80 million per year, have to be met by the hospital in which the consultants are employed. Ideally these payments should be related to performance and their award should act as signals to NHS purchasers and customers regarding the excellence of the care that is available. Unfortunately a rationale for these payments is absent. It may be that their allocation reflects excellence in some way but this has not been demonstrated by the advisory committee on Distinction Awards. Indeed the secrecy of the award system and the difficulty of explaining the distribution of awards with available “indicators” works to sustain a conspiracy theory that the awards are made to “the boys” to inflate their income whilst in practice and their pensionable earnings after they retire. Such assertions do little to enhance efficiency and the development of effective clinical management. The distribution of distinction awards between specialties and regions is described, and attempts are made to evaluate its efficiency. This statistical analysis shoes that there is little relationship between the value of awards and available crude indicators of productivity. Tens of millions of pounds are used annually to fund the system of distinction awards for NHS consultants. Those who determine the use of these resources are not accountable for them and few NHS managers understand the system let alone recognise the need to reform it and facilitate the true reward of excellence. There is a need for the medical profession to deal explicitly with payment for excellence and also for them to realise that such a remuneration system will have to be controlled in conjunction with NHS managers. Both professional groups, clinicians and managers must move rapidly to reform the way in which clinical excellence is rewarded in the NHS.

Despite radical reform in the NHS and the creation of purchaser-provider contracting, the pattern of doctors’ remuneration remains largely unaltered. Doctors are the key agents in access to the health care system, and the services they control determines who survives and who lives in pain and discomfort. Does the present system of doctors’ payment reflect their worth and produce efficient medical practice and good patient care? General practitioners are paid a target income of £40,010 p.a. which is partly made up of capitation payments (about 60% of total income) and fees per item of service. The cost effectiveness of many of the GP services rewarded by fees is unproven. Hospital consultants are paid a salary (£37,905 to £48,945 p.a.) and as many as one in three also receive a distinction award at varying levels, the top grade of which (£46,500) can double a consultant’s salary. Hospital specialist services appear to be organised in an anachronistic fashion (in medical and surgical “firms”) of unproven cost effectiveness. The allocation of distinction awards is covert and, like the salary, does not efficiently relate workload and quality to rewards. In addition to their salary and distinction awards, some 12,000 consultants have private practices and earn from this source alone an average of £40,000 per year. Could this be time for NHS Trust managers to reform payment methods so that efficiency is rewarded appropriately? The US Medicare doctor remuneration system has been reformed so that fees are related to the work spent by doctors on particular services, in particular the time input and intensity of activity, with an allowance for practice costs. This method of relating pay to careful measurement of workload effort has led in the US to enhanced fees for family physicians and lower payments to some surgeons and radiologists and pathologists, i.e. rewards are targeted more appropriately. Ideally pay should be related to the outcome achieved, in terms of improved health. In the absence of measures of outcome, managers in the NHS could experiment with some UK variant of the new US remuneration system. If this alternative is not adopted, some other way of determining the worth of doctors must be found if efficient practices are to be rewarded and the providers of poor quality care penalised. The present system of remunerating doctors in the UK is an inefficient product of history and trade union (British Medical Association) power. Its careful reform, if evaluated thoroughly, is an essential element in the development of a more efficient and user friendly NHS.

We wish to clarify some points raised by Norton and colleagues in their editorial accompanying our papers.1 2 3 The subtitle, stating that nurse endoscopy “is as clinically effective as that delivered by doctors, but may cost more,” is inaccurate. We found doctors more cost effective because their outcomes were slightly better, …

The American economist Robert Solow argued that labour markets “cannot be understood without taking account of the fact that participants, on both sides, have well developed notions of what is fair and what is not.”1 This may explain why many NHS trusts in Britain have been reluctant to implement local pay mechanisms and performance related pay. As a result the creation of the NHS internal market has not led to a more efficient market for clinical labour. Indeed, opportunities have been missed—the recent review of the distinction award system, for example, paid little attention to incentives for efficiency.2 Nevertheless, the present government is retaining the purchaser-provider split and is likely to continue to seek efficiencies. With care and a common sense approach, economics can contribute to the analysis and improvement of the clinical labour market. Some approaches to the analysis of labour markets reflect Solow's common sense approach. Efficiency wage models, for example, accept that workers …

The recent report of the Organisation for Economic Cooperation and Development (OECD) on Britain's health care reforms1 has been welcomed by the secretary of state for health as “the most authoritative assessment of the reforms produced so far.”2 The report is largely enthusiastic about the internal market reforms of the NHS. This is not surprising since the economists who wrote it are generally advocates of competition. There is, however, concern that the report and its conclusions appear to be based on inadequate evidence. The endorsement of the reforms by such a prominent body should therefore not induce complacency about the need for a better research base for health policy. Health care reform has three main objectives: cost containment, equity, and efficiency (the relation between quality and cost). The OECD's report attributes the British health reforms to the belief of some policymakers “that an alternative system could be devised that retained the advantages of the NHS - universal coverage and cost control - while expanding consumer choice and reducing supply side inefficiencies.”1 It begins by comparing health spending and outcomes in Britain with …

Context Unilateral cochlear implantation is a cost-effective intervention for profound bilateral hearing loss. There is worldwide interest in providing implants bilaterally. Objective To use modeling to estimate the cost of gaining a quality-adjusted life-year by providing implants to both ears of profoundly postlingually deafened adults. Design Economic scenario analysis relating the costs of providing implants to estimates of the gain in health-related quality of life (utility) from unilateral and bilateral implantation. Setting Fourteen hospitals in the United Kingdom National Health Service and 1 Medical Research Council research unit. Participants Normal-hearing adult volunteers with knowledge of implantation (n = 70). Adults undergoing unilateral implantation who either did not benefit from acoustic hearing aids preoperatively (type 1, n = 87) or benefited marginally (type 2, n = 115). Main Outcome Measures Changes in utility from unilateral and bilateral implantation estimated with the time trade-off technique (volunteers) and from unilateral implantation measured with the Mark II Health Utilities Index (patients); costs of providing implants and sustaining patients who have undergone implantation (health care perspective). Results Gains in utility from unilateral implantation estimated by volunteers did not differ significantly from gains recorded by patients, giving credibility to the volunteers' estimate of the gain from bilateral compared with unilateral implantation. Cost-utility ratios, in pounds sterling per quality-adjusted life-year, based on volunteers' estimates, were £16 774 (type 1: unilateral implantation vs no intervention), £27 401 (type 2: unilateral implantation vs management with hearing aids), £61 734 (simultaneous bilateral implantation vs unilateral implantation), and £68 916 (provision of an additional implant vs no additional intervention). Conclusion More quality of life is likely to be gained per unit of expenditure on unilateral implantation than bilateral implantation.

This is the first of three papers to review international policies to control spending on drugs and improve the efficiency of drug use. Policies can target three main groups: patients, prescribing doctors, and the drugs industry. In this paper we examine policies aimed at patients, particularly restrictions on reimbursement (such as prescription charges). Rigorous experimental and quasi-experimental studies suggest that policies to limit the level of reimbursement of drugs reduce the use of essential as well as non-essential drugs and may do more harm than good. Spending on drugs in the British NHS represents over 10% of the total NHS budget and has increased steadily over recent decades.1 2 Similar increases have occurred in health care systems throughout the developed world, and governments have adopted policies to control drug costs that affect both the supply of and demand for drugs. We reviewed recent policy in several developed countries to provide insights for British health policy. We assessed the impact of these policies on prescribing by examining evaluative studies with rigorous designs that we identified through a comprehensive search strategy. In this paper we examine the impact of policies intended to reduce patient demand for drugs. In future papers we consider policies aimed directly at prescribers and policies intended to regulate the activities of the drugs industry. Policies to control drug costs and to improve the cost effectiveness of drug use in the developed world are subject to frequent change. We used published descriptive studies and extensive contact with experts in relevant countries to ensure that our review was up to date and that policy initiatives were interpreted correctly. Where necessary, foreign language publications were translated to enable up to date analysis of policy. In order to assess the impact of such policies in practice, and gaps in knowledge, we …

The UK NHS has a number of important strengths. Its costs are relatively low compared to the health care systems of other developed countries due in part to cash limited central budgeting. It is extremely popular with the electorate and surveys show overall satisfaction with the NHS despite some dissatisfaction with waiting lists and a public perception of underfunding. The NHS model of general medical care provided by independent contractors has been acclaimed as "a British success" (General Medical Services Council, 1983). The role of the UK GP combines providing primary care and acting as a gatekeeper to secondary care. This increases equitable access to care for the population and assists in cost containment. As a model, it is currently being emulated in other countries including Sweden and US Health Maintenance Organizations but, as in these countries, the UK primary care model has been evaluated poorly. There are of course continuing weaknesses in the UK health care system. There is insufficient knowledge upon which to base health care services and increase efficiency. In the future, if a knowledge-based health care service is to be created, a considerable amount of research and evaluation is required to identify "what works" in health care (i.e., what is effective) and also the cost effective ways of altering provider behaviour to maximise the amount of health gain which can be achieved using a limited budget. The NHS reforms created a lot of enthusiasm and energy but its effects are difficult to disentangle from the simultaneous increases in funding. There is little evidence from the UK or elsewhere that competition in health care produces efficiency or improvements in resource allocation. Evaluation is required to identify which of the reforms are increasing efficiency. Competition needs to be used with caution and recognised as a mean and not an end in itself. It is remarkable how both clinical practice and health policy reform, in the UK and elsewhere, is poorly evaluated. Medical practice varies substantially locally, regionally, and internationally, e.g., patients with similar age and stage of cancer receive very different levels of radiotherapy across Europe. For most interventions, the appropriate level of treatment may be asserted but is not based on cost effectiveness knowledge. Health policy analysts, like clinicians, make assertions about competition and other health care reforms which are value- rather than knowledge-based. Both groups of decision-makers should be more cautious, informing their choices with research rather than relying on unsubstantiated optimism!

After the introduction of Bassini's procedure in the late 19th century, methods of repairing hernias changed little until the 1990s, when synthetic mesh and laparoscopic methods arrived.1 In contrast to the open mesh technique, laparoscopic surgery remains uncommon. In January 2001, the National Institute for Clinical Excellence (NICE) issued guidance that stated, “For repair of primary inguinal hernia, open [mesh] should be the preferred surgical procedure.”2 We describe patterns of surgical repair of inguinal hernias and assess the impact of NICE's guidance. We found 217 000 cases with a primary procedure code for primary surgery for an inguinal hernia from the hospital episode statistics database for England from April 1998 to December 2001. Of these, secondary procedure codes for minimal access surgery identified 8960 (4.1%) cases in which surgery was laparoscopic. We …

Background: Poor maternal mental health can impact on children’s development and wellbeing; however, there is concern about the comparability of screening instruments administered to women of diverse ethnic origin. Methods: We used confirmatory factor analysis (CFA) and exploratory factor analysis (EFA) to examine the subscale structure of the GHQ-28 in an ethnically diverse community cohort of pregnant women in the UK (N = 5,089). We defined five groups according to ethnicity and language of administration, and also conducted a CFA between four groups of 1,095 women who completed the GHQ-28 both during and after pregnancy. Results: After item reduction, 17 of the 28 items were considered to relate to the same four underlying concepts in each group; however, there was variation in the response to individual items by women of different ethnic origin and this rendered between group comparisons problematic. The EFA revealed that these measurement difficulties might be related to variation in the underlying concepts being measured by the factors. Conclusions: We found little evidence to recommend the use of the GHQ-28 subscales in routine clinical or epidemiological assessment of maternal women in populations of diverse ethnicity.

A propos de 282 morts enregistrees entre 1971 et 1983. Augmentation notable de la frequence des morts, malgre les efforts d'information et l'impression que l'abus serait «passe de mode»