Freeman G K, Meakin R P, Lawrenson R A, Leydon G M, Craig G
Division of Primary Care and Population Health Sciences, Imperial College School of Medicine, Chelsea & Westminster Hospital, London.
Br J Gen Pract. 1999 Feb;49(439):107-10.
In 1992, the Tomlinson Report recommended a shift from secondary to primary care, including specific primary care provision in accident and emergency (A&E) departments. Availability of short-term so-called Tomlinson moneys allowed a number of experimental services. A study of the experience of A&E-based staff is reported to assist general practitioners (GPs) and purchasers and identify areas for further research.
To find the number and scope of primary care facilities in A&E services in North Thames; to find factors encouraging or inhibiting the setting-up of a successful service; to examine the views of a range of A&E staff including GPs, consultants, and nurses; and to suggest directions for more specific research.
A postal questionnaire was sent to all North Thames A&E departments, and an interview study of staff in one unit was arranged, leading to a questionnaire study of all GPs employed in North Thames primary care services in A&E. This was followed by interviews of staff members in five contrasting primary care units in A&E.
By mid-1995, at least 16 of the 33 North Thames A&E departments ran a primary care service. Seven mainly employed GPs, the others employed nurse practitioners (NPs). Problems for GPs included unclear role definition and their non-availability at times of highest patient demand. GPs' reasons for working in A&E sometimes differed from the aims of primary care in an A&E service. Staff interviews revealed differing views about their role and about use of triage protocols. Ethnicity data were being collected, but not yet being used, to improve service to patients.
A number of benefits follow the introduction of primary care practitioners into A&E. Different models have evolved, with a variety of GP and NP staffing arrangements according to local ideas and priorities. There is some confusion over whether these services aim to improve A&E-based care or to divert it to general practice. Cost information is inadequate so far, though the use of GPs has shown the possibility of economy. Appropriate location of services requires clearer identification of costs. This may be possible for the proposed primary care groups.
1992年，《汤姆林森报告》建议从二级医疗转向初级医疗，包括在事故与急救（A&E）部门提供特定的初级医疗服务。短期的所谓“汤姆林森资金”使得一些实验性服务得以开展。本文报告了一项对在事故与急救部门工作的人员的经验研究，以协助全科医生（GP）和购买者，并确定进一步研究的领域。
了解北泰晤士地区事故与急救服务中的初级医疗设施的数量和范围；找出促进或阻碍成功设立此类服务的因素；考察包括全科医生、顾问医生和护士在内的一系列事故与急救部门工作人员的观点；并为更具体的研究提出方向。
向北泰晤士地区所有事故与急救部门发送了邮政调查问卷，并安排了对一个部门的工作人员进行访谈研究，随后对北泰晤士地区事故与急救服务中受雇的所有全科医生进行了问卷调查。接着对事故与急救部门中五个不同的初级医疗单位的工作人员进行了访谈。
到1995年年中，北泰晤士地区33个事故与急救部门中至少有16个开展了初级医疗服务。其中7个主要雇佣全科医生，其他的则雇佣执业护士（NP）。全科医生面临的问题包括角色定义不明确以及在患者需求高峰期无法提供服务。全科医生在事故与急救部门工作的原因有时与事故与急救服务中初级医疗的目标不同。工作人员访谈揭示了他们对自身角色以及分诊方案使用的不同看法。正在收集种族数据，但尚未用于改善对患者的服务。
将初级医疗从业者引入事故与急救部门带来了诸多益处。根据当地的想法和优先事项，已经形成了不同的模式，有多种全科医生和执业护士的人员配置安排。这些服务的目标是改善基于事故与急救部门的护理还是将其转移到全科医疗方面存在一些混淆。到目前为止，成本信息不足，不过使用全科医生已显示出节省费用的可能性。服务的合适地点需要更明确地确定成本。对于提议的初级医疗团体来说，这或许是可行的。
