McLean Gary, Guthrie Bruce, Sutton Matt
General Practice & Primary Care, University of Glasgow, Glasgow, UK.
BMC Health Serv Res. 2007 May 29;7:74. doi: 10.1186/1472-6963-7-74.
Health policy in the UK has rapidly diverged since devolution in 1999. However, there is relatively little comparative data available to examine the impact of this natural experiment in the four UK countries. The Quality and Outcomes Framework of the 2004 General Medical Services Contract provides a new and potentially rich source of comparable clinical quality data through which we compare quality of primary medical care for coronary heart disease (CHD), stroke, hypertension and diabetes across the four UK countries.
A cross-sectional analysis was undertaken involving 10,064 general practices in England, Scotland, Wales and Northern Ireland. The main outcome measures were prevalence rates for CHD, stroke, hypertension and diabetes. Achievement on 14 simple process, 3 complex process, 9 intermediate outcome and 5 treatment indicators for the four clinical areas.
Prevalence varies by up to 28% between the four UK countries, which is not reflected in resource distribution between countries, and penalises practices in the high prevalence countries (Wales and Scotland). Differences in simple process measures across countries are small. Larger differences are found for complex process, intermediate outcome and treatment measures, most notably for Wales, which has consistently lower quality of care. Scotland has generally higher quality than England and Northern Ireland is most consistently the highest quality.
Previously identified weaknesses in Wales related to waiting times appear to reflect a more general quality problem within NHS Wales. Identifying explanations for the observed differences is limited by the lack of comparable data on practice resources and organisation. Maximising the value of cross-jurisdictional comparisons of the ongoing natural experiment of health policy divergence within the UK requires more detailed examination of resource and organisational differences.
自1999年权力下放以来，英国的卫生政策迅速分化。然而，可用于研究这一自然实验在英国四个国家所产生影响的比较数据相对较少。2004年全科医疗服务合同的质量与结果框架提供了一个新的且可能丰富的可比临床质量数据来源，我们借此比较英国四个国家冠心病（CHD）、中风、高血压和糖尿病的初级医疗护理质量。
进行了一项横断面分析，涉及英格兰、苏格兰、威尔士和北爱尔兰的10,064家全科诊所。主要结局指标为冠心病、中风、高血压和糖尿病的患病率。四个临床领域在14项简单流程、3项复杂流程、9项中间结局和5项治疗指标方面的达成情况。
英国四个国家之间的患病率差异高达28%，但这并未反映在各国之间的资源分配上，而且使高患病率国家（威尔士和苏格兰）的诊所处于不利地位。各国在简单流程指标上的差异较小。在复杂流程、中间结局和治疗指标方面发现了更大的差异，最明显的是威尔士，其护理质量一直较低。苏格兰的质量总体上高于英格兰，北爱尔兰的质量最稳定地处于最高水平。
先前发现的威尔士在等待时间方面的弱点似乎反映了威尔士国民保健服务体系中一个更普遍的质量问题。由于缺乏关于诊所资源和组织的可比数据，对观察到的差异进行解释受到限制。要使英国境内正在进行的卫生政策分化自然实验的跨辖区比较的价值最大化，需要更详细地审视资源和组织差异。
