Bosanquet N, Leese B
Centre for Health Economics, University of York.
Br Med J (Clin Res Ed). 1988 Jun 4;296(6636):1576-80. doi: 10.1136/bmj.296.6636.1576.
Family doctors have been presented with changes in government policies and incentives in a recent white paper on primary care. Little work has been done, however, to find out how general practitioners respond to such measures. The response of general practitioners to professional and economic incentives was examined in relation to the location of the practice and the characteristics of the practitioners in seven different areas of England. The areas represented urban, rural, affluent, and deprived communities. The overall response rate was 74%, but the response varied among the areas, being poorest (64%) in an inner city area. Practices were subdivided as innovative, traditional, or intermediate, according to whether they employed a nurse and participated in the cost rent scheme and the vocational training scheme. Innovative practices were defined as fulfilling two of these criteria and traditional practices as fulfilling none; the remainder were classed as intermediate. The results showed that these three types of practice had distinct strategies that were related to financial constraints and the local population. Innovative practices had more partners and were often located in rural or affluent suburban areas; traditional practices had fewer partners and were more common in urban and working class areas. Innovative practices seemed to be in the best position to increase their services, and hence their incomes, in response to the recent proposals in the white paper. Practices in areas of developmental difficulty (predominantly urban but not necessarily inner city areas) had been less able to respond to existing incentives and had a smaller margin available for developing their services. In view of the effect of local constraints of economics and population on the strategy of practices, concentrating resources for primary care in local budgets for working class and urban areas may be preferable to extending the system of charging fees for services provided by family doctors.
在最近一份关于初级医疗保健的白皮书中，家庭医生面临着政府政策和激励措施的变化。然而，对于了解全科医生如何应对这些措施，所做的工作甚少。在英格兰七个不同地区，针对全科医生对专业和经济激励措施的反应，与诊所的位置及医生的特征进行了研究。这些地区代表了城市、农村、富裕和贫困社区。总体回应率为74%，但各地区的回应情况有所不同，其中一个市中心城区的回应率最低（64%）。根据诊所是否雇佣护士、是否参与成本租金计划和职业培训计划，将诊所分为创新型、传统型或中间型。创新型诊所被定义为满足其中两条标准，传统型诊所则一条都不满足；其余的归为中间型。结果表明，这三种类型的诊所具有与财务限制和当地人口相关的不同策略。创新型诊所合伙人更多，且通常位于农村或富裕的郊区；传统型诊所合伙人较少，在城市和工人阶级地区更为常见。创新型诊所似乎最有能力根据白皮书中的最新提议增加服务，从而增加收入。处于发展困难地区（主要是城市地区，但不一定是市中心城区）的诊所，对现有激励措施的反应能力较弱，且用于发展服务的空间较小。鉴于当地经济和人口限制对诊所策略的影响，将初级医疗保健资源集中在工人阶级和城市地区的地方预算中，可能比扩大家庭医生提供服务的收费系统更为可取。
