Surender R, Bradlow J, Coulter A, Doll H, Brown S S
Department of Public Health and Primary Care, University of Oxford, Radcliffe Infirmary.
BMJ. 1995 Nov 4;311(7014):1205-8. doi: 10.1136/bmj.311.7014.1205.
To compare outpatient referral patterns in fundholding and non-fundholding practices before and after the NHS reforms in April 1991.
Prospective collection of data on general practitioners' referrals to specialist outpatient clinics between June 1990 and January 1994 and detailed comparisons of three phases--October 1990 to March 1991 (phase 1), October 1991 to March 1992 (phase 2), and October 1993 to January 1994 (phase 3).
10 first wave fundholding practices and six non-fundholding practices in the Oxford region.
Patients referred to consultant out-patient clinics.
NHS referral rates increased in fundholding practices in phase 2 and phase 3 of the study by 8.1/1000 patients a year (95% confidence interval 5.7 to 10.5), an increase of 7.5% from phase 1 (107.3/1000) to phase 3 (115.4/1000). Non-fundholders' rates increased significantly, by 25.3/1000 patients (22.5-28.1), an increase of 26.6% from phase 1 (95.0/1000) to phase 3 (120.3/1000). The fundholders' referral rates to private clinics decreased by 8.8%, whereas those from non-fundholding practices increased by 12.2%. The proportion of referrals going outside district boundaries did not change significantly. Three of the four practices entering the third and fourth wave of fundholding increased their referral rates significantly in the year before becoming fundholders.
No evidence existed that budgetary pressures caused first wave fundholders to reduce referral rates, although the method of budget allocation may have encouraged general practitioners to inflate their referral rates in the preparatory year. Despite investment in new practice based facilities, no evidence yet exists that fundholding encourages a shift away from specialist care.
比较1991年4月英国国家医疗服务体系（NHS）改革前后，实行基金持有制和非基金持有制的诊所的门诊转诊模式。
前瞻性收集1990年6月至1994年1月期间全科医生转诊至专科门诊的数据，并对三个阶段进行详细比较，即1990年10月至1991年3月（第一阶段）、1991年10月至1992年3月（第二阶段）以及1993年10月至1994年1月（第三阶段）。
牛津地区的10家首批实行基金持有制的诊所和6家非基金持有制的诊所。
转诊至顾问门诊的患者。
在研究的第二阶段和第三阶段，实行基金持有制的诊所的NHS转诊率每年每1000名患者增加8.1例（95%置信区间为5.7至10.5），从第一阶段（107.3/1000）到第三阶段（115.4/1000）增加了7.5%。非基金持有制诊所的转诊率显著增加，每1000名患者增加25.3例（22.5 - 28.1），从第一阶段（95.0/1000）到第三阶段（120.3/1000）增加了26.6%。基金持有制诊所转诊至私立诊所的比率下降了8.8%，而非基金持有制诊所的这一比率增加了12.2%。转诊至地区边界以外的比例没有显著变化。进入第三和第四批基金持有制的四家诊所中，有三家在成为基金持有制诊所的前一年转诊率显著增加。
没有证据表明预算压力导致首批实行基金持有制的诊所降低转诊率，尽管预算分配方法可能在筹备年度鼓励了全科医生提高转诊率。尽管对基于诊所的新设施进行了投资，但尚无证据表明基金持有制会促使患者减少寻求专科护理。
