Scott A
Department of Public Health University of Aberdeen, Foresterhill.
J Public Health Med. 1996 Mar;18(1):19-26. doi: 10.1093/oxfordjournals.pubmed.a024456.
The substitution of primary for secondary care is progressing at a fast pace, yet there has been little evaluation of the appropriateness of such a fundamental change in health service organization. The aim of this paper is to raise some issues for discussion about the contribution of economics to future research on the substitution of primary for secondary care. Given the central role general practitioners (GPs) will play in a "primary care led' National Health Service, the paper concentrates on the replacement of secondary care by GP-based services.
The existing empirical evidence relevant to the replacement of secondary care by GP-based services is summarized. From this, issues for further research from an economic perspective are identified and discussed.
The evidence comprises studies examining the efficiency or cost-effectiveness of substituting GP-based care for secondary care and studies examining the effects of incentives on the mixture and range of services provided. Cost-effectiveness evidence is scarce and inconclusive. The evidence on incentives suggests that new services are being provided in local areas which need them least. Several avenues of further research are suggested. As well as more economic evaluation, future research should concentrate on developing methods to elicit patients' and communities' preferences for GP-based care versus secondary care. Research into incentives should concentrate on assessing those factors, beyond practice characteristics, that influence GP's decisions about whether to provide services and how much to provide. This would help to design more appropriate incentives for GPs.
The appropriate balance between primary and secondary care is unknown. The transfer of services from secondary care to general practice (and other primary care providers) should be based on empirical evidence on cost-effectiveness, as should the incentives given to GPs. Although the research agenda is challenging, it is necessary in ensuring that a "primary care led' health system is the right way forward for the NHS.
初级医疗取代二级医疗的进程正在快速推进，但对于医疗服务组织这一根本性变革的适宜性，却鲜有评估。本文旨在提出一些问题以供讨论，内容涉及经济学对未来初级医疗取代二级医疗研究的贡献。鉴于全科医生（GPs）在“以初级医疗为主导”的国民医疗服务体系中将发挥核心作用，本文聚焦于以全科医生为基础的服务取代二级医疗的情况。
总结了与以全科医生为基础的服务取代二级医疗相关的现有实证证据。据此，从经济角度确定并讨论了进一步研究的问题。
证据包括考察以全科医生为基础的医疗取代二级医疗的效率或成本效益的研究，以及考察激励措施对所提供服务的组合和范围的影响的研究。成本效益证据稀缺且尚无定论。关于激励措施的证据表明，新服务正在最不需要它们的地区提供。文中提出了几个进一步研究的方向。除了更多的经济评估外，未来的研究应集中于开发方法，以了解患者和社区对以全科医生为基础的医疗与二级医疗的偏好。对激励措施的研究应集中于评估那些除了执业特征之外，影响全科医生关于是否提供服务以及提供多少服务的决策的因素。这将有助于为全科医生设计更合适的激励措施。
初级医疗和二级医疗之间的适当平衡尚不清楚。从二级医疗向全科医疗（以及其他初级医疗提供者）的服务转移应基于成本效益的实证证据，给予全科医生的激励措施也应如此。尽管研究议程具有挑战性，但对于确保“以初级医疗为主导”的卫生系统是国民医疗服务体系的正确发展方向而言，这是必要的。
