Examines how evidence-based medicine can be applied in general practice, and how its benefits can be realized in the form of effective treatments. It argues for rational rationing, using clinical effectiveness to exclude ineffective measures. MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict Cover 1 Title Page 2 Copyright Page 3 Contents 4 About the authors 7 Foreword 8 1 An introduction to primary care 10 Primary care and the cost equation 10 Whence primary care? 11 Whither primary care? 12 The global context 12 The primary care vision 14 Primary care policy 15 What is happening to primary care? 17 Is general practice changing too? 20 The policy-drivers 20 The paradigm shift takes hold 22 References 24 2 A primary care-led NHS in the modern world 26 The independent contractor 26 The impact of reform 27 Continuing reform 30 The political objectives of reform 32 The need for leadership 33 A new primacy for primary care 35 The politics of primary care 35 Medical politics 36 The extension of partnership 38 The power thing again 39 Party politics and primary care 39 References 40 3 Evidence-based medicine in general practice 42 The NHS R&D strategy and beyond 42 It's not as bad as it seems 46 In fact, it's quite promising 47 Off-the-shelf information and experience 51 The future will look like this 52 And these are worth more than a passing glance 52 References 53 4 A hierarchy of primary care needs 56 The grief reaction 59 The pace of change 60 Management 62 Practice administration or practice management? 64 A hierarchy of needs in primary care 66 References 70 5 Delivering the evidence 72 Continuing medical education for the 21 st century 73 Can we start from here? 74 Chance, bias and confounding variables 76 Types of study 77 Observational - hypothesis-forming 78 Analytical - hypothesis-testing 78 Tests of significance 87 Probability 87 Confidence intervals 88 Advantages and disadvantages of difference types of study 88 Getting appraisal skills into practice 90 Barriers 91 Sources of information 91 Uses of Medline 92 The Internet 94 Guidelines, protocols and electronic reminders 95 Managing the environment 96 Overcoming professional inertia and perceived usefulness 97 Bringing it all together 97 References 98 6 Choosing priorities and targeting action 100 linking to need 100 Local commissioning 101 The Health of the Nation 103 The example of heart disease 103 Selecting a disease or condition 109 Collecting data 110 Problems with the GP computer data 111 Making audit work 112 Collaborative enquiry 113 Summary 117 References 117 7 Realizing the benefits 120 Benefits for the patients 120 Benefits for the doctors 121 Benefits for the economics of health services 121 Better clinical outcomes and population benefits 122 Improving prescribing practice 123 Effective use of health services 125 Effective and appropriate care 126 The trouble with nihilism 127 The Health of the Nation and evidence-based medicine 128 An evidence-based health care market 129 References 130 8 Future prospects for clinical effectiveness in primary care 132 The role of the public voice 132 The educational challenge 134 The paradoxes of knowledge 134 The financial aspects of effective health care 136 The limitations of clinical effectiveness 137 The future of primary care 137 References 139 Index 140
