ECRS (extra-contractual referrals). Mind the gaps.

METHOD. Buckinghamshire HA's ECR account budget sheet was reviewed for a five-month period from April 1993, to identify adult mental health patients who were residents. Children under 16 and patients with physical disabilities were excluded from the study. All local consultant psychiatrists who either referred the patients or were responsible for their care were interviewed by a public health doctor, using a structured questionnaire. Basic demographic details, diagnoses, details of the ECR request, reasons for referral, current care needs and future patient plans were analysed for patients known by their consultants. RESULTS. Thirty-two patients were identified from the ECR account sheet. Twenty-eight patients were known by a local consultant and included in the analysis. Of the outstanding four patients (14 per cent), one had returned to their local provider unit but was still being invoiced as an ECR patient, and three were long-term chronically ill patients referred before ECRs were introduced.

The management of hyperlipidaemia: are specialist lipid clinics needed?

A survey of all general practitioners in Oxfordshire was undertaken to determine what use they wanted to make of a district lipid clinic, and to assess how effectively it met their needs. The response rate was 85% (288/340) but some respondents failed to answer each section of every question. One hundred and eighty-five general practitioners (64%) had previously referred patients to the clinic. Most respondents selectively asked for blood cholesterol measurements in patients with major cardiovascular risk factors (94%, 266/283), and few routinely asked for cholesterol as part of a health check (17%, 43/258). Most thought that referral to a clinic was appropriate for children (65%, 149/229), for patients aged 20 to 39 (85%, 209/247), and for older patients aged up to 60 (77%, 186/243). Ninety-four per cent (260/277) wanted access to specialist advice for patients with a cholesterol concentration exceeding 8.0 mmol l-1, and 73% (197/270) wanted specialist advice before starting treatment with a lipid-lowering drug. Although most respondents rated the service provided by the clinic favourably, more than half would have liked more information on prognosis, drug treatment, long-term follow-up, and screening of family members. We conclude that general practitioners would like access to specialist advice for the management of severe hyperlipidaemias, and that cardiovascular screening programmes in primary care have important resource implications for specialist services.

Lessons in class.

In the second of two articles, Jenny Griffiths and colleagues look at the evolution of health promotion in Oxford region over five years in the light of The Health of the Nation.