Dose dependent response of symptoms, pituitary, and bone to transdermal oestrogen in postmenopausal women

The figure compares the costs inherent in each mode. One third of a consultation's costs are allocated to administration; this is taken as one cost unit, which happens to approximate to the average cost of one item on prescription. No account is taken of opportunity costs by the patient through loss of earnings or by the fact that the specialist clinic continues to function. Nevertheless, the model shows that referral as an outpatient, for example, may be seen to be a highly expensive management decision. Morbidity studies of general practice show that the referral option is exercised with a high degree of discrimination (about 1 in 10). The general practitioner thus plays a key role in "sparing" expensive specialist resources. Nevertheless, there is a wide range of variation, suggesting that there may be scope for creating a greater awareness of cost effectiveness in primary care. Issuing a prescription may be obviated by using the counselling mode, but at the expense of consulting time. The figure shows the relative insignificance of prescribing as a cost, yet this management option has received so much attention. We need a reappraisal of primary medical care costs in a fuller context, to include the general practice-hospital interface and the public.3 J D E KNOX University Department of General Practice, Westgate Health Centre, Dundee DD2 4AD