This thesis examines the effects of general practitioners' use of a computer during consultations, on doctor-patlent communication and the delivery of care. The IBM Sheffield Primary Care System was used by GPs during routine consultations for the review and update of patients' records. The system also provided an interactive protocol for the management of patients with chronic hypertension. Video recordings were made of over 800 consultations with and without use of the computer. These were used to identify a comprehensive and reliable set of measures of doctor-patient communication. With medical collaboration measures of the standard of delivery of care were also developed. The measures were then used to investigate the effects of computer use. When used for the review and update of records the computer had little effect on doctor-patient communication. Doctors showed more solidarity with patients (e. g. by offering supportive comments), but there was no effect on the amount of information and advice offered or questions asked by either doctor or patient. However, overall, there was a slight impairment of the doctor's interpersonal manner and delivery of care. When the computer was used in direct support of clinical decision-making (i. e. through the hypertension management protocol) there was a marked improvement in the doctors’ clinical performance in terms of the number of relevant verbal and physical examinations conducted and recorded. The findings suggest ways in which future systems should be designed and used to avoid possible adverse consequences for doctor-patient communications. A research framework, including new methodologies, is also offered for the evaluation of future consulting room systems. Similar evaluative studies need to be performed on the more sophisticated systems now available, especially the clinically oriented ones which offer most potential.

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This study reviews the evaluative literature of air ambulances in other countries and concludes it has little relevance to Britain. Other reviews are undertaken of the British ambulance service, evaluative economics, and market istructures. The relationship between effectiveness, efficiency and equity is explored. It is concluded that there is a role for ak ambulances in servicing rural areas within the revised structure of the' NHS. This is tested by three studies of the Cornwall A k Ambulance. Initially, the resources and standards of the ambulance service in Cornwall are investigated by analysis of routine data spanning two years. It is concluded that standards of response and times to hospital are poor in North Cornwall. This was deduced from the modelling of response times and time to hospital for incidents from every electoral ward in the county. Two options of 'land ambulance only' and 'land ambulance with the air ambulance' are tested for effectiveness, equity and efficiency. The first study considers the effectiveness of service provision, while the second study considers geographic equity with the use of simple regression analysis to indicate the cost of service provision at differing levels of rurality. The^third uses a cost benefit analysis framework to indicate the costs and benefits associated with air ambulance use in a rural area. The contribution to knowledge is highly significant in the modelling of routine data to assess the effectiveness, efficiency and equity relationship, in appraising accessibility. This is the first study to apply economic principles to the ambulance service within the recently revised NHS.

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