Objective-To collect a valid, complete, con-, tinuous, and representative database of morbidity presenting to primary care and to use the data to help commission services on the basis of local need and effectiveness.Setting-Computerised general practices in Somerset.Methods-Participating general practices were selected to be representative of the district health authority population for general practice and population characteristics. All conditions presented at face to face consultations were assigned a Read code and episode type and the data were regularly validated. Data were sent by modem from the practices via a third party to the health authority each week.Main outcome measures-Proportion of consultations coded and accuracy of coding.Results-l1 practices agreed to participate. Validations for completeness during April 1994 to March 1995 revealed that 96.4% of the records were coded; 94 % ofthe 1090 records validated had appropriate episode types and 87% appropriate Read codes. The results have been used to help formulate the health authority's purchasing plans and have enabled a change in the local contracts for surgery for glue ear.Conclusions-The project has shown the feasibility of establishing a network of practices recording and reporting the morbidity seen in primary care. Early indications are that the data can be useful in evidence based purchasing.

Objective-To investigate the management of menorrhagia in primary care and its impact on referral and hysterectomy rates. Design-Prospective observational study. Setting-11 general practices from the Somerset Morbidity Project. Subjects-885 women consulting their general practitioner with menorrhagia over four years. Main outcome measures-Proportions of these women investigated and treated with drugs in primary care, referred to a gynaecologist and undergoing operative procedures. The relation between investigation and prescribing in primary care and referral to and surgery in secondary care. Results-Less than half of women had a vaginal examination (42%, 95% CI 39% to 45%), or a full blood count (39%, 95% CI 36% to 43%). Almost a quarter of women, 23% (95% CI 20% to 26%), received no drugs and 37% (95% CI 34% to 40%) received norethisterone. Over a third, 38% (95% CI 34% to 40%), of women were referred, and once referred 43% (95% CI 38% to 48%) of women were operated on. Women referred to a gynaecologist were significantly more likely to have received tranexamic acid and/or mefenamic acid in primary care ( 2 =16.4, df=1, p<0.001). There were substantial between practice variations in management, for example in prescribing of tranexamic acid and/or mefenamic acid (range 16% to 72%) and referral to gynaecology (range 24% to 52%). There was a significant association between high referral and high operative rates (Spearman's correlation coefficient=0.86, p=0.001). Conclusions-Substantial diVerences in management exist between practices when investigating and prescribing for menorrhagia in primary care. Rates of prescribing of eVective medical treatment remain low. The decision to refer a woman impacts markedly on her chances of subsequently being operated on. EVective management in primary care may not reduce referral or hysterectomy rates. (J Epidemiol Community Health 2000;54:709-713) Menorrhagia, defined as excessive menstrual loss of greater than 80 ml per period, 1 has a significant impact on many women's lives, as well as workload in primary and secondary care. Over 5% of women aged 30-49 years consult their general practitioner each year with this complaint.2 Menorrhagia accounts for 12% of gynaecology referrals, 1 and once referred surgical intervention is highly likely. In one study 60% of women underwent a hysterectomy within five years of referral.3 The treatment objective in menorrhagia is to improve quality of life by alleviating heavy menstrual flow. According to recent guidelines, general practitioners should oVer at least one course of eVective drug therapy before referral for gynaecological opinion.

AimsThe Symphony Project is designed to identify which groups of the South Somerset population in England would most benefit from greater integration across primary, community, acute and social care settings.MethodsWe analysed linked health and social care data for the entire South Somerset population for the financial year 2012/2013. The data captured acute, primary, community, mental health and social care utilisation and costs; demographic characteristics; and indicators of morbidity for each individual. We employed generalized linear models to analyse variation in annual health and social care costs for all 114,874 members of the South Somerset population and for 1458 individuals with three or more selected chronic conditions.ResultsWe found that multi-morbidity, not age, was the key driver of health and social care costs. Moreover, the number of chronic conditions is as useful as information about specific conditions at predicting costs. We are able to explain 7% of the variation in total annual costs for population as a whole, and 14% of the variation for those with three or more conditions. We are best able to explain primary care costs, but explanatory power is poor for mental health and social care costs.ConclusionsThe linked dataset makes it possible to understand existing patterns of health and social care utilisation and to analyse variation in annual costs, for the whole population and for sub-groups, in total and by setting. This has made it possible to identify who would most benefit from improved integrated care and to calculate capitated budgets to support financial integration.