The general practitioner as the first contacted health professional by patients with psychosocial problems: a European study.

BACKGROUND: There are considerable differences between and within countries in the involvement of general practitioners (GPs) in psychosocial care. This study aimed to describe the self-perceived role of GPs in 30 European countries as the first contacted professional for patients with psychosocial problems. and to examine the relationship with characteristics of the health care system, practice organization and doctors. METHODS: Data collected in the European Study of GP Task Profiles were analysed in relation to the self-perceived involvement of GPs in psychosocial care. In 30 countries 7233 GPs answered standardized questionnaires in their own languages about seven brief case scenarios. The questions focused on care given as the first health care professional contacted, and were answered in a scored scale (1-4) ranging from 'never' to 'almost always'. Independent variables examined were both on a national level and on an individual level, including: listed practice population, referral system, employment status of GPs, workload, measures of practice organization, contacts with social workers and urbanization of practice area. Data were analysed using multi-level techniques. RESULTS: Self-perceived involvement in psychosocial care was much higher in Western than in Eastern Europe and also in countries with a referral system. Cooperation with social workers, rural practice, keeping medical records, presence of an appointment system and high workload were positively associated with this perceived involvement. CONCLUSIONS: In countries with self-employed doctors and a referral system, GPs are in a better position to provide psychosocial care. GPs should be encouraged to cooperate with social workers and to keep medical records of their patient contacts routinely.     

Practice size: impact on consultation length, workload, and patient assessment of care.

BACKGROUND: Variations in practice list size are known to be associated with changes in a number of markers of primary care. Few studies have addressed the issue of how single-handed and smaller practices compare with larger group practices and what might be the optimal size of a general practice. AIM: To examine variations in markers of the nature of the care being provided by practices of various size. DESIGN OF STUDY: Practice profile questionnaire survey. SETTING: A randomised sample of general practitioners (GPs) and practices from two inner-London areas, stratified according to practice size and patients attending the practice over a two-week period. METHOD: Average consultation length was calculated over 200 consecutive consultations. A patient survey using the General Practice Assessment Survey instrument was undertaken in each practice. A practice workload survey was carried out over a two-week period. These outcome measures were examined in relation to five measures of practice size based on total list size and the number of doctors providing care. RESULTS: Out of 202 pratices approached, 54 provided analysable datasets. The patient survey response rate was 7247/11,000 (66%). Smaller practices had shorter average consultation lengths and reduced practice performance scores compared with larger practices. The number of patients corrected for the number of doctors providing care was an important predictor of consultation length in group practices. Responders from smaller practices reported improved accessibility of care and receptionist performance, better continuity of care compared with larger practices, and no disadvantage in relation to 10 other dimensions of care. Practices with smaller numbers of patients per doctor had longer average consultation lengths than those with larger numbers of patients per doctor. CONCLUSION: Defining the optimal size of practice is a complex decision in which the views of doctors, patients, and health service managers may be at variance. Some markers of practice performance are related to the total number of patients cared for, but the practice size corrected for the number of available doctors gives a different perspective on the issue. An oversimplistic approach that fails to account for the views of patients as well as health professionals is likely to be disadvantageous to service planning.     

Primary care group commissioning of services: the differing priorities of general practitioners and district nurses for palliative care services.

BACKGROUND: General practitioners (GPs) have become more responsible for budget allocation over the years. The 1997 White Paper has signalled major changes in GPs' roles in commissioning. In general, palliative care is ranked as a high priority, and such services are therefore likely to be early candidates for commissioning. AIM: To examine the different commissioning priorities within the primary health care team (PHCT) by ascertaining the views of GPs and district nurses (DNs) concerning their priorities for the future planning of local palliative care services and the adequacy of services as currently provided. METHOD: A postal questionnaire survey was sent to 167 GP principals and 96 registered DNs in the Cambridge area to ascertain ratings of service development priority and service adequacy, for which written comments were received. RESULTS: Replies were received from 141 (84.4%) GPs and 86 (90%) DNs. Both professional groups agreed that the most important service developments were urgent hospice admission for symptom control or terminal care, and Marie Curie nurses. GPs gave greater priority than DNs to specialist doctor home visits and Macmillan nurses. DNs gave greater priority than GPs to Marie Curie nurses, hospital-at-home, non-cancer patients' urgent hospice admission, day care, and hospice outpatients. For each of the eight services where significant differences were found in perceptions of service adequacy, DNs rated the service to be less adequate than GPs. CONCLUSION: The 1997 White Paper, The New NHS, has indicated that the various forms of GP purchasing are to be replaced by primary care groups (PCGs), in which both GPs and DNs are to be involved in commissioning decisions. For many palliative care services, DNs' views of service adequacy and priorities for future development differ significantly from their GP colleagues; resolution of these differences will need to be attained within PCGs. Both professional groups give high priority to the further development of quick-response clinical services, especially urgent hospice admission and Marie Curie nurses.     

Appraisal of family doctors: an evaluation study.

BACKGROUND: Appraisal has evolved to become a key component of workforce management. However, it is not clear from existing proposals for appraisal of doctors whether employers, health authorities or primary care organisations should take responsibility for appraisal processes. AIMS: To evaluate the introduction of a pilot peer appraisal system in general practice and to gain insight into the reactions of appraisers and doctors. DESIGN OF STUDY: Semi-structured telephone interviews combined with participant surveys and documentary analysis. SETTING: Five health authorities in Wales. PARTICIPANTS: General practitioners (GPs) appointed as appraisers and volunteer practitioners (doctors). METHOD: Twenty-six appraisers were appointed and given training in the appraisal process, each appraising an average of eight individuals. Appraisers and appraised doctors participated in semi-structured telephone interviews and completed separate participant questionnaires. RESULTS: GPs willingly undertook peer appraisal in a volunteer-based pilot study where participation was recompensed. The majority of participating clinicians were positive, with appraisers reporting the most gain. Appraisers were enthusiastic, provided the process remained non-judgemental and did not threaten or burden their colleagues. Appraised doctors were less enthusiastic but the most significant perceived benefit was the opportunity to reflect on individual performance with a supportive colleague. There were, however, repeated concerns about time, confusion with revalidation and personal development plans, worries about including health and probity queries, and an opinion that the process would be entirely different if conducted with non-volunteers or by representatives of 'management'. CONCLUSION: This study illustrated three fundamental problems for appraisal systems in general practice. First, there is as yet no organisational hierarchy in general practice. Perhaps the aggregation of practices into primary care organisations will generate a hierarchy. Second, the question of who conducts appraisals then becomes pertinent; this study illustrates a professionally-led peer appraisal model. Third, the spectre of summative assessment causes problems in appraisal schemes. Typically, only mutually agreed summaries are kept for future use in appraisal systems (for example, for promotion or discipline). So the proposal to use GP annual appraisal documentation as the basis of a summative 'revalidation' exercise is at odds with orthodox personnel practice, which regards appraisal as a formative process.     

General practice in Italy.

General practitioners in Italy work as independent contractors in a national health service. There are, however, many differences between Italy and the United Kingdom regarding the status, contract and culture of primary health care. The similarities and differences offer valuable insights into the benefits and disadvantages of the position in the UK, and serve to highlight the significant gains made in the past 30 years. This account of Italian general practice is based on the author's personal experience gained during a one month sabbatical visit to Italy in 1990.     

Stress and morale in general practice: a comparison of two health care systems.

BACKGROUND: Poor morale and high levels of stress among general practitioners (GPs) are causing concern. Little research has previously been carried out to study possible differences in morale and stress between GPs working in two different but geographically similar health care systems. AIM: To compare perceived levels of stress and morale between GPs working in two different health care systems--one having a state monopoly (Northern Ireland) and the other having mixed private and state funding (Republic of Ireland)--and to look for factors that might help explain any differences in stress levels and morale between the two systems. METHOD: Anonymous and confidential questionnaires were sent to all 986 National Health Service (NHS) GPs in Northern Ireland (NI) and a random sample of 900 GPs in the Republic of Ireland (ROI). A common set of core questions on demographic details, partners and work patterns, perceived levels of stress and morale, safety, violence, and complaints were asked. RESULTS: Response rates were high in both areas: 91% in NI and 78% in the ROI. GPs in NI had significantly higher stress levels and significantly lower levels of morale than GPs in the ROI. The NI sample expect matters to get worse over the following year. Doctors in the ROI were more likely to be single handed and to work from two sites. Also, more GPs in ROI had fears for their safety and had been the subject of physical violence, but fewer had received complaints and medico-legal actions than in NI. CONCLUSIONS: A significant proportion of both groups of doctors report feeling highly stressed but GPs in NI appear more unhappy and have a poorer outlook for the future. It is suggested that the structure, management, and expectations of the NHS have taken a severe toll on its GPs, whereas a system in which doctors have less practice support but more control is good for morale.     

Salaried general practice in Czechoslovakia: personal observations and impressions.

In 1991, a visit was undertaken, to the former Czechoslovakia, during which discussions were held with general practitioners. Some personal observations and impressions from the visit are presented. For four decades, salaried general practice was a feature of the Czechoslovakian health care system. Primary health care comprised three strands: paediatric services, an occupational health service and community general practitioner care. The main point of service delivery was the polyclinic which, although being large and impersonal, provided easy access to other primary and secondary services. General practitioners, over half of whom were women, had regular leave entitlement and predictable hours of work, out of hours work being provided through separate contracts based on primary care emergency centres. However, doctors were poorly paid compared with industrial workers. Following the 'velvet revolution' in 1989, all aspects of the health service have been subject to major review, and salaried general practice is likely to give way to a more entrepreneurial system.     

Patients in Europe evaluate general practice care: an international comparison.

BACKGROUND: Patients' evaluations can be used to improve health care and compare general practice in different health systems. AIM: To identify aspects of general practice that are generally evaluated positively by patients and to compare opinions of patients in different European countries on actual care provision. METHOD: An internationally-validated questionnaire was distributed to and completed by patients in 10 European countries. A stratified sample of 36 practices per country, with at least 1080 patients per country, was included. A set of 23 validated questions on evaluations of different aspects of care was used, as well as questions on age, sex, overall health status, and frequency of visiting the GP. RESULTS: The patient sample included 17,391 patients in 10 different countries; the average response rate was 79% (range = 67% to 89%). In general, patients visiting their general practitioner (GP) were very positive about the care provided. For most of the 23 selected aspects of care more than 80% viewed care as good or excellent; in particular, keeping records confidential, GP listening to patients, time during consultations, and quick services in case of urgent problems were evaluated positively. Patients were relatively negative about organisational aspects of care. The evaluations in different countries were largely similar, with some interesting differences; for instance, service and organisational aspects were evaluated more positively in fee-for-service health systems. CONCLUSIONS: Patients in Europe are positive about general practice but improvements in practice management in some countries are requested. More research is needed to study the complex field of differences in expectations and evaluations between countries with different health systems.     

General practitioners' attitudes to the development of midwifery group practices.

BACKGROUND: The report Changing childbirth (1993) has led to the development of midwifery-led schemes that aim to increase the continuity of maternity care. AIM: To determine the impact of midwifery group practices on the work of general practitioners (GPs) and their perceptions of midwifery group practice care. METHOD: Postal questionnaires were sent to 58 GPs referring women to the care of midwifery group practices (group-practice GPs), and a shorter questionnaire was sent to the remaining 67 GPs (non-group-practice GPs) within the same postcode area as a comparison group. In-depth interviews were conducted with 12 GPs. RESULTS: Questionnaires were returned by 71% of group-practice GPs and 81% of non-group practice GPs. One third of the group practice GPs felt that they were seeing group practice women too few times, and 50% thought midwives discouraged women from visiting their GP for antenatal checks. Over 80% of group practice GPs believed that midwives had the skills to detect deviation from the normal, and 66% would confidently refer women to their care. However, only 14% of group practice GPs believed that their own role was clear, while 64% agreed that communication with group practice midwives was poor, and concerns were expressed about the level of consultation before establishing schemes. Of the non-group practice GPs, 87% said they would consider referring women to the care of a midwifery group practice in the future. CONCLUSIONS: General practitioners were generally positive about the quality of care provided by midwifery group practices but identified issues that require addressing in developing this model of care.     

A survey of job satisfaction, sources of stress and psychological symptoms among general practitioners in Leeds.

BACKGROUND: The past seven years have seen rapid changes in general practice in the United Kingdom (UK), commencing with the 1990 contract. During the same period, concern about the health and morale of general practitioners (GPs) has increased and a recruitment crisis has developed. AIM: To determine levels of psychological symptoms, job satisfaction, and subjective ill health in GPs and their relationship to practice characteristics, and to compare levels of job satisfaction since the introduction of the 1990 GP contract with those found before 1990. METHOD: Postal questionnaire survey of all GP principals on the Leeds Health Authority list. The main outcome measures included quantitative measures of practice characteristics, job satisfaction, mental health (General Health Questionnaire), and general physical health. Qualitative statements about work conditions, job satisfaction, and mental health were collected. RESULTS: A total of 285/406 GPs (70%) returned the questionnaires. One hundred and forty-eight (52%) scored 3 or more on the General Health Questionnaire (GHQ-12), which indicates a high level of psychological symptoms. One hundred and sixty GPs (56%) felt that work had affected their recent physical health. Significant associations were found between GHQ-12 scores, total job satisfaction scores, and GPs' perceptions that work had affected their physical health. Problems with physical and mental health were associated with several aspects of workload, including list size, number of sessions worked per week, amount of time spent on call, and use of deputizing services. In the qualitative part of the survey, GPs reported overwork and excessive hours, paperwork and administration, recent National Health Service (NHS) changes, and the 1990 GP contract as the most stressful aspects of their work. CONCLUSIONS: Fifty-two per cent of GPs in Leeds who responded showed high levels of psychological symptoms. Job satisfaction was lower than in a national survey conducted in 1987, and GPs expressed the least satisfaction with their hours, recognition for their work, and rates of pay. Nearly 60% felt that their physical health had been affected by their work. These results point to a need to improve working conditions in primary care and for further research to determine the effect of any such changes.     

Access to and use of the Internet by South African general practitioners

INTRODUCTION: In the developed world, doctors use the Internet to support the delivery of health care. Their usage patterns are explained by Rogers' Diffusion of Innovations. There is no knowledge of Internet usage by doctors in the developing world. METHODS: In July 2006, 2600 survey forms were posted in the first national survey of South African (SA) General Practitioners' (GPs) use of the Internet. A sample of non-responders was followed up. The aim was to determine SA GPs' Internet usage patterns, to compare them to world usage, and to examine them in the light of Diffusion of Innovations. RESULTS: A 10% usable response rate was a major weakness, but similar surveys are unlikely to be more representative. 89% of SA GPs have Internet access, home usage is high, and overall usage patterns are equivalent to the usage patterns of international studies. DISCUSSION: In spite of the overall technological under-development in South Africa, as predicted by Diffusion of Innovations, SA GPs have adopted the technology, and use it for health care in much the same way as their international counterparts. Further studies on some of the details will be valuable. CONCLUSION: The indications are that SA GPs will reap the benefits of the Internet as it continues to evolve, and translate these into improved health care delivery in South Africa.     

Questioning in general practice--a tool for change.

In general practice, as in all branches of medicine, doctors are encouraged to ensure their decisions reflect research findings, and are 'evidence-based'. This depends upon general practitioners (GPs) questioning their practice, finding 'evidence-based' answers, and changing their practice where necessary. Questioning behaviour is therefore fundamental to this process. Research into the questioning behaviour and information needs of GPs is difficult and it is unknown whether better access to information necessarily results in behavioural change or better health outcomes. This paper summarises research on doctors' questioning behaviour, factors influencing their likelihood of finding answers, and discusses some of the obstacles they face in implementing change. Finally, we introduce the concept of a 'clinical informaticist', whose role is to provide evidence-based answers to specific questions raised by GPs. This service may facilitate learning and increase uptake of research findings.     

I don't think general practice should be the front line: Experiences of general practitioners working with refugees in South Australia

Introduction

Many refugees arrive in Australia with complex health needs. In South Australia (SA), providing initial health care to refugees is the responsibility of General Practitioners (GPs) in private practice. Their capacity to perform this work effectively for current newly arrived refugees is uncertain. The aim of this study was to document the challenges faced by GPs in private practice in SA when providing initial care to refugees and to discuss the implications of this for policy relating to optimising health care services for refugees.

Methods

Semi-structured interviews with twelve GPs in private practice and three Medical Directors of Divisions of General Practice. Using a template analysis approach the interviews were coded and analysed thematically.

Results

Multiple challenges providing care to refugees were found including those related to: (1) refugee health issues; (2) the GP-refugee interaction; and (3) the structure of general practice. The Divisions also reported challenges assisting GPs to provide effective care related to a lack of funding and awareness of which GPs required support. Although respondents suggested a number of ways that GPs could be assisted to provide better initial care to refugees, strong support was voiced for the initial care of refugees to be provided via a specialist refugee health service.

Conclusion

GPs in this study were under-resourced, at both an individual GP level as well as a structural level, to provide effective initial care for refugees. In SA, there are likely to be a number of challenges attempting to increase the capacity of GPs in private practice to provide initial care. An alternative model is for refugees with multiple and complex health care needs as well as those with significant resettlement challenges to receive initial health care via the existing specialist refugee health service in Adelaide.

     

Qualitative study of patients'' perceptions of the quality of care for depression in general practice.

BACKGROUND: Research into quality of care in primary mental health care has largely focused on the role of the general practitioner (GP) in the detection and management of patients' problems. AIM: To explore depressed patients' perceptions of the quality of care received from GPs. DESIGN OF STUDY: Qualitative study using semi-structured interviews. SETTING: General practices in Greater Manchester. METHOD: Purposive sampling and semi-structured interviewing of 27 patients who had received care from 10 GPs for depression. RESULTS: Quality of care in depression depends on good communication between the doctor and the patient, but patients who are depressed often have difficulty in discussing their problems with doctors. They are also unlikely to be active in seeking care; for example, in making follow-up appointments, especially when they are uncertain that depression is a legitimate reason for seeing the doctor. Patients sometimes accept care that does not meet professional standards, either because of low expectations of what the National Health Service (NHS) can provide, or because of low self-worth associated with their problem. CONCLUSION: The depressed person may feel that they do not deserve to take up the doctor's time, or that it is not possible for doctors to listen to them and understand how they feel. Doctors need to be active in providing care that meets professional standards. We advocate a model of care in which patients with depression are followed up systematically.     

Measuring disease prevalence: a comparison of musculoskeletal disease using four general practice consultation databases

BACKGROUND: Primary care consultation data are an important source of information on morbidity prevalence. It is not known how reliable such figures are. AIM: To compare annual consultation prevalence estimates for musculoskeletal conditions derived from four general practice consultation databases. DESIGN OF STUDY: Retrospective study of general practice consultation records. SETTING: Three national general practice consultation databases: i) Fourth Morbidity Statistics from General Practice (MSGP4, 1991/92), ii) Royal College of General Practitioners Weekly Returns Service (RCGP WRS, 2001), and iii) General Practice Research Database (GPRD, 1991 and 2001); and one regional database (Consultations in Primary Care Archive, 2001). METHOD: Age-sex standardized persons consulting annual prevalence rates for musculoskeletal conditions overall, rheumatoid arthritis, osteoarthritis and arthralgia were derived for patients aged 15 years and over. RESULTS: GPRD prevalence of any musculoskeletal condition, rheumatoid arthritis and osteoarthritis was lower than that of the other databases. This is likely to be due to GPs not needing to record every consultation made for a chronic condition. MSGP4 gave the highest prevalence for osteoarthritis but low prevalence of arthralgia which reflects encouragement for GPs to use diagnostic rather than symptom codes. CONCLUSION: Considerable variation exists in consultation prevalence estimates for musculoskeletal conditions. Researchers and health service planners should be aware that estimates of disease occurrence based on consultation will be influenced by choice of database. This is likely to be true for other chronic diseases and where alternative symptom labels exist for a disease. RCGP WRS may give the most reliable prevalence figures for musculoskeletal and other chronic diseases.     

Evaluation of death registers in general practice.

BACKGROUND: General practitioners (GPs) do not routinely receive information about the deaths of those patients whose death certificates they have not completed. We developed and evaluated a system for producing death registers for GPs. AIM: To evaluate GPs' and practice managers' views on, and uses of, the death register. METHOD: General practitioners in Newcastle (n = 161) and Sunderland Family Health Service Authority (n = 144) areas were sent a questionnaire on their sources and use of information about patients' deaths. Death registers were sent to Newcastle practices; Sunderland practices were the control group. A follow-up questionnaire was sent to Newcastle (n = 173) and Sunderland (n = 140) GPs after two years. Newcastle practice managers (n = 45) were interviewed after their practice had received death registers for one year. RESULTS: Ninety-two per cent of Newcastle responders had seen the death register. Seventy-three per cent saw it regularly. Of those who saw it, 92% found it useful for communication within the primary health care team, bereavement follow-up, and administration and medical audit. One fifth of GPs named the death register as their first source of information about their patients' deaths. Newcastle GPs reported greater levels of change in use of patient death information than the control group. Practice managers circulated, used, and recorded information from the death register. CONCLUSION: Death registers are valued and have demonstrable benefits with regard to administration, bereavement care, and medical audit.     

What makes a good general practitioner: do patients and doctors have different views?

BACKGROUND: General practitioners (GPs) are expected to be responsive to patients' expectations, but patients and doctors may have different views on what constitutes good general practice care. AIM: To elicit areas of controversy as well as areas of mutual agreement between the opinions of patients and GPs with regard to good general practice care. METHOD: A questionnaire, distributed to 850 patients and 400 GPs, measured which of 40 aspects of general practice care were given priority. A second questionnaire, distributed to 400 different GPs, measured the GPs' perception of the priorities of patients. RESULTS: The priority rank order of all 40 aspects was highly correlated for patients and GPs (0.72), as was the rank order of aspects for patients and the perception of them by GPs (0.71). Nevertheless, when comparing the priorities of patients and GPs, 23 out of 40 aspects differed significantly (P = 0.00125) in their rank number. Similarly, when comparing the priorities of patients with the perception of them by GPs, 23 aspects differed significantly. CONCLUSIONS: There is great similarity between the priorities of patients and those of GPs. GPs are quite capable of assessing most of the priorities of patients. However, potentially controversial areas of general practice care do exist.     

How common is medical training in palliative care? A postal survey of general practitioners.

BACKGROUND: General practitioners (GPs) have a central role in palliative care, yet research continues to reveal room for improvement in symptom control at home. There is a need to evaluate how well-prepared GPs are for this task of caring for the dying at home. AIM: To evaluate the training in palliative care GPs have received throughout their careers. METHOD: Postal survey of 450 randomly selected East Anglian GP principals, investigating training in five areas of palliative care (pain control, control of other symptoms, communication skills, bereavement care, use of syringe driver), as clinical students, junior hospital doctors, GP trainees (registrars), and GP principals. RESULTS: A response rate of 86.7% was obtained. While GPs were clinical students, training was uncommon, (32% reported no training in pain control, and 58% no training in bereavement care), although there has been a significant increase in more recent years. Training as junior doctors was particularly uncommon (over 70% report no training in communication skills or bereavement care); there was some evidence of an increase in more recent years. During the GP trainee year, training was much more common. For GP principals, most areas had been covered, although over 20% reported no training in communication skills and bereavement care. During the community-based years as trainee and principal, training was significantly more common than during the hospital-based years of training as clinical student and junior doctor. CONCLUSIONS: There is a continuing need for medical education in palliative care. Particular attention should be paid to the basic medical education of clinical students and the training of junior doctors, especially regarding communication skills and bereavement care.