Social workers in primary health care: the general practitioner's viewpoint

The success of general practitioner/social worker collaboration in primary care depends largely on how the doctors perceive the attachment.

We examined the replies of a group of general practitioners to a series of questions about such an attachment. Although the collaboration may lead to more work for the doctors, it was much appreciated by them.

     

Paediatric developmental screening: a survey of general practitioners

A questionnaire survey of 293 general practitioner trainers in England to investigate paediatric screening yielded a response rate of 86%. Paediatric screening sessions were being held by a practice member in the practices of 54% of respondents. In one-third of these practices the practice member was acting in the capacity of clinical medical officer. Of responding trainers 28% held sessions personally and these doctors did not differ significantly from the remainder in terms of sex, seniority, hospital paediatric experience or membership of the Royal College of General Practitioners. About one-third of the doctors holding sessions had spent six months or more working in hospital paediatric departments. First-hand experience of paediatric screening was gained by 60% of the current trainees.

Sixty-one per cent of trainers agreed with the view that developmental screening is an appropriate task for all general practitioners, while 71% saw it as an appropriate task for themselves. Eight-six per cent of trainers agreed that doctors should be paid for this service if trained for it, and 56% that they should be paid regardless of training.

Comparative figures were determined from a parallel survey of 333 non-training general practitioners of whom 225 (68%) replied. Paediatric screening sessions were held in the practices of 34% of respondents and personally by 21%.

It is concluded that there is a high level of interest in paediatric screening among general practitioners, but that there is a need for further expansion in postgraduate paediatric training.

     

Death in practice

For a nationwide study of terminal care, Gallup Polls took a sample of 950 general practitioners. Fourteen questionnaires could not be delivered; 376 doctors (40 per cent of the register) returned forms; 313 doctors (33.4 per cent) provided information on 301 home deaths and 292 hospital deaths and responded also to statements about care of the dying.

The patients who died at home were well supported by the general practitioner and the family and neighbourhood network. Control of pain was perceived to be better at home. Patients dying at home were more likely to be aware of their impending death. General practitioners usually discussed the imminence of death with relatives, but few relatives and patients raised the question of terminating life. All the available major services were under-used. There was support for more hospices and for more spending on social services. Postgraduate medical education on care of the dying was considered to be inadequate.

     

Patterns of work in general practice in the Bromley health district

The results of a survey of patterns of work in general practice over five days in one health district were linked to family practitioner committee data on individual general practitioners. Characteristics of doctors and practices were mostly unrelated to various aspects of workload. However, referral rates for pathological tests and to outpatient departments and claims for cervical cytology screening were significantly higher for younger principals than for older doctors, while younger doctors prescribed less frequently. Women general practitioners had significantly lower personal list sizes and claims for night visits and temporary residents than their male colleagues but saw only 10% fewer patients and made significantly more claims for cervical cytology screening. It was also found that UK graduates made more requests for pathological tests than doctors graduating in the Indian sub-continent. A correlation was found between list size and consultation rate, though the list size only explained a relatively small part of the variation in the rates.

The results have been fed back to doctors in the area and it is hoped that this will increase awareness of the patterns of work in general practice.

     

A course in collaboration for social workers and general practitioners

Patients have overlapping social and medical needs, yet social workers and doctors often have problems in working together to help with them. We planned a short experimental course which was to look at this situation and to help members of both professions learn about each other. This was to encourage attitudes of mutual trust and respect in order to promote future collaboration.

The social workers had all qualified within the past year and were working in their first appointment, based either in the community or in a hospital. The doctors were training to become general practitioners and were either members of a three-year vocational training programme or were working in a one-year attachment in local practices.

Each session started and ended with the whole course together, but the core of each meeting was case discussion among small mixed groups. In this way social workers and doctors were able to explore together mutual problems of patient care.

     

A comparison of hospital and general practice blood pressure readings using a shared-care record card

Shared-care blood pressure record cards were issued to 149 consecutive hypertensive patients attending our hospital clinic. In 108 (72.5 per cent), general practitioners entered readings they had obtained onto the cards. The use of the record card has proved helpful in the management of patients, and we are encouraged by the co-operation of the family doctors.

A comparison of blood pressures measured in hospital and in general practice showed that general practitioners found systolic pressures to be an average of 5.5 mm Hg lower than hospital doctors, but there were no differences in diastolic pressure. In many cases, wide discrepancies were found both in hospital and general practice. We conclude that it is a myth that patients' blood pressures are lower when they consult their family doctor, or that outpatient blood pressure readings are falsely elevated by the stress of hospital attendance.

     

Norfolk general practice: a comparison of rural and urban doctors

A postal questionnaire was sent to all Norfolk practitioners, allowing a comparison to be made between rural general practice and urban practice in Norwich and Great Yarmouth. However, when Norfolk town and country doctors were compared, little difference was found in their personal or practice characteristics. In respect of their workload rural doctors, as expected, carried out more procedures overall but, somewhat surprisingly, did not make more home visits. Both sets of doctors had similar views on their present and future role in general practice.

When Norfolk doctors collectively were compared with general practitioners nationally their service appeared to be of a high standard. The only uncertainty surrounded the effects of the greater clustering of Norfolk surgeries, together with the levels of home visiting and their attendant effects on patient accessibility.

     

Comparison of the health and lifestyle of general practitioners and teachers.

A total of 704 general practitioners and 588 teachers responded to a questionnaire about their health and lifestyle in 1991 (response rates 82% and 87%, respectively). The results for lifestyle measures were compared with those of a similar questionnaire completed by about half of each group two years before--there were no changes in the answers of either occupational group in the intervening two years. In 1991, 9% of general practitioners and 15% of teachers drank 22 units of alcohol per week or more; 13% of general practitioners and 23% of teachers reported troublesome depression and 31% of doctors and 37% of teachers excessive anxiety in the preceding 12 months. Teachers had more sickness absence, and significantly more experienced a need for daily alcohol and binge eating, and reported sleep difficulties, depression and anxiety than general practitioners. Self-medication among general practitioners was common and overall accounted for 83% of the medication taken by doctors. A follow-up survey of non-respondents found that only 11% of general practitioners and 11% of teachers indicated they had a health problem they wished to conceal or that they felt the questions were too intimate. General practitioners' lifestyle habits are better than those of teachers and published figures for the general population. The frequency of reported mental health problems in both professions gives cause for concern.     

Effects of a community mental health service on the practice and attitudes of general practitioners.

Recent years have seen closer links developing between general practitioners and mental health specialists. A study was undertaken in Manchester to determine the effects of a new community mental health service on the practice and attitudes of general practitioners. Ten doctors had access to the community based psychiatric team over a three year period while another 10 doctors continued to use hospital services. Those with access to the team were significantly more satisfied with the specialist support services, and were more likely to give high priority to community psychiatric nurses and psychiatric social workers working as part of a primary health care team than those without access to the service. Those with access were more willing than those without access to share with psychiatrists the care of patients with chronic neurotic disorders. The community mental health team was considered particularly helpful in reducing the burden posed by patients with neurotic and psychosocial problems, but this resulted in the general practitioners doing less counselling themselves. The study did not find that the new service had an effect on the general practitioners' ability to detect or manage psychiatric illness.     

Variation in general practitioners' referral rates to consultants

The variation in the number of patients general practitioners refer to hospital is a source of concern because of the costs generated and the implications for quality and quantity of care This paper compares 32 general practitioners with high referral rates with 35 doctors with low referral rates drawn from a study of 201 doctors. The mean referral rate for all 201 doctors was 6.6 per 100 consultations – for those with high referral rates the mean was 11.8 and for those with low referral rates 2.9. Differences between doctors with high and low referral rates with respect to age, sex, social class and diagnostic case mix of patients consulting were small. Doctors with high referral rates referred more patients in all categories. There were also few differences between the two groups with respect to the characteristics of the doctors themselves or their practices. The findings are discussed in the context of proposals to provide general practitioners with information on their own referral rates compared with those of other doctors.     

Appropriate place of death for cancer patients: views of general practitioners and hospital doctors.

BACKGROUND. The majority of cancer patients in the United Kingdom die in a National Health Service hospital, a setting that is contrary to the wishes of those patients expressing a preference to die elsewhere, for example at home or in a hospice. AIM. A study was undertaken to determine clinicians' views of the appropriate place of death for cancer patients and to examine factors leading to patients being admitted to a hospital specialist services unit where they died. METHOD. A questionnaire was sent to all general practitioners and hospital doctors who had cared for cancer patients who had died between May 1991 and April 1992 in a single health district. The appropriateness of the place of death, whether the patient was terminally ill, reasons for hospital admission and effect on management had different resources been available were determined. RESULTS. A total of 1022 deaths attributable to cancer were recorded for patients registered with general practitioners in the study area. Questionnaires were returned by general practitioners for 951 of the deaths (93%); hospital doctors returned questionnaires for 216 out of 268 patients (81%) who had been admitted to hospital under the care of a consultant. For deaths which had occurred at home, in a community hospital, residential/nursing home or Marie Curie hospice, the place of death was considered appropriate by general practitioners in over 92% of cases. For deaths in the hospital specialist services unit the place of death was considered probably or definitely appropriate by general practitioners in 83% of the 212 cases, but not appropriate in 17% of cases (P < 0.001 compared with all other settings). Hospital doctors considered 27% of deaths in the unit inappropriate. Significantly fewer cases fulfilled the criteria for terminal illness (death expected and palliative treatment commenced) according to general practitioners among those dying in the specialist services unit compared with deaths elsewhere (P < 0.001). The most common main reasons for admission to the specialist services unit were for investigation, because of difficult symptom control (apart from pain) and for curative/active treatment. General practitioners reported that management of between a sixth and a quarter of patients admitted to the specialist services unit would have been affected by the availability of 24-hour home cover, community hospital beds and a city-based hospice. Among the group of patients fulfilling the study criteria for terminal illness, the effect of other services on patient management would have been considerably higher. CONCLUSION. A greater proportion of cases where patients died from cancer in settings other than a specialist services unit were considered appropriate by general practitioners compared with deaths in a specialist services unit. For a considerable minority of patients, death in a specialist services unit was not considered appropriate by the general practitioners or by the hospital doctors. Improvements in local hospice facilities, community hospitals and community support would mean that a substantial proportion of hospital admissions could be avoided and thus cancer patients could die in more appropriate settings.     

General practitioners and social help for the handicapped

A study was undertaken by the Greater London Association for the Disabled in consultation with the Royal College of General Practitioners, to explore the depth of knowledge of the Chronically Sick and Disabled Persons Act and statutory and voluntary social provision, of 22 general practitioners in 16 practices served by one area social services office in a London borough.

The doctors were mainly middle-aged, of British or Irish birth and training and had no language barrier. The majority lived in or near their practices. Half the practices were groups or partnerships, half were singlehanded. Only in three groups was there any attached district nursing staff and in only one was there an attached health visitor. More than half the general practitioners had reception staff only during surgery hours. Four practices had no reception staff during National Health Service surgery hours, two of which had no reception staff at all. In no practice was there any privately employed nursing staff. All the practices had private patients.

Nine of the 22 doctors in the study had never heard of the Chronically Sick and Disabled Persons Act, and a further five had not mentioned the Act to their patients. Fifty per cent had no knowledge of the extent of functional disability in their practice. More than half the doctors knew no more of the social services than that home helps and meals-on-wheels were available, while six doctors knew of no provision at all. Knowledge and use of the voluntary services was almost non-existent. No meetings with team members were held, other than in the group practices with attached staff, and the team members were largely unknown to most of the doctors.

Attempts were made through various channels to extend the knowledge of the general practitioners of the services provided by both statutory and voluntary agencies, and to introduce them and their receptionists to their team, but little use was made of the opportunity.

     

Acute sore throat—diagnosis and treatment in general practice

This study tested how general practitioners diagnose streptococcal infection on clinical grounds alone, in patients who presented with sore throats.

Four hundred and fifty-two patients were admitted to the study. A clinical diagnosis, prognosis and follow-up was completed in each case and the clinical assessment was checked by throat swabbing at first contact and a week later.

The doctors were inaccurate in predicting streptococcal infection, but better than might be expected if prediction were a matter of pure guesswork. Colds and influenza implied negative prediction, tonsillitis a positive prediction, and pharyngitis was doubtful.

In this series negative prediction for pharyngitis was 85·2 per cent and positive prediction 31·5 per cent accurate. The equivalent figures for tonsillitis were 61·5 per cent and 38·9 per cent respectively. There was a general tendency to overpredict streptococcal infection which was most marked in acute follicular tonsillitis, but this led to few false negatives. The tendency to overpredict streptococci was most marked when the patient was an adolescent female.

There were differences between the urban and rural patterns. During the same period, influenza (and similar illnesses) was recorded less often in the country, whereas urban practitioners were more likely to predict streptococcal infection. Rural practitioners were more accurate in prediction because they were less prone to implicate streptococcal infection than their urban colleagues; there was a higher proportion of cases with proven streptococcal infection in the town and there is a disproportionately high number of adolescent females among the urban patients.

     

The outcome of hidden neurotic illness treated in general practice

One thousand patients attending a general practice surgery were asked to complete the general health questionnaire as the first stage of screening for hidden minor psychiatric disorders. Those who had an unexpectedly high score of 20 or more were randomly allocated to doctors or health visitors for treatment. After one year, these two groups were reinterviewed by the doctors and health visitors respectively and comparable rates of recovery were found. After five years, they were interviewed again and a second general health questionnaire completed. It was found that both groups had improved significantly, and that there was no significant difference between them.

Poor outcome was associated with problems with children, household or neighbours and with a previous history of psychiatric illness. Improvement was associated with physical treatment of the original disorder, resolution of the original problem and job satisfaction.

The implication of these findings for the comparative management of minor psychiatric disorders by general practitioners and non-medical health workers in primary care are discussed.

     

Health and Mortality in Korean Healthcare Workers

BackgroundTo evaluate the health status of healthcare workers (doctors and nurses) compared to those in the general population based on the National Health Insurance Service database and the cause of death data from Statistics Korea.MethodsThe subjects of this study were 104,484 doctors and 220,310 nurses working in healthcare facilities from 2002 to 2017, and who had undergone at least one general medical examination. Based on the subject definition, the subject data were extracted from the National Health Insurance healthcare facility database and qualification database. We collected medical use details included in the research database, general medical examination results, medical history included in the health examination database, and additional data on the cause of death from the National Statistics database to analyze the main cause of death and mortality.ResultsIn terms of the major causes of death and mortality among healthcare workers, the mortality rate associated with intentional self-harm, injury, transportation accident, heart disease, addiction, and falling was significantly higher than that in the general population. Further, the prevalence of respiratory and gastrointestinal diseases was high. When analyzing the proportional mortality ratio (PMR) by cause of death for healthcare workers, the PMR values for death related to malignant neoplasm was the highest. In terms of diseases, both doctors and nurses had higher rates of infectious diseases such as maternal sepsis, rubella, and measles.ConclusionThe health status of healthcare workers differs from that of the general population. Thus, it is important to consider the occupational characteristics of healthcare personnel. This study is unique in that it was conducted based on medical use indicators rather than survey data.     

General practitioners' use of community psychiatric nursing services: a preliminary survey.

A questionnaire on general practitioners' use of community psychiatric nursing services was sent to a random sample of 100 general practitioners in two contrasting areas, Croydon and Cambridgeshire. General adult services were widely available though used less often by Cambridgeshire general practitioners than Croyden doctors. Apart from services for the elderly, specialist services were uncommon. Over a third of doctors reported that their adult services were based in a psychiatric hospital. Less than a quarter of general practitioners had access to primary care based nurses. The pattern of responses demonstrates the wide variety of ways in which general practitioners relate to community psychiatric nurses, even where the psychiatric nursing services are long-established. There remains a need for more consistent and coherent policies about the ways in which community psychiatric nurses are employed in primary care.     

Consultations for women''s health problems: factors influencing women''s choice of sex of general practitioner.

AIM. This study set out to examine the degree to which women choose to visit a woman doctor for women's health problems and the determinants of this choice. The differences between women and men doctors with regard to treating women's health problems were also studied. METHOD. Data from the Dutch national survey of general practice were used. All group practices with both women and men general practitioners were selected. Analyses were restricted to consultations among women aged 15-65 years about menstruation, the menopause, vaginal discharge, breast examination and cervical smear tests. RESULts. Given the size of their female practice population, women doctors saw considerably more women with women's health problems than did their male colleagues. Women were more likely to consult a woman general practitioner if she was more available (that is, working longer hours), and younger women were more likely than older women to choose women general practitioners. Sex differences in the treatment of women's health problems were small and mainly related to the verbal part of the consultation: counselling and providing information. The doctors' availability and their certainty about the working diagnosis explained differences in the verbal aspects of consultations. Women general practitioners had longer consultations than their male colleagues mainly because more health problems were presented per consultation. CONCLUSION. In order to increase the possibility of patients choosing women general practitioners, policy should be directed towards the education of more women general practitioners and women general practitioners should be encouraged to work more days a week.     

One-year prospective study of cases of suspected acute myocardial infarction managed by urban and rural general practitioners.

BACKGROUND: The role of the general practitioner in the management of patients with suspected acute myocardial infarction is important and specific. It has been recommended that eligible patients should receive thrombolysis within 90 minutes of alerting medical or ambulance services. The administration of prehospital thrombolysis by general practitioners is controversial. Most research into the management of acute myocardial infarction has been hospital based and has not explored differences between urban and rural general practice. AIM: In 1993-94 a one-year prospective survey was undertaken of samples of urban and rural general practitioners to examine their management of cases of suspected acute myocardial infarction and to determine whether differences in management existed between the two settings. METHOD: General practitioners were recruited through the continuing medical education faculty network of the Irish College of General Practitioners. Participating general practitioners completed a report form for cases of suspected acute myocardial infarction. Six-week follow-up forms were also completed. RESULTS: A total of 113 general practitioners (54 urban and 59 rural) participated in the study. A total of 57 general practitioners contributed 195 cases, 49 from urban and 146 from rural areas. The mean number of cases of suspected acute myocardial infarction per participant for urban and rural doctors was 0.9 and 2.5, respectively. Median delay time from onset of symptoms to contacting the general practitioner was 90 minutes for both urban and rural patients. Median general practitioner response times for urban and rural doctors were 10 and 15 minutes, respectively. Median estimated journey times from location of the patient to hospital for urban and rural patients were 10 and 40 minutes, respectively (P<0.001). Rural doctors were more likely, in comparison with their urban counterparts, to administer aspirin (given to 40% of patients versus 16%, P<0.01) but less likely to administer intravenous morphine (26% versus 41%, P<0.05). Twenty one patients (11%) died at the scene; follow-up forms were received for 94% of the remaining patients. Of these 163 patients, 99% were admitted to hospital; 49% were discharged with a diagnosis of acute myocardial infarction and a further 25% had final diagnoses consistent with acute coronary heart disease. CONCLUSION: This study suggests that the management of patients with suspected acute myocardial infarction differs in urban and rural settings. Delay times suggest that in order to meet current guidelines, prehospital thrombolysis must become a reality in rural areas.     

The role of practice manager—changes in attitudes promoted by the Royal College of General Practitioners

Because of the roles traditionally required of them, and because of the insularity of ancillary staff in general medical practice, many senior ancillary staff may not have been giving their doctors the most effective support of which they are capable. This is changing as a result of the change-promoting activities of the North of England Faculty of the Royal College of General Practitioners.

A survey of ancillary staff and general practitioners in the North of England has shown that the Royal College of General Practitioners has assisted ancillary staff to a greater consensus of more progressive views about the emerging role of practice manager than is the case amongst general practitioners. The results also show that differences in the size of practices have determined whether or not a need for a practice manager is perceived.

The focus of interest created by this faculty of the Royal College of General Practitioners has resulted in the formation of special interest groups of senior ancillary staff in the North of England. These groups form a valuable resource for exploration and innovation to discover more effective means of organising and managing general medical practice.