Postgraduate education allowance: general practitioners'' attendance at courses outwith their region.

A study was undertaken to investigate the number of doctors attending postgraduate education courses outwith their own region. During the one year study period general practitioners from the west of Scotland obtained 2262.0 half-day sessions accredited for the postgraduate education allowance from 335 different courses outwith their region and 10 different distance learning programmes. Four hundred and thirteen doctors from the west of Scotland region (22.6%) attended courses in other areas and 85 doctors (4.6%) participated in 258.6 half-days of distance learning. More than half of the education sessions (56.0%) were in the category of disease management. Sixty four doctors (3.5%) attended 10 or more half-day sessions outwith their region. Almost half the courses were in England and 32.5% of courses were in south east Scotland. Over the same period 122 doctors outwith the area attended 263 different courses in the west of Scotland region. Despite concern regarding the removal of travel and subsistence contributions for postgraduate education activities, general practitioners are attending education courses outwith their region.     

Demographic characteristics of general practitioners attending educational meetings.

There are many factors which influence general practitioners' behaviour with regard to attendance at education meetings. The demographic characteristics of general practitioners in the west of Scotland attending educational meetings were studied over a two year period. A total of 1672 doctors had attended sufficient sessions to claim their postgraduate education allowance and of these 1551 (93%) responded to the questionnaire. Overall attendance at meetings did not vary between age groups, but older doctors (those born before 1935) attended the highest mean number of education sessions on disease management and the lowest mean number on service management and health promotion. Doctors in rural areas attended fewer meetings than those in urban areas with the largest difference in the disease management category. Doctors from smaller practices attended significantly fewer sessions on service management than those from larger practices. There was no difference between sexes regarding the mean total number of education sessions attended but men attended significantly more sessions on service management and women attended more on health promotion. Full-time doctors attended more service management sessions than part-time doctors. Those who were widowed or divorced attended fewer sessions in total, the differences being greatest in service management and health promotion. Multiple regression analysis showed that location of practice, whether working full time or part time and marital status had a small but statistically significant bearing on overall attendance at meetings. Although the differences are small, these factors should be noted by education providers, negotiators and government.     

Continuing education for general practice and the role of the pharmaceutical industry.

A survey of the involvement in and attitudes towards continuing medical education of 101 general practitioners achieved a 95% response rate. Ninety per cent of the 96 doctors worked in practices which held meetings the content of which was organized by representatives of pharmaceutical companies but only 46% worked in practices which organized their own educational meetings. Seventy six per cent attended meetings away from their practice which were organized by drug companies and 75% had attended at some time continuing medical education activities organized by a local postgraduate centre. The promotional aspects of the drug company organized meetings were disliked by a majority of respondents (58%); more of the trainers (62%) and more of those who had entered general practice within the last seven years (71%) disliked this aspect. Nonetheless the educational content of both meetings held in the practice and those held elsewhere was the aspect most liked by over half of the respondents (59% and 53% respectively). Only 16% of all respondents thought that visits by representatives from pharmaceutical companies were educationally valuable and 37% thought that educational events organized by these companies were of value. Surprisingly 60% of those who worked in practices which held meetings organized by drug company representatives thought them to be of little or no educational value. There is clearly a need for practice based continuing medical education but the current level of dependence on drug companies for organizing these meetings must be questioned. Alternative strategies for the provision of independent non-sponsored educational activities should be sought.     

Postgraduate education allowance: educational attainment of subscribers and non-subscribers to a centrally organized educational scheme.

The educational attainment of general practitioners in the west of Scotland region who subscribed to a centrally organized educational scheme for the postgraduate education allowance was compared with that of their colleagues who did not subscribe to the scheme. During the year studied (1990-91) 1712 of the 1830 principals in general practice in the region had sufficient sessions to claim their postgraduate education allowance. Of these 1712 doctors the 1353 who subscribed to the educational scheme attended a mean of 15.7 educational half day sessions during the study year in comparison with a mean of 12.5 half days attended by the 359 doctors who did not subscribe to the scheme. This difference was observed in all three categories of education--disease management, service management and health promotion--and was greatest in health promotion where subscribers attended a mean of 4.7 half days and non-subscribers 3.1. The doctors who were members of the scheme had achieved a better balance of education. A higher number had attended an educational day in each of the three categories, with the increase being 10.5% for subscribers versus non-subscribers for disease management, 20.0% for service management and 39.1% for health promotion. The differences between the two groups were greater for combinations of categories and 66.6% of subscribers had attended an educational day in each of the three categories compared with 40.9% of non-subscribers. A centrally organized educational scheme for a region can give a balanced spread of education and is likely to meet the educational requirements of the new contract for general practitioners.     

Inviting infrequent attenders to attend for a health check: costs and benefits.

A total of 114 patients who had not attended their general practitioner in the previous three years were identified by searching a sample of 1488 records (12.8% of the practice list). An invitation for a health check was sent, in keeping with the requirements of the new general practitioner contract. Seventeen out of 94 patients invited (18%) attended. Surgery staff spent 28 hours and the practice doctors spent 15 hours on arranging and carrying out the investigation. The group responding to the invitation were in general healthy; the only new finding of remediable disease was mild hypertension in one man. The smoking rate and alcohol consumption rate were low. Of 13 patients who needed tetanus immunization, five refused it and five failed to return. All three women who were overdue for a cervical smear failed to return to have it done. It is concluded that screening infrequent attenders is not an efficient use of medical time.     

Attendance at a London casualty department

Patients who attended the casualty department of the Middlesex Hospital during one week in 1973 were interviewed. A predominantly young and working population used the department. Relatively few patients lived close to the hospital but many worked nearby. One third of all attendances were by patients who had been asked to return by casualty doctors. About half the new patients came of their own accord; the next largest group had been sent directly from work by an employer or occupational health service. Half the patients came with injuries, many of them superficial, although there were also serious accident cases. One fifth of the patients had no general practitioner whom they could consult. Age and geographical mobility were related to whether or not patients were registered with a general practitioner. The main reasons for not consulting a general practitioner were that patients felt they needed hospital treatment or that it was more convenient to attend the casualty department. It is suggested that the view that casual attenders with relatively trivial complaints should be encouraged to go to a general practitioner is not always applicable since social as well as medical circumstances determine whether or not patients decide to visit casualty.     

General practitioners' attendance at courses accredited for the postgraduate education allowance.

An analysis was undertaken in the northern half of the South Western Regional Health Authority of general practitioners' attendance at courses accredited for the postgraduate educational allowance over one year. A total of 358 courses provided 2341 hours of accredited education and produced a total general practitioner attendance of 50,389 hours. The mean attendance per principal in the area was 49.2 hours although the region may be a net importer of attenders from outside the area. Of the 50,389 total hours of attendance, 28.3% were in health promotion, 48.2% in disease management and 23.5% in service management. Course provision and attendance varied considerably over the year. September, October and November accounted for 42.7% of the total hours of attendance, compared with 6.8% in June, July and August. Courses of two to four days or of one week duration accounted for 48.3% of total attendance hours; 10.1% of total attendance hours were at commercially organized courses and 5.6% at courses organized by practices. A total of 66.1% of attendance hours were in postgraduate centres and 6.8% in the practice. Courses with more than 30 participants accounted for 15.9% of courses attended. A total of 174 general practitioners and others organized courses, 21 of them influencing 33,521 hours of general practitioner education. The study shows that in this area, there was an encouraging provision, range and uptake of continuing education courses for general practitioners. The concentration of educational activities in postgraduate centres underlines the need for increased provision for developing educational skills for clinical tutors.     

General practitioners'' views on continuing medical education.

BACKGROUND. The 1990 contract for general practitioners altered the provision of continuing medical education. AIM. This study set out to examine doctors' experiences of postgraduate education before and after the contract and their preferences for the provision of postgraduate education. METHOD. In 1991 a structured questionnaire was sent to 1959 doctors registered on the database held by the west of Scotland postgraduate office. RESULTS. An 82% response rate was obtained. Eighty eight questionnaires had to be excluded. Of 1523 respondents, 74% were entitled to study leave under the terms of their practice agreement, an increase of 15% since the introduction of the contract. When attending courses 11% reported that they always employed a locum (32% occasionally). Those who did so were more likely to be general practitioners in rural areas than in urban or mixed areas. Almost all respondents (1485, 98%) had participated in postgraduate education since April 1990. Lectures remained popular (47% of respondents indicated it was their preferred or most preferred choice) while distance learning and practice based learning were least preferred. Evening meetings and afternoon meetings were the most popular, and Wednesday and Thursday were reported to be the most suitable days for educational meetings. CONCLUSION. Organizing education for a large number of people is difficult, but individuals' preferences and difficulties have emerged which must be taken into account when doing so. In terms of attendance, postgraduate education seems to have been a success although its value in influencing quality of care is more doubtful. Perhaps the development of personal education plans may make learning more useful and relevant.     

A profile of attenders at the A&E Department of the Children's Hospital, Temple Street, Dublin

The Department of Health state that the prime function of the A&E department is to provide for the reception and initial management of every variety of medical emergency, provided that the condition could not be treated by the General Practitioner. The A&E department in the Children's Hospital, Temple Street, Dublin receives an average of 55,000 visits annually. The study profiled attenders according to their: socioeconomic status; reasons for attendance; appropriateness of attendance; and outcome of attendance. Attenders parents were more likely to be unemployed (22%), single (26%) and GMS card holders (52%) than national average figures. Families who attended out of hours (i.e. after 5pm) and/or who were self-referred did not differ socio-economically from other attenders. 74% of all attenders were self-referred and the self-referred group were more likely to attend after 5pm. 54% of attenders had attended the department more than once in the previous twelve months. 37% of all attendance were due to accidents. Casualty doctors assessed that 39% of all attendance did not require hospital services. However, the percentage of 'GP referred' and 'self-referred' groups deemed to require hospital services were comparable (47% v 38%). Furthermore, only 19% of GP referrals were admitted. These figures suggest that a large number of children who attend the A&E department should be attending a medical paediatric out patient unit, rather than an A&E department.     

Motivation of general practitioners attending postgraduate education.

BACKGROUND: The 1990 Contract encouraged general practitioners to participate in continuing medical education by providing a financial incentive. AIM: The study was designed: to determine the motivation of general practitioners attending education events; and to compare motivation and reasons for attendance pre- and post-Contract at commercial and non-commercial meetings, and at the different educational categories of Disease Management (DM), Health Promotion (HP) and Service Management (SM). METHOD: Two structured questionnaires were used. The first was sent to all general practitioners in the West of Scotland and asked about motivation pre-1990 Contract and the second, post-Contract, looked at motivation and reasons for attending a course as part of post course assessment. This latter was part of a much larger study evaluating continuing medical education. RESULTS: A total of 1161 practitioners responded to questionnaire I and 552 general practitioners attended 27 randomly selected postgraduate meetings. Finance was a motivator in 3.8% pre-Contract, and this increased to 33.3% post-Contract and was the most commonly stated reason for attendance in 81.3%. Financial incentive had the biggest influence on those attending HP sessions (91.5%), then SM (87.2%) and finally DM (78.6% (chi 2 = 8.68; P < or = 0.013). It was also important to 73% attending drug-company-sponsored meetings compared with 83.7% going to non-commercial ones. Interest was a good motivator both pre- and post-Contract, but more so for DM than other categories and drug company as opposed to non-commercial meetings (chi 2 = 9.4; P < 0.002). Lack of knowledge became a less-important motivator post-Contract, and doctors felt least knowledgeable in SM (62.2%), as opposed to DM (57.9%) and HP (23.6%) (chi 2 = 38.8; P < 0.001, with each differing significantly from both others). Doctors found the topics provided by the pharmaceutical companies more interesting (chi 2 = 9.4; P < 0.002) and the hospitality provided more alluring than scheme meetings (chi 2 = 28.6; P < 0.001). CONCLUSIONS: Finance has a major effect on attendance at postgraduate meetings but may not be a good incentive for learning. Planning for education must take into account the different motivational factors for the different categories. Reasons for attending commercial meetings differ from non-commercial ones and these events should be closely monitored.     

Counselling in general practice

In 1976, a group practice in South Oxfordshire established a counselling service. The counsellor is available in the health centre for three half-day sessions per week, and we describe a survey of the subjective and objective effects of counselling on the first 80 patients who used this service. There was an improvement, as measured by the feelings of the patients and doctors, and by some reduction of psychotropic drugs and medical consultations. The majority of the patients who returned the questionnaires said they preferred to see the counsellor rather than the general practitioner for their problem.     

Case against targeting long term non-attenders in general practice for a health check.

A study was undertaken to describe the consequences of implementing that part of the 1990 contract for general practitioners which requires them to offer health checks to all patients aged 16-74 years not seen within the previous three years. A random sample of 679 patients who had not attended for three years and 379 patients who had attended in this period were identified from 30 practice lists (including eight inner city practices) in five family health services authority areas. All patients were sent an invitation to a health check by their own practice and an attempt was made by the research team to conduct a home interview. The results showed that a considerable proportion of non-attenders were not in a position to take advantage of such an invitation; 17% of those at inner city practices were known to have received the invitation, 68% in practices elsewhere. Interviewed non-attenders (76% of those known to have received their invitation) had sociodemographic characteristics similar to the comparison group of interviewed attenders, although women aged 55-74 years were over-represented. At interview, non-attenders reported relatively less use of accident and emergency services and preventive health care and scored significantly better on all six dimensions of the perceived health status measure. Overall, 3% of all identified non-attenders in the inner city practices and 13% elsewhere accepted the invitation to a health check. Low levels of morbidity were found at health checks for those who had and who had not attended their general practitioners in the previous three years.(ABSTRACT TRUNCATED AT 250 WORDS)     

Work patterns of general practitioners before and after the introduction of the 1990 contract.

A questionnaire survey was undertaken to examine the work patterns of general practitioners before and after the introduction of the 1990 contract. A total of 408 and 697 general practitioners responded to the questionnaire in 1989 and 1991, respectively (response rates of 47% and 82%). In 1991 general practitioners reported spending significantly more evenings on paperwork than in 1989 and significantly more reported being exhausted or stressed at the end of five or more working days. General practitioners were significantly less likely to work four or more sessions per week outside the practice in 1991 than in 1989. There was no difference between 1989 and 1991 in the number of surgeries carried out per week or the number of nights spent on call in a month. In 1991 there was no correlation between the Jarman index allocated to a practice principal and the numbers of surgeries per week, sessions worked outside the practice per week, nights on call per month, weekdays exhausted or stressed, or evenings each week spent on paperwork. Older doctors in 1991 were significantly more likely to work 12 or more nights on call per month, to spend more time doing paperwork in the evenings and more likely to report exhaustion than younger doctors. Women doctors in 1991 were significantly more likely to report doing 10 or more surgeries per week than their men colleagues. It has become more common for general practitioners to complete paperwork at home and report exhaustion or stress since the introduction of the 1990 contract.     

Psychiatric intervention in primary care for mothers whose schoolchildren have psychiatric disorder.

BACKGROUND. Psychiatric disorder in schoolchildren has been linked to increased general practice attendance rates. This increase may, in part, be a result of maternal stress focused on the disturbed child, and of a decrease in confidence in parenting. AIM. A study was undertaken to pilot the feasibility of a single session, psychiatric intervention in primary care for mothers of disturbed children and to examine uptake rates and reported immediate and long-term effects. METHOD. Single psychiatric sessions by a child psychiatrist in general practice were offered to mothers of 26 schoolchildren. The schoolchildren (age range 7-12 years, mean nine years) were frequent attenders in general practice with physical symptoms, and were identified from research interviews carried out with a parent (usually their mother) as psychiatrically disordered. The main outcome measures were the mothers' ratings of helpfulness of the intervention; degree of behavioural, emotional or health problems in their children and confidence in managing them; the Rutter A parental behaviour questionnaire; and children's yearly general practice attendance rates. RESULTS. Sixteen mothers (62%) who were offered appointments attended for the intervention. Nine of the 14 who responded at three-month follow up (64%) reported that the intervention had been markedly or extremely helpful. The main areas of perceived improvement at both three months and at 18-24 months were in the child's behaviour, emotional and health problems, and in the mother's confidence in dealing with these. Mothers also found the specific advice discussed and the ability to talk to somebody about the problems helpful. Mothers were less likely to find the intervention extremely or markedly useful where the child had had previous psychiatric intervention. The mean yearly attendance rate for the whole group of 23 children (data missing for three) decreased from 6.5 consultations before the intervention to 2.8 afterwards; there was a non-significant trend for the drop in attendance to be more marked in the group whose mothers attended the intervention and who felt helped by it, than among the group of children whose mothers only reported finding the intervention slightly useful. CONCLUSION. Standardized child psychiatric interventions which may be used in the primary care setting appear acceptable and may be helpful to mothers in addressing psychiatric disorders associated with somatic presentation in their schoolchildren.     

Frequent attenders' consulting patterns with general practitioners.

BACKGROUND: Despite the growing literature on frequent attendance, little is known about the consulting patterns of frequent attenders with different doctors. To develop appropriate intervention strategies and to improve the clinical care of frequent attenders, a full understanding of these consulting patterns is essential. AIMS: This paper has three aims: to determine whether frequent attenders consult more with some doctors than others; to determine how many different doctors frequent attenders consult with; and to determine whether frequent attenders exhibit greater continuity of care than non-frequent attenders. METHOD: Analysis of a validated dataset of 592,028 consultations made by 61,055 patients from four practices over 41 months. Comparisons between the consulting patterns of the frequent attenders, defined as the most frequently consulting 3% of the population by practice, with non-frequent attenders and the overall practice populations. RESULTS: There was considerable variation in the numbers and proportions of consultations with frequent attenders between individual doctors. Most of the frequent attenders consulted with most or all of the doctors within practices over the timeframe. Frequent attenders exhibited more continuity of care than non-frequent attenders. CONCLUSION: The reasons why some doctors have more consultations with frequent attenders is unclear. Some doctors may actively encourage frequent attendance. While many frequent attenders have clear allegiances to one doctor, many also consult widely with a large number of doctors. The consequences of such behaviour are unknown. These findings have important implications in the development of appropriate interventions for reducing problematic frequent attendance.     

Diabetes and its care--what do patients expect?

A sample of 77% of the non-insulin dependent diabetics aged 30-70 years from two urban practices offering no structured diabetic care were interviewed. The 55 patients (mean age 60 years) were asked about their experiences and expectations of diabetes and the health professionals involved in their care. Twenty-six patients attended the hospital diabetic clinic regularly but 13 patients received no review at all; 46 patients wanted their general practitioner to be involved in future care and only six wanted to continue with hospital review alone. Patients gave hospital doctors and general practitioners similar high ratings for knowledge of diabetes and its management but general practitioners and practice nurses were rated more highly for communication and accessibility. The aspect of care valued most was being given clear information about diabetic management. Twenty two patients thought that diabetes would have a significant impact on their future health and 35 rated regular diabetic review as extremely important in keeping themselves healthy. Most patients felt it likely that they would have a high blood glucose level most of the time and develop diabetic complications. Little difference was found between the views of clinic attenders and non-attenders, and there was no evidence that non-attenders had actively rejected review. These non-insulin dependent diabetics considered diabetes to be a serious disorder warranting regular care and expressed confidence in the primary care team's ability to provide such care.     

A clinic for the prevention of osteoporosis in general practice

A clinic for women aged 40-60 years, offering screening and education about diet and hormone use and other measures for the prevention of osteoporosis, was organized in a group practice. Out of 582 eligible women contacted from the age-sex register, 252 (43%) attended the clinic. A year after the start of the clinic postal questionnaires were sent to all attenders and non-attenders to ascertain smoking habit, hormone use, calcium intake and social class. The use of hormone replacement therapy by the clinic attenders increased from a baseline of 15% to 45% but this had decreased to 38% one year later. Attending women were of higher social class and had slightly higher calcium intake than non-attenders. Although the use of hormone replacement therapy for prevention of osteoporosis is controversial, the risks and benefits were explained carefully to the women and the clinic provided a valuable opportunity for screening for weight problems, high blood pressure, menstrual problems and for health education about diet for the woman and her family.     

Psychooncological provision in a general hospital: the Herford model

Since October 1995 a Department of Psychooncology exists at the Herford Community Hospital. It was founded by a private foundation with the aim of supporting patients who suffer from cancer. The psychooncological section is an independent unit. This state of independence proved to be very useful and functional. The Herford Model is based on four compartments: psychosocial support for the patients; support for the patients' relations; the education of doctors and nurses; the evaluation of the activities of the team members, one music therapist and three psychologists. During the past 2.5 years 846 patients have had contact with the Department of Psychooncology. The mean age was about 62 years within a range from 15 to 92 years. Of the patients, 48% were men and 52% were women. The maximum number of meetings was 49: 29% of the patients had between four and eight therapeutical meetings, 12% had more than nine sessions. It is the aim of this report to show how the section is organized. The daily work and the rate of provision is shown and an outlook of the team's work in the future is given.     

Invitation to attend a health check in a general practice setting: comparison of attenders and non-attenders

A sample of 1570 men and women aged 20-45 years registered with an inner-city Cardiff practice were offered the opportunity by their general practitioner to have a health check at the surgery. The demographic characteristics, attitudes, beliefs and preventive health behaviour and past contact with the practice were compared for a sample of 259 non-attenders and 216 attenders. The results showed that attenders were generally better educated, better motivated to look after their health, had fewer ties and commitments, performed more healthapproved practices, had had more recent contact with their own practice and accepted the legitimacy of a general practitioner's interest in his patients' lifestyle. Offering cohorts of patients additional screening services is unlikely to be efficient or effective since it is the low-risk people already known to the doctor who are most likely to attend. The onus lies on primary health care to provide services in a way which permits appropriate screening of the high-risk groups as they attend for other reasons.