Provision of obstetric care by general practitioners in the south western region of England.

BACKGROUND. Recent government reports have suggested changes to the organization of maternity care in the United Kingdom which may well affect the contribution of general practitioners. AIM. This study set out to document the range of obstetric care provided by general practitioners, their perceived competence at various obstetric procedures, and their beliefs about their role in maternity care. METHOD. A postal questionnaire was sent to a random one in four sample of general practitioners in the South Western Regional Health Authority of England. RESULTS. Of 424 questionnaires sent out, 333 (79%) were returned. Of 303 respondents, 98% provided both antenatal and postnatal care. Of 294 respondents, 45% provided intrapartum care and 27% booked women for home deliveries. Of 117 respondents providing hospital intrapartum care 47% booked 10 or fewer women each year, and most provided little practical intrapartum care. Compared with those providing only antenatal and postnatal care, those who provided intrapartum care believed themselves to be more competent at various obstetric procedures and their perceived competence was significantly correlated to the number of procedures that they performed. Those general practitioners providing intrapartum care made significantly more postnatal visits than those providing only antenatal/postnatal care and were significantly more likely to believe that general practitioners have an important role in labour. CONCLUSION. Many general practitioners in the south western region of England still provide a choice in maternity care for women, and believe that they have an important role in such care. Further work is required to establish what women and their general practitioners believe the latter contribute to maternity care.     

Liaison psychiatry in general practice: a comparison of the liaison-attachment scheme and shifted outpatient clinic models.

Most psychiatrists who visit health centres use the shifted outpatient clinic model, the main aim of which is to improve secondary care by providing it in the primary care setting. For five years we have employed a liaison-attachment scheme in which support and advice from the psychiatrist enables general practitioners to improve their care of patients with psychiatric and psychological problems. One of the advantages of the latter model is that the psychiatrist can contribute to the care of patients not seen by the specialist psychiatric service and also to the development of the primary care team. The scheme is cost effective as psychiatrists can advise on the care of far more patients than they could see in formal referrals, fewer patients are taken on for a course of psychiatric treatment that could be provided by general practitioners and the skills of general practitioners and their trainees are enhanced. It is hoped that more general practitioners will adopt this pattern of working so that it can be fully developed and evaluated.     

Views of pregnant women on the involvement of general practitioners in maternity care.

BACKGROUND: The reorganization of maternity services in England following the report Changing childbirth is likely to impinge upon general practitioners' contribution to maternity care. Professionals and managers are increasingly expected to take account of patients' views when reorganizing services. AIM: This study aimed to elicit women's views about the involvement of general practitioners in maternity care and to establish the extent of continuity provided by general practitioners. METHOD: A prospective cohort postal questionnaire survey was undertaken in the Bath health district to elicit the views of pregnant women about the general practitioner's role in maternity care, the continuity provided, patient satisfaction and the general practitioner-patient relationship. Responses were rated on five-point Likert scales. Women completed questionnaires at 24 and eight weeks before the birth and at two and eight weeks after the birth. RESULTS: Of 164 women entering the study (28 of whom were booked for home delivery and 136 for hospital delivery), 116 (71%) completed all four survey questionnaires. Of respondents 68% agreed that general practitioners play an important role in routine antenatal care and 53% that they have an important role in normal labour. These opinions appeared to be stable over time. Most women (73%) were cared for throughout their pregnancy by one general practitioner whom they knew well; such continuity was desired by nearly all the women in the study. Approximately three quarters of women were satisfied with the antenatal, postnatal and overall care provided by their general practitioner. Over half of respondents (56%) wished to get to know the doctor who would be present at the birth: the general practitioner was involved in 19 labours (16%), being present at the birth for only nine women. Women delivering at home were significantly more likely to agree with the statement that they knew the doctor present at the birth compared with those women delivering at hospital. Most women (91%) had their final six-week postnatal check with their general practitioner. CONCLUSION: Most women in this study believed that general practitioners are important in maternity care, providing continuity of antenatal and postnatal care but not of intrapartum care. These beliefs might be an indicator of the future situation in the United Kingdom when more women give birth at home and under non-consultant care. The vocational training and continuing education of general practitioners should accommodate their possible future roles in maternity care.     

The biopsychosocial model of general practice: rhetoric or reality?

BACKGROUND: For more than 20 years, general practitioners have been encouraged to adopt a 'biopsychosocial' model of health care, that is, encompassing physical, psychological and social aspects. AIM: A study was undertaken to explore the extent to which general practitioners' views about the acceptable boundaries of their work are consistent with a biopsychosocial model. METHOD: A semi-structured postal questionnaire was sent to all 494 members of the Royal College of General Practitioners in Mersey Region who were general practitioner principals. The general practitioners were asked to list up to three topics presented by patients that they considered to be appropriate, and up to three topics that they considered to be inappropriate, to a general practitioner's knowledge and skills. The general practitioners were asked to rate, on a five-point scale of appropriateness, each of a list of 12 topics about which patients might have problems and present. Responses were analysed by sex and age of respondents. RESULTS: The response rate was 42%. Acute physical problems were most often listed appropriate by respondents, followed by chronic physical and psychological problems. The topics most often considered inappropriate were bureaucracy and social issues. Among the list of 12 specified topics, respondents considered terminal care and hypertension to be more appropriate than housing issues, spiritual worries, welfare rights or political issues. The sex of respondents did not relate to differences in results. Respondents aged 35 years and over generally considered topics presented by their patients to be more appropriate than did their younger colleagues. CONCLUSION: The general practitioner respondents in this study appeared to hold the view that general practitioners should work to a bio(psycho) rather than a biopsychosocial model of health care.     

Annual assessments of patients aged 75 years and over: views and experiences of elderly people.

BACKGROUND. The 1990 contract requires general practitioners to offer all their patients aged 75 years and over an annual health check. Increasing importance is being placed on consumers' views of service provision. AIM. A study was undertaken in June 1992 to investigate elderly patients' views and experiences of the annual health check, and to compare these with the previously reported views of general practitioners and practice nurses who had also been surveyed as part of the study. METHOD. Twenty family health services authorities wrote to a sample of 1500 elderly patients asking if the patient's name could be passed to researchers. Patients who agreed were then interviewed. RESULTS. A total of 664 elderly patients (44%) were interviewed. Only 64% of respondents were aware of their entitlement to a health check. Vulnerable patients, such as those in poor health or who lived alone, were less likely to know about the health checks than other patients. Only 31% of respondents thought they had had a health check. Of these, fewer than half recalled the doctor or nurse discussing the findings with them, although 80% of doctors reported that they always or mostly discussed results with patients. Elderly patients were more likely to recall the physical aspects of the health check rather than discussion about particular health aspects. However, doctors and nurses felt that routine checks were useful for giving advice rather than detecting medical problems. Of those who had had a health check, 82% reported no improvement in their health as a result, but 93% thought that they were a good idea. Only 7% of doctors thought they were of value, compared with the majority of nurses. CONCLUSION. It appeared that the inverse care law was operating, with those more in need of the service being less likely to have known about it. Discrepancies were found between general practitioners' and practice nurses' reports of service provision and those of elderly patients. Evidence about the cost-effectiveness of regular health checks may help the conflict between professional scepticism and consumer enthusiasm for these assessments.     

Epilepsy monitoring and advice recorded: general practitioners'' views, current practice and patients'' preferences.

BACKGROUND: Epilepsy is a common condition that is managed at the interface between primary and secondary care. AIM: A study aimed to describe general practitioners' criteria for aspects of optimal epilepsy care and their estimates of current levels of care achieved; to compare these estimates with clinical data extracted from their patients' medical records; and to compare general practitioners' estimates and recorded data with information provided by the patients themselves. METHOD: Thirty seven general practitioners from six practices in the south Thames region were sent a questionnaire enquiring about current practice with regard to general practitioner and specialist monitoring of patients with epilepsy and provision of advice, and about their criteria for the optimum levels of aspects of epilepsy care. Of patients aged over 15 years in the study practices, 0.6% were found to have active epilepsy; 283 of these 326 patients were sent a questionnaire enquiring about their epilepsy, the service and advice provided, and whether they required more information. Responses to the general practitioners' questionnaire and to the patients' questionnaire were compared and also compared with information extracted from the patients' medical records. RESULTS: Ninety five per cent of the general practitioners responded. Of 255 patient questionnaires (90%) returned, 251 could be analysed. Of 247 patients, 168 (68%) reported having had no seizure in the previous six months. Forty of 241 patients (17%) had a regular arrangement to see their general practitioner regarding their epilepsy. Of 191 patients who expressed a preference, 116 (61%) reported preferring to receive their epilepsy care mainly from their general practitioner. General practitioners reported that ideally patients should be monitored in primary care every six months (the median recorded frequency was 14 months) and that there should be a record of advice given to all patients on driving, adverse effects of antiepileptic drugs, and self-help groups. Advice was recorded in patients' records as having been given on driving (46% of records), adverse effects of antiepileptic drugs (9%), and self-help groups (3%); 82 of 237 patients (35%) reported not receiving enough advice. CONCLUSION: Patients generally preferred to receive their epilepsy care in general practice. Monitoring and provision of advice were less than optimal from both the general practitioners' and the patients' point of view. New resources and skills will be necessary to bridge this perceived gap. Specially trained nurses may have a role in this monitoring and advice provision.     

Residents of private nursing homes and their care.

A study was undertaken to examine the characteristics of residents in private nursing homes, to measure residents' dependency levels, to determine the adequacy of procedures for admitting new residents and to explore general practitioners' work with residents. Details were obtained of 61 nursing homes registered by Nottingham district health authority and of a selection of residents. Information about residents provided by the nurses in charge included aspects of self care, orientation and social integration, these items contributing to a dependency score for each resident. General practitioners completed postal questionnaires. Information was sought on the numbers of residents on the general practitioners' lists, visiting patterns, and opinions on their work with residents. It was found that almost half of the reports accompanying residents on admission were considered inadequate by the nurses in charge. The 357 residents varied widely in dependency level, need for nursing care and medication; 31% had low dependency scores. Most of the residents (57%), had been admitted from hospital, 26% from their own home and 15% from other nursing or residential homes. Higher overall dependency levels, problems with mobility and continence and need for care of wounds, catheters or colostomies were more frequent in residents admitted from hospital or nursing or residential homes than in those admitted from their own home. The 70 responding general practitioners varied widely in the numbers of residents on their lists and in their visiting patterns. The 16 general practitioners providing medical care for entire nursing homes were significantly more likely than the other general practitioners to visit routinely.(ABSTRACT TRUNCATED AT 250 WORDS)     

The Worcester development project: general practitioner satisfaction with a new community psychiatric service.

General practitioners in the Worcester development project area were interviewed about their experience of using the new community based psychiatric services. Of those who remembered the previous asylum based services most thought the new services were an improvement in many respects and were satisfied with the care provided for their patients. However, there were difficulties in obtaining emergency admissions, and criticisms of the social work service being slow to respond to requests for help. General dissatisfaction was expressed about feedback, particularly from the community psychiatric nursing service. General practitioners are expected to have a key role in the coordination of community services. However, most general practitioners interviewed had no particular interest or training in psychiatry. This, coupled with the inadequate information they received and the possibility of their workload increasing as more patients move out of hospital, raises questions about how they may be helped to fulfil this coordinating role in community psychiatric services.     

Annual assessment of patients aged 75 years and over: general practitioners'' and practice nurses'' views and experiences.

BACKGROUND. The new contract for general practitioners, introduced in 1990, required them to offer an annual assessment, or 'health check', to patients aged 75 years or more. AIM. A study was undertaken to collect details of practice organization of these assessments, general practitioners' and practice nurses' experience of assessments, and their views of the value of such assessments. METHOD. A nationwide postal survey of 1000 general practitioners and interview surveys with general practitioners and practices nurses from 150 practices were carried out in 1992. RESULTS. The postal survey yielded a response rate of 69% and the interview survey a practice response rate of 76%. Organization of assessments varied enormously between, and often within, practices with a variety of methods of invitation and assessment instruments being used. Of general practitioners 13% did not use a letter of any sort to invite patients to attend, and many doctors excluded certain patients from assessment, particularly those who were seen regularly or had been seen recently. However, 70% of general practitioners estimated that they had assessed over 60% of their elderly patients in the first year (1990-91). A substantial proportion of assessments were estimated to have been conducted on an opportunistic basis and few practices were doing all the assessments of those aged 75 years and over in the patients' homes. In the majority of practices, the general practitioners and practice nurses were the only personnel carrying out assessments. Only 9% of the doctors and 34% of the nurses interviewed had been specially trained to carry out the assessment; 54% of nurses said they would like more training in this area. Both doctors and nurses reported that the assessments did detect previously unknown problems, although over half of doctors reported that they rarely picked up new mental health problems. Increased referrals to social services as a direct result of the assessments were reported by 63% of doctors. The majority of doctors and nurses reported that routine assessments were useful in providing advice and reassurance to elderly people. Two thirds of doctors said they would continue to offer at least selected groups of their elderly patients routine assessments, even if not contractually obliged to do so. CONCLUSION. The findings suggest that the experiences of the first two years of this activity had convinced some general practitioners that routine assessment of elderly patients is worthwhile. However the increased demand for other services must obviously be met by an increase in resources if the effectiveness of these assessments is not to be undermined.     

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.     

What do health visitors contribute to the care of children? A study in the north of England.

All the health visitors in the north of England, and more than half the general practitioners, were sent questionnaires about the primary health care of children. More than 90% of the health visitors responded. Most of them took part in developmental screening and considered it primarily their responsibility; some conducted developmental or well baby clinics with no other professionals present. Clinics run by health authorities often occupied several hours per week, and were more frequently attended by health visitors than clinics run by general practitioners. Almost all the health visitors' remaining time was spent in attached practices, despite the fact that more than half said they had neither office nor clinic space of their own on practice premises. A high proportion of time was spent on clerical work; more help with this could free the health visitor to provide better developmental care for all children.     

Integrated care for patients with asthma: views of general practitioners.

BACKGROUND. In 1989, a shared or integrated care scheme was developed for hospital outpatients with asthma, using the computerized patient record system of Grampian Health Board, Scotland. Patients with asthma attending hospital clinics were entered into this scheme and were invited to attend their general practitioner instead of an outpatient clinic for review of their asthma. Three-monthly questionnaires covering clinical aspects of asthma were sent to these patients and their general practitioners; the latter then returned them to the specialist. Patients could be recalled to the hospital clinic if either the general practitioner or consultant felt this was necessary and all patients were reviewed after one year by the specialist. The success of integrated care for patients with asthma relies on the cooperation of general practitioners. AIM. The aim of this study was to investigate how this scheme worked in general practice, and general practitioners' perceptions of it, in order to identify factors that enhance or inhibit integrated care for patients with asthma in general practice. METHOD. A qualitative survey was carried out with a random, stratified sample of 38 of the 317 general practitioners in the region. Semi-structured interviews were designed to elicit general practitioners' accounts of their operation of integrated care and their attitudes towards the scheme. RESULTS. General practitioners perceived the scheme to have several advantages: the continuity and quality of care provided was improved; and the transmission of information between general practitioner and specialist was enhanced. Regular general practitioner reviews, instigated by standard letters generated by computer, were favoured as being clearly structured. Concerns were raised about the processing of paperwork, and the possibility that unnecessary reviews might be generated. CONCLUSION. Integrated care for asthma patients is an acceptable management option among general practitioners.     

Links between mental health care professionals and general practices in England and Wales: the impact of GP fundholding.

BACKGROUND: Fundholding general practitioners are able to determine the type of contracts they place with providers of mental health care, and are able to employ some categories of mental health care professionals directly. The impact of this on the care of the mental health of patients in non-fundholding practices is not yet fully known. AIM: A survey was undertaken of 100 fundholding general practices and 100 similarly sized non-fundholding practices in order to investigate the changes in mental health provision made by general practitioners. METHODS: A sample of 100 fundholding general practices in England and Wales was randomly chosen from the list supplied by the Association of Fundholders and matched to a similarly randomly chosen sample of non-fundholding practices. Postal questionnaires were sent to the senior partner and to the practice manager in each practice. RESULTS: The number of mental health care professionals who are either employed by or attached to general practices, or who visit the general practice on a regular basis appears to have increased substantially since 1991. This increase was particularly marked in fundholding practices. The results suggest that general practitioners with specific links to particular mental health care providers were more satisfied with the service provided by the mental health care team, and more likely to increase referrals to that service in the last 2 years, than general practitioners without such links. There was little evidence to suggest that increasing the number of mental health care professionals in primary care had brought about a major reduction in referrals to psychiatrists. CONCLUSION: General practitioners, particularly fundholders, are increasing their links with mental health professionals, and community psychiatric nurses, psychiatrists, psychologists and counsellors are spending more time either based in general practice or visiting regularly. While the shift of resources to primary care, particularly to fundholders, may increase the treatment options available to patients with less severe illnesses, this may have the effect of reducing the services available for the long-term and severely mentally ill.     

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.     

Prevention in general practice: the views of doctors in the Oxford region.

A postal questionnaire was sent to all 1291 general practitioners in the Oxford region to determine the pattern of preventive care and their beliefs about its effectiveness. Replies were received from 1014 doctors (79%). Doctors' attitudes to their role in prevention and health promotion were very positive and a large majority claimed to discuss health related topics with their patients when indicated. Fewer respondents said they made a point of discussing smoking habits (64%), alcohol intake (26%), diet (12%), or exercise (11%) as a matter of routine with all their adult patients. Most general practitioners said they usually offered simple advice, leaflets, or other aids when they had identified a problem, but few said they would refer these patients to the practice nurse. With the exception of cervical screening (45%), few respondents said they maintained statistics on the distribution of risk factors in their practice population. Despite considerable enthusiasm for their role in preventive health care, before the imposition of the new contact most general practitioners in the Oxford region had not yet embraced the model of prevention which the contract aims to encourage: systematic screening for risk factors and lifestyle advice for all patients.     

The management of vaginal discharge in general practice

A group of general practitioners in active practice were asked to report how they preferred to manage the symptoms of vaginal discharge presented by a woman in her twenties. Subsequently the same practitioners reported their management of such patients in their practice.

A shortfall was found for all practitioners between their declared intention and their actual practice.

This method of analysis offers a way of working towards a consensus in clinical care and also of auditing medical performance in general practice.

     

Anti-smoking advice in general practice consultations: general practitioners'' attitudes, reported practice and perceived problems.

BACKGROUND: Anti-smoking advice from general practitioners has proven efficacy. However, general practitioners do not exploit a large proportion of opportunities to discuss smoking with patients. AIM: A study aimed to explore general practitioners attitudes towards discussing smoking with patients and to assess how these influence the quantity of anti-smoking advice that general practitioners report giving during routine consultations. It also aimed to determine the extent to which general practitioners report using evidence-based interventions against smoking and to discover the problems they experience when discussing smoking with patients. METHOD: A postal survey of all 468 general practitioners on the Leicestershire Family Health Services Authority list was conducted. General practitioners' attitudes were assessed by scoring 13 attitude statements using a six-point Likert-type scale. They were also asked to rank (from a list of 12 items) the five approaches that they found most productive and (from a list of 11 items) the five problems that they most commonly encountered when giving anti-smoking advice to patients. RESULTS: A total of 327 questionnaires (70%) were returned. Most respondents (97%) thought that their advice was more effective when linked to patients' presenting problems and 65% reported that linking their anti-smoking advice to patients' presenting complaints was one of their three most preferred approaches to discussing smoking. Advising all presenting smokers to quit was considered by 40% of respondents to be an appropriate use of time but 76% reported that patients' lack of motivation was one of the three most commonly encountered problems. An analysis of the ratings of the 13 statements suggested that general practitioners who reported the greatest smoking cessation activity during routine consultations held more positive attitudes towards discussing smoking with patients. CONCLUSION: This study suggests that general practitioners believe that their anti-smoking advice is more effective when linked to patients' presenting complaints, and this belief appears to be reflected in the way in which general practitioners approach smoking cessation with patients. The findings may indicate that general practitioners are unlikely to accept a role in a population-based anti-smoking strategy which demands that they discuss smoking with all presenting smokers.     

Current issues in fitness for work certification.

This paper explores some current issues for certifying medical practitioners in the United Kingdom (UK), particularly general practitioners (GPs), who provide medical advice to their patients on fitness for work. Medical statements that doctors use to record this advice, such as form Med 3 and form Med 4, may be used by patients as evidence to support claims for financial benefits, including Statutory Sick Pay (SSP) and state incapacity benefits. The UK employment context for sick or disabled people of working age is beginning to change, but many barriers to work retention and work resumption still exist. The UK government has embarked on a wide range of reforms that are aimed at improving work opportunities for disabled people. Research evidence on certification practice, coupled with a better understanding of the factors that can create and perpetuate sickness absence from work, suggest possible areas for reviewing clinical practice. An agenda for improving the quality of advice provided to patients of working age in the primary health care setting will need to encompass visible professional leadership, more research into current practice, and an adequately resourced programme of education for all key stakeholders.     

Primary care teams and the elderly in Northern Ireland

The results of a questionnaire were used to examine how primary care workers set about the management and surveillance of their elderly patients. The majority of practices had attached visitors (76 per cent) and attached district nurses (59 per cent), while 61 per cent of general practitioners worked in health centres. Over half of the responding practices had agesex registers. Few of the practices (14 per cent) had screened their elderly patients in the last five years and maintained an `at-risk' register. Twenty per cent of practices held a regular meeting concerning their elderly patients but only half of these reviews involved the available health visitors and district nurses.

At least half of the general practitioners and district nurses plus three quarters of the health visitors felt dissatisfied with the care of the elderly.

A single and systematic review of elderly patients conducted jointly by general practitioners, health visitors and district nurses would do much to improve the care of this group of patients and the morale of these workers.