Predictors of the provision of intrapartum care by general practitioners: five-year cohort study.

BACKGROUND: There is little published evidence that any aspect of vocational training for general practice improves the quality of care provided by general practitioners (GPs). AIM: To investigate whether aspects of education and vocational training predict whether GPs provide intrapartum care. METHOD: A five-year prospective cohort study was carried out in the United Kingdom (UK) using responders to a 1990 national survey of GPs for whom a current UK address could be found. Main outcome measures were factors associated with provision of GP intrapartum care in 1995. RESULTS: In 1995, a minority of ex-trainees (65 out of 349, 18%) provided intrapartum care as GPs, although 28% would ideally have wished to do so; 8% provided home delivery care. Four education and training variables were associated with ex-trainees booking women for GP delivery in 1995: the number of partners in the ex-trainee's GP training practice providing GP intrapartum care (odds ratio (OR) = 1.30); performing forceps deliveries as an obstetric senior house officer (SHO) (OR = 1.24), witnessing episiotomies as a student (OR = 1.17), and witnessing twin deliveries as a student (OR = 0.75). CONCLUSIONS: In the case of GP intrapartum care, future service provision is associated with certain education and training variables. There is a mismatch between GPs' ideal and actual maternity care provision. Changes to enhance such care would be needed at least at three levels: selection and approval of training practices, content and base for SHO posts, and practice arrangements for maternity cover.     

Reasons why doctors choose or reject careers in general practice: national surveys

Background

Less than one-third of newly qualified doctors in the UK want a career in general practice. The English Department of Health expects that half of all newly qualified doctors will become GPs.

Aim

To report on the reasons why doctors choose or reject careers in general practice, comparing intending GPs with doctors who chose hospital careers.

Design and setting

Questionnaire surveys in all UK medical graduates in selected qualification years.

Method

Questions about specialty career intentions and motivations, put to the qualifiers of 1993, 1996, 1999, 2000, 2002, 2005, 2008, and 2009, 1 year after qualification, and at longer time intervals thereafter.

Results

‘Enthusiasm for and commitment to the specialty’ was a very important determinant of choice for intending doctors, regardless of chosen specialty. ‘Hours and working conditions’ were a strong influence for intending GPs (cited as having had ‘a great deal’ of influence by 75% of intending GPs in the first year after qualification), much more so than for doctors who wanted a hospital career (cited by 30%). Relatively few doctors had actually considered general practice seriously but then rejected it; 78% of the doctors who rejected general practice gave ‘job content’ as their reason, compared with 32% of doctors who rejected other specialties.

Conclusion

The shortfall of doctors wanting a career in general practice is not accounted for by doctors considering and rejecting it. Many do not consider it at all. There are very distinctive factors that influence choice for, and rejection of, general practice.     

Occupational medicine and training for general practice.

The inclusion of occupational health topics in vocational training for general practice is limited-principally by course overload, and by a lack of local contact between occupational physicians and general practitioners (GPs). There is a need for the Royal College of General Practitioners and the Faculty of Occupational Medicine to review communication and training opportunities between the specialties.     

Analysis of the hospital experience completed by general practitioner trainees in 1984-87.

This report gives details of the hospital experience undertaken by doctors who have completed vocational training for general practice and is based on the information presented by applicants for the certificate of the Joint Committee on Postgraduate Training for General Practice.     

One trainee's clinical experience

I report my clinical experience as a trainee. I am doubtful about the usefulness of hospital medical and accident and emergency posts, but obstetric and paediatric posts are highly relevant. There was little experience and teaching in the general practice year about psychiatry and gynaecology. It seems possible that trainees are not seeing enough chronic illness or associated problems, such as obtaining social services, therapy in chronic cases, and correct delegation to practice nurses. These points all suggest that the work of doctors undergoing vocational training should be monitored, at least at present.     

Service profiles of general practitioners in Europe. European GP Task Profile Study.

BACKGROUND: General practice is the focal point of primary care. There are national differences in the structure and organization of practice, the relationship with secondary care is being redefined, and in some countries major changes are taking place. AIM: To describe and examine differences in the service profiles of general practitioners (GPs) in European countries. METHOD: Standardized questionnaires in the national languages were sent to samples of GPs in 1993. Four areas of service provision were measured: the GP's position in the first contact with selected health problems, the involvement in minor surgery and the application of medical procedures, disease management and preventive care. The importance of the gatekeeping role, remuneration system, and geographical region in Europe was examined by comparing scores in appropriate national groupings. RESULTS: Data were received from 7233 GPs in 30 countries. Most national samples were random and the average response rate was 47%. In countries where GPs have a gatekeeping role, they had a relatively stronger position as doctors of first contact. In those countries where GPs were usually self-employed, they had a stronger role in disease management and screening for blood cholesterol. In the examination of the three structural elements of health care, the most striking differences were evident in the comparison between eastern and western Europe. GPs throughout Europe had a comparatively small role in organized health education. CONCLUSION: The position of GPs is weak in eastern Europe and some Mediterranean countries, where service profiles have a limited range. General practice was more comprehensive where the doctors had a gatekeeping role.     

Appraisal of family doctors: an evaluation study.

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

The benefits and costs of a master's programme in primary health care: a cross-sectional postal survey

Background

Master''s programmes can provide continuing professional development, equipping GPs to teach, research, and lead general practice. A previous evaluation of the MSc in primary health care found that graduates were contributing significantly to the discipline of general practice. Given the changes in general practice over the last 10 years, it was considered useful to investigate longer-term outcomes.

Aim

To assess the benefits GPs have derived from the MSc in terms of the intended learning outcomes and their own plans for involvement in research and teaching.

Design of study

A cross-sectional survey using a postal questionnaire.

Setting

Department of Primary Care and Public Health Sciences, King''s College London.

Method

A postal questionnaire was sent to the graduates of MSc in primary health care from 1997 until 2008.

Results

A total of 50 completed questionnaires were returned (response rate 76%). After graduation, 22 GPs had completed another degree or diploma and 21 had work accepted for publication, resulting in 74 papers. Nine held academic posts at lecturer or senior lecturer level, 21 were GP trainers, and 21 undergraduate teachers. Twenty-five GPs held more than one teaching-related post. The majority of the graduates confirmed the attainment of the MSc''s intended outcomes. Positive influences of the MSc were identified, including career development, personal development, and job satisfaction.

Conclusion

Graduates reported a number of benefits to themselves, their practices, and their patients. As the requirements for continuing professional development of GPs become more stringent, and with the advent of revalidation, the current ad hoc approach to career development in general practice is becoming unsustainable. To enhance its credibility as an academic discipline, general practice must continue to develop its capacity for research and scholarship. Master''s programmes are likely to have an important role in supporting professional development in general practice in the future.     

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

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

Perceived future career prospects in general practice: quantitative results from questionnaire surveys of UK doctors

BackgroundThere are more studies of current job satisfaction among GPs than of their views about their future career prospects, although both are relevant to commitment to careers in general practice.AimTo report on the views of GPs compared with clinicians in other specialties about their future career prospects.MethodQuestionnaires were sent to the doctors at different times after graduation, ranging from 3 to 24 years.ResultsBased on the latest survey of each graduation year of the 20 940 responders, 66.2% of GPs and 74.2% of hospital doctors were positive about their prospects and 9.7% and 8.3%, respectively, were negative. However, with increasing time since graduation and increasing levels of seniority, GPs became less positive about their prospects; by contrast, over time, surgeons became more positive. Three to 5 years after graduation, 86.3% of those training in general practice were positive about their prospects compared with 52.9% of surgical trainees: in surveys conducted 12–24 years after graduation, 60.2% of GPs and 76.6% of surgeons were positive about their prospects.ConclusionGPs held broadly positive views of their career prospects, as did other doctors. However, there was an increase in negativity with increasing time since graduation that was not seen in hospital doctors. Research into the causes of this negativity and policy measures to ameliorate it would contribute to the continued commitment of GPs and may help to reduce attrition.     

Vocational training and recruitment into general practice

A recent survey of doctors in the practice year of vocational training indicates a strong preference for group practice from purpose-built premises (health centre and other) with multidisciplinary staffing and attachments. While it might be assumed that the introduction of mandatory vocational training would provide a continuing supply of well trained recruits into general practice, it may well raise recruitment problems for those areas where practice facilities and opportunities do not meet with expectations. This possibility is of particular concern for those metropolitan regions encompassing inner city areas which have traditionally been highly dependent on hospital-based services, but where deficiencies in primary care provision, particularly in terms of practice structure and premises, have been identified repeatedly over the past 30 years. In view of the present policies for changing the balance of care away from the hospitals, there is an urgent need to develop primary care facilities which will accord with the expectations of vocationally trained general practitioners and their population of patients.     

A follow-up of some North-East London trainees

General practitioner trainees from the period 1963-80 were followed up with a postal questionnaire, yielding a 62 per cent response rate. Questions were asked about their training and their current posts. Of the ex-trainees, 62 per cent were graduates from overseas medical schools, 92 per cent were now general practitioner principals in the United Kingdom and 25 per cent had experienced difficulty in finding a practice. Trainees from a three-year vocational training scheme (VTS), predominantly from UK medical schools, scored higher on an Index of Attainment than those not from a VTS. Sixty-three per cent of trainees had settled within 10 miles of training area. Only 27 per cent of trainees now worked in a health centre, compared with 61 per cent of trainers. Comments on the training programme suggested financial matters were inadequately dealt with. Twelve per cent would have preferred a longer period in the training practice and 18 per cent made negative comments about their training.     

Vocational training and beyond--listening to voices from a void.

This paper is written from the viewpoint of a doctor who has recently undergone general practice vocational training, and has first-hand experience of some of the opportunities, difficulties, and uncertainties facing doctors at this stage of their careers. The literature on vocational training and the issues concerning young doctors are explored in the light of concerns that recruitment into general practice is falling, that registrars may feel lost in a 'void' at the end of training, and that the 'new world' of post-training work brings problems for many new general practitioners (GPs). Instead of a traditional partnership, one of the authors (RB) chose a salaried, educationally oriented introduction to inner-city general practice. Some innovative, educational schemes, which are aiming to improve the appeal of general practice, are discussed.     

Diagnostic ultrasound: a primary care-led service?

BACKGROUND: A training programme has been proposed for general practitioners (GPs) to perform ultrasound in primary care. This has generated considerable concern among radiologists as to the adequacy and appropriateness of such training. AIM: To assess the current provision of ultrasound services to primary care in the former Northern health region of England, the level of interest among GPs in undertaking recommended training, and the willingness or ability of radiology departments to provide it. METHOD: Postal questionnaires were sent to GPs (n = 334), their practice managers (n = 281) and all clinical directors/heads of radiology departments (n = 19) in the region. RESULTS: Altogether, 67% of GPs, 59% of practice managers, and 68% of radiologists returned questionnaires. Overall, 48% of GPs have open access to obstetric/gynaecological ultrasound compared with 77% for general diagnostic requests. A total of 73% of GPs would prefer an open access service and 15% a practice-based service. Some 48% of GPs were not interested, 36% moderately interested, and 16% very interested in participating in the training programme. Only two out of 13 radiology, departments were willing to provide such training. CONCLUSION: Despite recommendations from the Royal College of General Practitioners, around half the respondents in this survey do not have direct access to ultrasound for obstetric referrals, and a quarter for non-obstetric referrals. Interest shown by GPs in a primary care-led service is not mirrored by their radiology colleagues. Open access to ultrasound was considered the optimum service, suggesting that resources be targeted at improving hospital services rather than transferring facilities to primary care.     

What can general practice learn from complementary medicine?

Complementary medicine is popular in Britain. This suggests that patients who use complementary medicine believe that there are deficiencies in the care they receive from their general practitioners (GPs). Studies of patients using complementary medicine have shown that these patients are sometimes dissatisfied with the communication skills of conventional doctors, the explanations they give for their illnesses, the dangers of modern drugs, and a perceived lack of holistic care. The patients using complementary medicine trusted their bodies' own healing potential and they generally believed that they had more control over their bodies than those patients who did not use complementary medicine. They particularly valued the longer appointment times usually given by the complementary therapists and also the in-depth discussions of their illnesses. Patients using complementary medicine tended to be those with chronic illnesses and these patients particularly valued the positive approach of, and the psychological support given by, the complementary therapists. General practitioners know that all of these aspects of care are important, but the fact that many of our patients go to complementary therapists to satisfy them should encourage us to look at our own practices to see how we as GPs can fulfill these needs.     

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

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

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

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

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

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

The state of primary care in the United States of America and lessons for primary care groups in the United Kingdom.

The health care system of the United States of America (USA) is lavishly funded and those with adequate insurance usually receive excellent attention. However, the system is fragmented and inequitable. Health workers often find it difficult to separate vocational roles from business roles. Care tends to focus on the acute rather than the chronic, on 'episodes of illness' rather than 'person-centred' care, on short-term fixes rather than long-term approaches, on scientific/technical solutions rather than discourse or the 'art of healing', and on individual health rather than population health. The majority of US doctors are trained in the 'hightech' hospital paradigm and there is no equivalent of the United Kingdom (UK) general practitioner (GP), who lies at the hub of a primary health care team (PHCT) and who is charged with taking a long-term view, co-ordinating health care for individual patients, and acting as patient advocate without major conflicting financial incentives. However, primary care groups/trusts (PCGs) could learn from US management and training techniques, case management, NHS Direct equivalents, and the effects of poorly developed PHCTs. PCGs could develop the UK's own version of utilisation management. A cash-limited, unified budget within an underfunded National Health Service poses threats to general practice. In both the USA and the UK, primary care is a prominent tool in new attempts at cost control. PCGs offer the opportunity of better integration with public health and social services, but threaten GPs' role as independent advocates by giving them a rationing role. Managed care has forced a similar role onto our US counterparts with consequent public displeasure and professional disillusion. UK GPs will have to steer a careful course if they are to avoid a similar fate.     

The development and reliability of the Royal College of General Practitioners' questionnaire for measuring senior house officers' satisfaction with their hospital training.

BACKGROUND: The training provided for senior house officers (SHOs) has been the subject of debate, and variable satisfaction with training has been reported. The reliability of the instruments used for measuring satisfaction has not been adequately addressed. AIM: To develop a reliable questionnaire to measure SHO satisfaction with hospital training. METHOD: A 42-item questionnaire with eight scales was developed using criteria from the joint hospital visiting guidelines of the Royal College of General Practitioners. The questionnaire was sent to SHOs in Anglia before monitoring visits from the royal colleges, the postgraduate dean and the Joint Committee on Postgraduate Training for General Practice. RESULTS: Response rates varied from 37.0% to 100%, with an overall response rate of 58.8%. The internal reliability of the whole questionnaire was 0.82. Levels of internal reliability for the individual scales were satisfactory, Cronbach's alpha coefficient being 0.75 or more in all but two of the scales. Test-retest reliability using Pearson's product moment correlation coefficient was greater than 0.82 for six of the scales. There were significant differences in total satisfaction between SHOs reporting on posts accredited by the different royal colleges and also between SHOs training for general practice and those training to be specialists. CONCLUSION: A reliable questionnaire has been developed to measure SHO satisfaction with hospital training that is acceptable to doctors and feasible to administer. National acceptance of a single questionnaire for monitoring SHO posts would enable standards to be monitored regularly at a time of considerable change in hospital training.