A comparison of research general practices and their patients with other practices--a cross-sectional survey in Trent.

BACKGROUND: When interpreting results of studies undertaken by research networks we need to know how representative volunteer practices and their registered patients are of the total population of practices and patients in their locality. AIM: To compare the following in research and non-research general practices in one region: practice and population demography, morbidity and mortality, selected performance indicators, and health outcomes. DESIGN OF STUDY: Cross-sectional survey. SETTING: Sixty-six Trent Focus Collaborative Research Network general practices and 749 other general practices in Trent, United Kingdom. METHOD: Practice characteristics and GP contract data were obtained from the NHS Executive, Quarry House, Leeds. The Trent Regional NHS Hospital Admission Database was searched to identify all relevant admissions to hospital from all practices between 1 April 1993 and 31 March 1997. Ward-linked data on cancer were obtained from the Trent Cancer Registry. RESULTS: Of the 815 general practices in Trent Region in the study period, 66 (8%) were in the Trent Focus network. They were more likely to be involved in training GPs and to have a female partner. They tended to be larger, with fewer single-handed doctors and younger GPs. Network practices prescribed a higher proportion of generics (median % prescribed/practice = 70%, versus 51%, Mann-Whitney U = 1615, P<0.0001). There were no clinically important differences between hospital admission rates between the two groups or waiting times for surgical procedures. There was no difference in the incidence of cancer and standardised mortality ratios related to the electoral wards of the GP surgery. CONCLUSION: Although there were differences in practice structure and some aspects of performance, we found no important differences in the demography of registered patients, nor in morbidity, mortality, or access to or use of secondary care.     

Assessing the capacity of the health services research community in Australia and New Zealand

BACKGROUND: In order to profile the health services research community in Australia and New Zealand and describe its capacity, a web-based survey was administered to members of the Health Services Research Association of Australia and New Zealand (HSRAANZ) and delegates of the HSRAANZ's Third Health Services Research and Policy Conference. RESULTS: Responses were received from 191 individuals (68%). The responses of the 165 (86%) who conducted or managed health services research indicated that the health services research community in Australia and New Zealand is characterised by highly qualified professionals who have come to health services research via a range of academic and professional routes (including clinical backgrounds), the majority of whom are women aged between 35 and 54 who have mid- to senior- level appointments. They are primarily employed in universities and, to a lesser extent, government departments and health services. Although most are employed in full time positions, many are only able to devote part of their time to health services research, often juggling this with other professional roles. They rely heavily on external funding, as only half have core funding from their employing institution and around one third have employment contracts of one year or less. Many view issues around building the capacity of the health services research community and addressing funding deficits as crucial if health services research is to be translated into policy and practice. Despite the difficulties they face, most are positive about the support and advice available from peers in their work settings, and many are actively contributing to knowledge through academic and other written outputs. CONCLUSION: If health services research is to achieve its potential in Australia and New Zealand, policy-makers and funders must take the concerns of the health services research community seriously, foster its development, and contribute to maximising its capacity through a sustainable approach to funding. There is a clear need for a strategic approach, where the health services research community collaborates with competitive granting bodies and government departments to define and fund a research agenda that balances priority-driven and investigator-driven research and which provides support for training and career development.     

General practice in New Zealand.

General practice in New Zealand has evolved into a 'user pays' system and although operating within a national health service, it has many interesting differences from general practice in the United Kingdom. Emphasis is placed on biculturalism in health care. Income is derived through a fee for service, which includes a proportion from patients dependent on their means tested reimbursement from the government for provision of general medical services. Consultations are fewer in number and longer in duration. New Zealand society has considerable awareness in the area of medical ethics and there is a medical insurance scheme which covers ill health as a result of accidents. Great advances have been made in provision for out of hours work. New Zealand has its own royal college of general practitioners, membership examination and scheme for vocational training. This paper, based on the authors' personal experience of 12 months' study leave in New Zealand in 1991-92, examines these important areas of difference and reflects on the health reforms that are currently taking place in New Zealand.     

Factors associated with immunisation coverage and timeliness in New Zealand

Background

Immunisation coverage in New Zealand is lower than what is necessary to prevent large epidemics of pertussis. Primary care is where most immunisation delivery occurs. General practices vary in their structure and organisation, both in a general sense and specifically with respect to immunisation delivery.

Aim

To identify the structural and organisational characteristics of general practices associated with higher immunisation coverage and more timely immunisation delivery.

Design of study

A random sample of practices during 2005 and 2006.

Setting

General practices in the Auckland and Midland regions, with over-sampling of indigenous Maori governance practices.

Method

Practice immunisation coverage and timeliness were measured. Primary care practice characteristics relevant to immunisation delivery by the practice were described. Associations of these practice characteristics with higher practice immunisation coverage and more timely immunisation delivery were determined.

Results

A total of 124 (61%) of 205 eligible practices were recruited. A median (25th to 75th centile) of 71% (57–77%) of registered children at each practice were fully immunised, and 56% (40–64%) had no immunisation delay. In multivariate analyses, both practice immunisation coverage (P<0.001) and timeliness (P<0.001) decreased with increased social deprivation. After adjustment for socioeconomic deprivation, region, and governance, immunisation coverage and timeliness were better at practices that enrolled children at a younger age (coverage: P = 0.002; timeliness P = 0.007), used one of the four available practice management systems (coverage: P<0.001; timeliness: P = 0.006), and had no staff shortages (coverage: P = 0.027; timeliness: P = 0.021).

Conclusion

Practice immunisation coverage and timeliness vary widely in New Zealand. General organisational and structural aspects of general practices are key determinants of general practice immunisation delivery.     

Judgments of laypersons and general practitioners on justifiability and legality of providing assistance to die to a terminally ill patient: a view from New Zealand

As part of a larger study, four decisions related to a vignette scenario of the elective death of a terminally ill patient suffering intractable pain are examined (doctor supplying information and drugs, assisting patient to take the drugs, or administering a lethal injection). Judgments on justifiability and legality of actions were obtained from laypersons and general practitioners (GPs) in Auckland, New Zealand. The results show that over 72% of laypersons and over 30% of GPs judged all four actions justified. Despite illegality a significant number of laypersons and some doctors were unsure of the legal status of actions. The current law in New Zealand prohibiting physician-assisted death may not reflect judgments by the majority of laypersons or 30% of general practitioners on the justifiability of elective death options for a terminally ill patient with intractable pain. Judgments on justifiability may be related to confusion over the legality of actions.     

Sarcoptes scabiei on hedgehogs in New Zealand

Parasitology Research - European hedgehogs (Erinaceus europaeus) were introduced into New Zealand from Britain during the period from 1869 to the early 1900s. The only mite found on New Zealand...     

General practice and the New Zealand health reforms – lessons for Australia?

New Zealand's health sector has undergone three significant restructures within 10 years. The most recent has involved a Primary Health Care Strategy, launched in 2001. Primary Health Organisations (PHOs), administered by 21 District Health Boards, are the local structures for implementing the Primary Health Care Strategy. Ninety-three percent of the New Zealand population is now enrolled within 79 PHOs, which pose a challenge to the well-established Independent Practitioner Associations (IPAs).Although there was initial widespread support for the philosophy underlying the Primary Health Care Strategy, there are concerns amongst general practitioners (GPs) and their professional organisations relating to its implementation. These centre around 6 main issues:1. Loss of autonomy2. Inadequate management funding and support3. Inconsistency and variations in contracting processes4. Lack of publicity and advice around enrolment issues5. Workforce and workload issues6. Financial risksOn the other hand, many GPs are feeling positive regarding the opportunities for PHOs, particularly for being involved in the provision of a wider range of community health services. Australia has much to learn from New Zealand's latest health sector and primary health care reforms.The key lessons concern:? the need for a national primary health care strategy? active engagement of general practitioners and their professional organisations? recognition of implementation costs? the need for infrastructural support, including information technology and quality systems? robust management and governance arrangements? issues related to critical mass and population/distance trade offs in service delivery models     

General practitioners' use of guidelines in the consultation and their attitudes to them.

BACKGROUND: There is concern about the apparent lack of uptake of management and referral guideline information by general practitioners (GPs) in their day-to-day consultations with patients. Little is understood about the barriers to the uptake of guidelines as perceived by GPs. AIMS: To explore how GPs gain access to and use guidelines, including computer-based guidelines, in day-to-day consultations with their patients; and to identify the perceived problems and barriers to the use of guidelines in such situations. METHOD: Postal questionnaires enquiring about the practices and attitudes towards the use of guidelines in general practice were completed by 391 of 600 randomly selected GPs in the South and West NHS region. RESULTS: GPs found guidelines a useful method of accessing expert information. Key factors in their uptake were brevity, an authoritative and unbiased source of evidence, and resonance with the GP's usual practices; they also needed to be flexible enough to incorporate individual viewpoints. Guidelines were perceived as being valuable to enable safe delegation of care to other health professionals and for sharing decision-making with patients. Dissemination of guidelines through the medium of computers was acceptable to the majority of GPs. Virtually all (93%) responders reported adapting guidelines to the needs of individual patients. Older GPs from non-fundholding practices were least likely to show a positive attitude towards guidelines. CONCLUSION: In principle, there is a very positive attitude towards the use of guidelines in general practice. However, those developing guidelines for use by GPs in the consulting room need to be aware of the factors that facilitate their use in practice. Educational strategies aimed at increasing the use of guidelines need to take into account the significant proportion who show negative attitudes towards guidelines, whose characteristics have been identified in this study.     

The evaluation of a mental health facilitator in general practice: effects on recognition, management, and outcome of mental illness.

BACKGROUND: Facilitation uses personal contact between the facilitator and the professional to encourage good practice and better service organisation. The model has been applied to physical illness but not to psychiatric disorders. AIM: To determine if a non-specialist facilitator can improve the recognition, management, and outcome of psychiatric illness presenting to general practitioners (GPs). METHOD: Six practices were visited over an 18-month period by a facilitator whose activities included providing guidelines and organising training initiatives. Six other practices acted as controls. Recognition (identification index of family doctors), management (psychotropic prescribing, psychological consultations with the GP, specialist mental health treatment, and the use of medical interventions and investigations), and patient outcome at four months were assessed before and after intervention. RESULTS: The mean identification index of facilitator GPs rose from 0.51 to 0.64 following intervention, while that of the control GPs fell from 0.67 to 0.59 (P = 0.046). The facilitator had no detectable effect on management or patient outcome. CONCLUSIONS: The facilitator improved recognition of psychiatric illness by GPs. Generic facilitators can be trained to take on a mental health role; however, the failure to achieve more fundamental changes in treatment and outcome implies that facilitator intervention requires development.     

Research general practices: what, who and why?

BACKGROUND: By the autumn of 1995, 14 research general practices had been funded. These are service NHS general medical practices that are supportive of primary care research and have a lead GP who has research experience as evidenced by publication in peer-reviewed journals. AIM: To ascertain the characteristics of those who have been successful in securing the first 14 grants, the effect the process has had on them, and the practical advice they would offer to future applicants and to future funding bodies. METHOD: A confidential postal survey of research general practices. RESULTS: They are atypical practices (high level of research and teaching involvement, mostly non-urban) with atypical lead GPs (male, research degrees, possess MRCGP, publications and grants obtained). Practices contemplating applying for future research practice grants should consider planning ahead, use of grant monies, protection of research time, involving the primary health care team, and sources of both internal and external support. Funding bodies need to make adequate funding available for capital expenditure and running costs as well as staff and lead GP time. CONCLUSION: Research general practices are ideal for integrating the core values of the medical profession, providing clinical care by medical generalists, teaching the discipline and researching its basis. Such practices should be funded on a rolling basis and throughout the United Kingdom. Future evaluation of funding such practices is needed and should confirm their utility both to the discipline and to patient care within the NHS.     

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

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

The barriers to effective management of heart failure in general practice.

BACKGROUND: Several studies have shown that most patients with heart failure are not investigated and treated according to published guidelines. More effective management could reduce both mortality and morbidity from heart failure. AIM: To identify the reasons for gaps between recommended and actual management of heart failure in general practice. DESIGN OF STUDY: A nominal group technique was used to elicit general practitioners' (GPs') perceptions of the reasons for differences between observed and recommended practice. SETTING: Ten Medical Research Council General Practice Framework practices in the North Thames region. METHOD: Data were collected on the investigation and treatment of heart failure in the 10 participating practices and presented to 49 GPs and 10 practice nurses from those practices. RESULTS: Of the 674 patients requiring echocardiograms, 226 were referred for echocardiography (34%), and 183/391 (47%) with probable heart failure were prescribed angiotensin-converting enzyme inhibitors. A wide variety of barriers were elicited. The main barrier to the use of echocardiograms in the diagnosis of heart failure was lack of open access. The main barrier to the use of angiotensin-converting enzyme inhibitors in treating heart failure was GPs' concerns about their possible adverse effects. CONCLUSION: The barriers to the effective management of heart failure in general practice are complex. We recommend further research to establish whether multifaceted intervention programmes based on our findings can improve the management of heart failure in primary care.     

Estimation of the number of people with Down syndrome in Australia and New Zealand

PurposePrevious research estimated the effect of selective terminations on birth prevalence and population prevalence of people with Down syndrome (DS) in the United States and Europe. This study provides comparative data from Australia and New Zealand.MethodThe number of live births (LBs) with DS—in the absence of DS-related terminations of pregnancy—was estimated on the maternal age distribution in the general population. Actual LBs were modeled on registry data. We applied constructed survival curves to annual LBs to predict population numbers.ResultsFor 2016-2020, we estimated 265 annual LBs with DS (1 in 1158) in Australia and 41 annual LBs (1 in 1450) in New Zealand. For this period, the reduction percentage—the net result of DS-related terminations on LB prevalence—was estimated at 66% for Australia, 71% for New Zealand, 62% for Europe (excluding the former East Bloc), and only 32% for the United States.ConclusionThe total population of people with DS has been decreasing since 2000 in Europe (West Bloc) and 2011 in New Zealand owing, in large part, to increased selective terminations. By contrast, the population continues to increase, as of 2020, in Australia and the United States.     

Psychological factors account for variation in metabolic control and perceived quality of life among people with type 2 diabetes in New Zealand

Background: Many people with diabetes experience poor metabolic control and reduced quality of life (QoL). Purpose: This study investigates the relationships between psychological variables, metabolic control, and QoL among adults with type 2 diabetes. Method: Research participants (n = 615) were randomly selected from a medical database of people with type 2 diabetes held in Wellington, New Zealand. Self-report psychological data was collected using a mailed questionnaire survey. Clinical characteristics were obtained through a review of medical records with participants’ written consent. Results: Psychological perceptions of diabetes explain approximately 8% of differences in metabolic control and 16% of variability in quality of life, even when controlling for key clinical characteristics. Belief that diabetes is temporary, a perception that diabetes is difficult to control, strong negative emotional representation of diabetes, and agreement that diabetes has serious consequences were linked to poor illness outcomes. Conclusion: Psychological variables make a unique and statistically significant contribution to the explanation of differences in both physiological and emotional diabetes outcomes. Potentially, modification of personal views about diabetes could help promote positive health outcomes for people with type 2 diabetes. This study highlights specific illness perceptions that could be targeted in future interventions. The following organizations are acknowledged for their generous support of this research: Wellington Regional Diabetes Trust, Massey University, Palmerston North Medical Research Foundation, Foundation for Research, Science, and Technology, Novo Nordisk New Zealand.     

A retrospective study of New Zealand case law involving assisted reproduction technology and the social recognition of 'new' family

The New Zealand Human Assisted Reproductive Technology (HART) Act became law in 2004. In this article, we provide a retrospective analysis of New Zealand case law from September 1990 to March 2004, leading up to the creation of the HART Act. We examine the new understandings of parenting (developed through the routine use of ART in New Zealand) which the case law attempted to test. We examine these concepts against the previous understandings of family enshrined in the pre-existing legislation, which formed the basis for judicial rulings in the various cases to which we refer. In conclusion, we provide a brief summary of the 2004 HART legislation and draw comparisons between the old and new legislative and bureaucratic frameworks that define and support New Zealand family structure. We suggest that a change in cultural backdrop is occurring from the traditional western ideology of the nuclear family towards the traditional Maori concept of family formation, which includes a well-accepted traditional practice of guardianship and a more open and extended family structure. This 'new' structure reflects the contemporary lived experience of family kinship in western societies as individualized and open to choice.     

Health at work in the general practice.

BACKGROUND: Poor mental health and high stress levels have been reported in staff working in general practice. Little is known about how practices are tackling these and other issues of health at work in the absence of an established occupational healthcare service. AIM: To establish the extent of knowledge and good practice of health at work policies for staff working in general practice. METHOD: Practice managers in 450 randomly selected general practices in England were interviewed by telephone, and the general practitioner (GP) with lead responsibility for workplace health in the same practice was surveyed by postal questionnaire. We surveyed the existence and implementation of practice policies, causes and effects of stress on practice staff, and agreement between practice managers and GPs on these issues. RESULTS: Seventy-one per cent of GPs and 76% of practice managers responded, with at least one reply from 408 (91%) practices and responses from both the practice manager and GPs from 252 (56%) practices. Seventy-nine per cent of practices had a policy on monitoring risks and hazards. The proportion of practices with other workplace health policies ranged from 21% (policy to minimize stress) to 91% (policy on staff smoking). There was a tendency for practices to have policies but not to implement them. The three causes of stress for practice staff most commonly cites by both GP and practice manager responders were 'patient demands', 'too much work', and 'patient abuse/aggression'. Sixty-five per cent of GPs felt that stress had caused mistakes in their practices. Although there was general agreement between the two groups, there was a considerable lack of agreement between responders working in the same practices. CONCLUSIONS: The study revealed substantial neglect of workplace health issues with many practices falling foul of health and safety legislation. This report should help general practices identify issues to tackle to improve their workplace health, and the Health at Work in the NHS project to focus on areas where their targeted help will be most worthwhile.