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.     

Measuring consultation skills in primary care in England: evaluation and development of content of the MAAS scale.

BACKGROUND: Consultation skills are essential for general practice. Tools for measuring consultation skills in everyday practice are not well developed AIM: To examine and develop the content validity of the MAAS History-taking and Advice Checklist GP (MAAS-GP) tool which is used in The Netherlands for testing consultation skills, with simulated patients in United Kingdom general practice from the perspectives of both general practitioners and patients. DESIGN OF STUDY: Qualitative research using semi-structured interviews. SETTING: Alternate patients attending seven general practices in the north west of England. METHOD: Thematic analysis of the contents of patient and GP interviews, and of focus groups, mapping key themes to the MAAS-GP. RESULTS: There was strong agreement between patients and GPs on issues mapping to 46 out of 68 items of the MAAS-GP. Eight further MAAS-GP items were linked to issues only raised by patients and four to issues raised only by GPs. The remaining 10 items could not be related to issues raised by either. All of the issues raised by GPs could be mapped but 27 patient items could not. These were included in a revised checklist, the Liverpool MAAS (LIV-MAAS). CONCLUSION: the revised tool seems to have content validity in measuring consultation skills. Measurement of its relability is now required.     

Comparing the cost of nurse practitioners and GPs in primary care: modelling economic data from randomised trials

BACKGROUND: The role of nurse practitioners in primary care has recently expanded. While there are some outcome data available for different types of consultations, little is known about the relative cost. AIM: To compare the cost of primary care provided by nurse practitioners with that of salaried GPs. DESIGN OF STUDY: Synthesis, modelling, and analysis of published data from the perspective of general practices and the NHS. DATA SOURCES: Two published randomised controlled trials. METHOD: A dataset of resource use for a simulated group of patients in a typical consultation was modelled. Current unit costs were used to obtain a consensus mean cost per consultation. RESULTS: Mean cost of a nurse practitioner consultation was estimated at 9.46 UK pounds (95% confidence interval [CI] = 9.16 to 9.75 pounds) and for a GP was 9.30 UK pounds (95% CI = 9.04 to 9.56 pounds) according to salary and overheads, that is, from the perspective of general practices. From the NHS perspective, which included training costs, the estimated mean costs were 30.35 UK pounds (95% CI = 27.10 to 33.59 pounds) and 28.14 UK pounds (95% CI = 25.43 to 30.84 pounds) respectively. Sensitivity analysis suggested that the time spent by GPs contributing to nurse practitioners' consultations (including return visits) was an important factor in increasing costs associated with nurse practitioners. CONCLUSION: Employing a nurse practitioner in primary care is likely to cost much the same as employing a salaried GP according to currently available data. There is considerable variability of qualifications and experience of nurse practitioners, which suggests that skill-mix decisions should depend on the full range of roles and responsibilities rather than cost.     

A randomised controlled trial of joint consultations with general practitioners and cardiologists in primary care.

BACKGROUND: Joint consultation sessions of a small group of general practitioners (GPs) and a specialist in orthopaedics proved to be an effective way of decreasing the referral rate of orthopaedic patients. Cardiac complaints comprise an important category of health problems with high referral rates. AIMS: To study the effects of joint consultation on the quality of care and referrals for patients with cardiac complaints. DESIGN OF STUDY: Randomised controlled trial. SETTING: Forty-nine GPs participated in 16 consultation groups, each with one of 13 cardiologists, in monthly joint consultations over a period of about 18 months. METHOD: The GPs selected patients about whom they were uncertain, and those needing urgent referral were excluded. Patients were randomly assigned to joint consultation or to usual care. After a follow-up period all patients had a joint consultation for outcome assessment. Referral data were provided by two regional health insurance companies and questionnaires were given to the patients, GPs, and cardiologists to gauge their opinion of the trial. RESULTS: One hundred and forty-eight patients in the intervention group and 158 patients in the control group fulfilled the whole protocol. The quality of care was similar in both groups. In the intervention group, 34% of the patients were referred, compared with 55% in the control group (P = 0.001), and fewer patients underwent further diagnostic procedures (7% compared with 16%, P = 0.013). Referrals to cardiology as a proportion of all referrals decreased in the practices of the participating GPs, compared with their reference districts (P = 0.024). CONCLUSION: Joint consultation is an effective method that provides a quality of care that at least equals usual care and that contributes to a better selection of patients who need specialist care.     

Deprivation, psychological distress, and consultation length in general practice.

BACKGROUND: Recent research has shown the benefits of longer consultations in general practice. Approximately 40% of patients presenting to general practitioners (GPs) are psychologically distressed. Studies have shown that psychological morbidity increases with increasing socioeconomic deprivation. The combined effects of psychological morbidity and socioeconomic deprivation on consultation length are unknown. In addition, though it is known that doctors correctly identify half their distressed patients as such, the effect of consultation length on identification is unknown. AIM: To examine factors associated with presentation and recognition of psychological distress in GPs' surgeries and the interaction of these factors with consultation length. DESIGN OF STUDY: A cross-sectional study. SETTING: Nine general practices in the West of Scotland, involving 1075 consultations of 21 full-time GPs. METHOD: The main outcome measures were patient psychological distress (measured by General Health Questionnaire-12), doctors' identification of psychological distress, consultation length, and Carstairs deprivation category scores. RESULTS: The mean consultation length was 8.71 minutes (SD = 4.40) and the prevalence of positive GHQ scores was 44.7%. Increasing GHQ (greater psychological distress) and lower deprivation category scores (greater affluence) were associated with longer consultations. Positive GHQ scoring increased with greater socioeconomic deprivation and also peaked in the 30 to 39 years age group. Recognition of psychological distress was greater in longer consultations (50% increase in consultation length associated with 32% increase in recognition). CONCLUSION: Increasing socioeconomic deprivation is associated with higher prevalence of psychological distress and shorter consultations. This provides further evidence to support Tudor Hart's 'inverse care law' and has implications for the resourcing of primary care in deprived areas.     

A controlled evaluation of small-group education of general practitioners in the management of drug users.

We evaluated the effectiveness of small-group education of general practitioners (GPs) in the management of drug users. A total of 40 doctors were trained. Some 28 doctors who were unable to attend and 30 who did not want training participated as comparison groups. Sixteen months after the education, trained doctors notified significantly more drug users to the British Home Office database and more often prescribed methadone at first consultation with a drug user.     

Computer use by general practitioners in Scotland.

BACKGROUND: Despite the widespread adoption by general practitioners (GPs) of desktop computers, there has been very little evaluation of the way in which the computer is actually used during consultations and the way in which it affects patient satisfaction. AIM: To ascertain the extent to which the computer is used in the consultation and to investigate the possible relationship between computer use and patient satisfaction. METHOD: Six GPs completed a short questionnaire about the extent to which they use the computer during surgeries. Eighty-four consultations from the surgeries of these GPs were video recorded. Patient satisfaction data on these 84 patients were collected at the time of the surgery using the previously validated Consultation Satisfaction Questionnaire. RESULTS: All six GPs stated that they usually used the computer during consultations. However, video observation revealed that the computer was used in just 51% of surgeries. The proportion of time that the computer was used for varied from 0.03 to 0.4, with a mean value of 0.12. The commonest function for which the computer was used was prescribing. The consultations in which the computer was used (CU) were on average 148 seconds longer than the non-computerized consultations (NCU). There was no difference in patient satisfaction between the two groups. CONCLUSION: Despite this group of GPs having a self-declared interest in the use of computers, the extent to which the computer was used was much lower than expected from the GPs' self-reported use. This may be partly explained by the fact that using the computer takes up valuable time within the consultation and does not appear to contribute to patient satisfaction. If desktop computers are to be used to their full potential in general practice, more work is required to evaluate their impact on the consultation process itself.     

Training general practitioners in behavior change counseling to improve asthma medication adherence

OBJECTIVE: Adherence to asthma medication regimens is problematic in general practice. We developed and evaluated a communication training for general practitioners (GPs) to help them address medication adherence during routine consultations. This paper describes the development of the training and evaluation results of a pilot study. METHODS: The training was based on behavior change counseling (BCC), a technique derived from motivational interviewing. We developed a five phases BCC consultation model. Participating GPs answered questions at baseline (T0), directly after (T1) and 4-10 months after (T2) the training that assessed their attitudes and confidence regarding adherence communication. They completed evaluation forms at T1 and T2. RESULTS: The 19 participating GPs were positive about the course and the feasibility of BCC in GP consultations. Also, after the training, their attitudes and confidence had improved (p<0.05) and all reported to use BCC skills at least sometimes 4-10 months after the training. CONCLUSION: These positive effects provide us with some hope that the training positively influenced the GP's communication behavior. PRACTICE IMPLICATIONS: If further data on physician behavior and patient outcomes justify implementation of the training, it would then be worthwhile to also involve practice nurses.     

General practitioners' use of computers during the consultation.

This study documents the extent of reported computer use by general practitioners (GPs) in consultations with patients, and identifies barriers to their use. There was a 65% response rate from a random sample of 600 GPs in the South and West National Health Service (NHS) region who were sent a questionnaire. Ninety-one per cent (357) had a desktop computer terminal in their consulting rooms. Of these, 98% used the computer to look up information or prescribe medication, 75% entered details about selected problems presented by patients, and 36% entered information about the patient's presenting problem at every consultation. Only 18% used computers to access reference information. Use of the computer for anything other than looking up patient information or prescribing was positively associated with fundholding status and use of a personal computer at home, and was independent of number of years in practice. Sixty-five per cent of responders had positive attitudes to the inclusion of management guidelines on the computer software, and 45% of responders held positive views towards the idea of integrating management guidelines with the patient's personal computerized medical record. Consideration should be given to targeting training at those GPs who appear to be reluctant to use computers during the consultation.     

Factors influencing discussion of smoking between general practitioners and patients who smoke: a qualitative study.

BACKGROUND: Anti-smoking advice from general practitioners (GPs) is effective and recent evidence-based guidelines urge GPs to advise all patients against smoking at every opportunity. GPs do not exploit many opportunities to discuss smoking with patients and the reasons for this are unclear. AIM: To elicit, relate, and interpret GPs' accounts of why they discuss smoking with some patients and not others. METHOD: Thirty-nine Leicestershire GPs were purposively selected so as to have a range of attitudes towards discussing smoking with patients. Each GP had one surgery session video-recorded and afterwards participated in a qualitative, semi-structured interview. Prior to each interview, GPs were shown a video-recording of one of their consultations with a smoker to enhance their recall of events. RESULTS: Being aware of patients' smoking status did not necessarily result in GPs discussing smoking with patients. GPs were keen to preserve good doctor-patient relationships and avoid negative responses from patients once the topic of smoking had been raised, and this was felt to be best achieved by restricting most discussions about smoking to situations where patients presented with smoking-related problems and in circumstances where the doctors perceived the doctor-patient relationship was strong. Doctors also thought it important to address patients' agendas relating to the current consultation before discussing smoking. CONCLUSIONS: General practitioners have strong reasons for preferring to discuss smoking when patients present with smoking-related problems. Those wishing to increase the amount of advice-giving by GPs might be more successful if they encouraged GPs to make greater use of problem-orientated opportunities to discuss smoking.     

Improving general practitioner clinical records with a quality assurance minimal intervention.

BACKGROUND: Although good medical records have been associated with good care, there is considerable room for their improvement in general practice. AIM: To improve the quality of general practice medical records at minimal cost. METHOD: A total of 150 randomly sampled general practitioners (GPs) in suburban Brisbane, Australia, were randomized in a controlled trial to receive or not receive an intervention. The intervention consisted of 6 to 12 one-hour monthly meetings when the pairs of GPs assessed samples of each other's medical records using a 12-item instrument. This was developed previously by a process of consensus of general practice teachers. Mean scores of 10 medical records selected at random from before the intervention started and one year later were compared. RESULTS: After the intervention, the increase in the total score (for which the maximum possible was 18) for the intervention GPs (from a baseline of 11.5 to 12.3) was not significantly greater than for the controls (from 11.4 to 11.7). Legibility and being able to determine the doctor's assessment of the consultation were significantly improved. The post-intervention increase of 1.06 (9.3%) of the total scores of the 47% of intervention GPs who complied with the intervention was significantly greater than that for the controls. CONCLUSION: The quality assurance activity improved some components of the quality of GPs' clinical records. However, the improvement was small, and the search for activities for Australian GPs that demonstrate an improvement in the quality of their practice must continue.     

The patient-centredness of consultations and outcome in primary care.

BACKGROUND: There is general support for general practitioners (GPs) using patient-centred styles. However, there is limited British evidence of beneficial outcomes for patients from such styles. AIM: To explore whether, for patients presenting for new episodes of care, the GP's consulting style, specifically the patient-centredness of the consultation, is related to five generic outcomes. METHOD: General practitioners in South Wales were recruited, and one surgery consulting session was audiotape recorded for each participating clinician. Questionnaires were given to consenting patients before their consultations, immediately afterwards, and, by post, at two weeks to measure the following outcomes: doctor-patient agreement (on the nature of the problem and management), patient satisfaction, resolution of symptoms, resolution of concerns, and functional health status. From the patients consulting for a new episode of care and completing all three questionnaires, one patient was selected at random for each GP and the audiotape of their consultation rated for patient-centredness. Statistical analysis employed correlation coefficients and t-tests, followed by multiple regression and logistic regression to control for potential confounders. RESULTS: In total, 143 patients consulting 143 GPs were studied. The patient-centred score was positively and statistically significantly associated with patient satisfaction (Pearson correlation = 0.28; P = 0.002). No other associations were found with the other outcomes measured. CONCLUSION: The study presents evidence that patient-centred styles of consulting produce benefits in terms of increased patient satisfaction for patients consulting for new episodes of care in Britain.     

Risk factors for urinary tract symptoms in women: beliefs among general practitioners and women and the effect on patient management.

BACKGROUND: Urinary tract symptoms are common in women. A variety of risk factors have been investigated in the past. One of the more likely risk factors for these symptoms is recent sexual intercourse; another is diaphragm use. Morbidity levels are increasing, although effective antibiotic treatment is available. AIM: To study the beliefs of women and their general practitioners (GPs) about urinary tract symptoms and to determine how these may affect management. METHOD: An interview survey with 113 women consulting with urinary tract symptoms and the 22 GPs they consulted. RESULTS: Doctors and women have similar beliefs about the 'causes' of urinary tract symptoms, but the relative importance differs. Both acknowledge the association with sexual intercourse but fail to communicate about this during the consultation. Patients reported being embarrassed on their own and their GP's behalf if sensitive subjects were raised. Doctors failed to ask women what they thought had caused the symptoms and were also unlikely to suggest to them likely causes. They also reported reticence to do more than prescribe, at least in first consultations, and half of the doctors routinely prescribed antibiotics, regardless of a near patient diagnostic urinary stick test result. The advice given was not necessarily evidence based. CONCLUSIONS: GPs need to be more aware of the risk factors associated with urinary tract symptoms in women and should formulate their advice accordingly. The reticence to discuss sensitive subjects by both GPs and patients has implications for the ability to broach sexual matters in any consultation in which they are not the reason or focus for that consultation.     

How general practice patients with emotional problems presenting with somatic or psychological symptoms explain their improvement.

BACKGROUND: The emotional problems of patients presenting only somatic symptoms are frequently not detected by general practitioners (GPs), yet clinical outcomes have often been found to be no different from emotional problems directly presented. AIM: To compare clinical outcomes and attributions for improvement of patients with emotional problems presenting only somatic symptoms to GPs, with patients directly presenting emotional problems. DESIGN OF STUDY: Survey of patients with General Health Questionnaire (GHQ) scores in the symptomatic range, with follow-up after three months of a repeat GHQ and a questionnaire of patients' attributions for improvement. SETTING: A sample of 152 adult patients from nine general practices in North and East London. METHOD: Consecutive patients were invited to complete an adapted GHQ prior to their consultation. The consultations were audiotaped and coded to indicate the extent to which psychological discussion took place, as against discussion of other issues. The GPs recorded whether they considered each patient to be emotionally disturbed or psychiatrically ill at the time of the consultation, to assess GP detection of emotional disturbance. To form the initial sample, interviews were conducted one to five days after the consultation with patients who intended to present with either psychological or somatic problems, with a follow-up questionnaire after three months. RESULTS: A total of 106 patients provided follow-up information, of whom 57 presented psychological problems directly at initial consultation and 49 presented only somatic symptoms. There were no differences in clinical outcome at three months between the two groups. Somatic presenters who improved were more likely than psychological presenters to attribute improvement to change in their physical health (68% versus 31%) while psychological presenters were more likely to attribute improvement to the GP's listening and counselling in the consultation (44% versus 18%). Other attributions for improvement, such as passage of time, change in life circumstances, support of family and friends, medication, and 'working through problems myself', were equally common in both groups. CONCLUSIONS: Patients with emotional problems presenting only somatic symptoms have equivalent clinical outcomes to patients presenting psychological problems directly, but are more likely to attribute emotional improvements to change in their physical health. For some such emotionally disturbed patients it may be sufficient for GPs to treat the physical health problems and to reassure the patient, without attempting to treat the underlying emotional disturbance.     

Clinically inexplicable frequent attenders in general practice.

This study was based in an isolated rural practice, and it identified 107 frequent attenders (1.95% of the practice population), who created five times the consultation workload of a similar group matched for age and sex. The general practitioners (GPs) classified 60 (56%) of these patients as attending for clinically inexplicable reasons. This subgroup had higher rates of long-term medication and hospital referral, and more free access to primary health care. The study also identified very high levels of kinship and relationship by marriage within this group (47%).     

The relationship between consultation length, process and outcomes in general practice: a systematic review.

The aim of the study was to examine differences in consultation process and health outcomes between primary care physicians who consult at different rates. A systematic review of observational studies was carried out, restricted to English language journal papers reporting original research or systematic reviews. Qualitative analysis with narrative overview of methodology and key results was undertaken, using MEDLINE (1966 to 1999), EMBASE (1981 to 1999), and the NHS National Research Register. Secondary references from this search were also considered for inclusion. Main outcome measures were objectively measured process or healthcare outcomes. Thirteen papers, describing ten studies, were identified. There were consistent differences in several elements of process and outcome between general practitioners (GPs) who consult at different rates. Although average consultation length may be a marker of other doctor attributes, the evidence suggests that patients seeking help from a doctor who spends more time with them are more likely to have a consultation that includes important elements of care.