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1.
Peter Griffiths Trevor Murrells Jill Maben Simon Jones Mark Ashworth 《The British journal of general practice》2010,60(570):e36-e48
Background
In many UK general practices, nurses have been used to deliver results against the indicators of the Quality and Outcomes Framework (QOF), a ‘pay for performance’ scheme.Aim
To determine the association between the level of nurse staffing in general practice and the quality of clinical care as measured by the QOF.Design of the study
Cross-sectional analysis of routine data.Setting
English general practice in 2005/2006.Method
QOF data from 7456 general practices were linked with a database of practice characteristics, nurse staffing data, and census-derived data on population characteristics and measures of population density. Multi-level modelling explored the relationship between QOF performance and the number of patients per full-time equivalent nurse. The outcome measures were achievement of quality of care for eight clinical domains as rated by the QOF, and reported achievement of 10 clinical outcome indicators derived from it.Results
A high level of nurse staffing (fewer patients per full-time equivalent practice-employed nurse) was significantly associated with better performance in 4/8 clinical domains of the QOF (chronic obstructive pulmonary disease, coronary heart disease, diabetes, and hypertension, P = 0.004 to P<0.001) and in 4/10 clinical outcome indicators (diabetes: glycosylated haemoglobin [HbA1C] ≤7.4%, HbA1C ≤10% and total cholesterol ≤193 mg/dl; and stroke: total cholesterol ≤5 mmol/L, P = 0.0057 to P<0.001).Conclusion
Practices that employ more nurses perform better in a number of clinical domains measured by the QOF. This improved performance includes better intermediate clinical outcomes, suggesting real patient benefit may be associated with using nurses to deliver care to meet QOF targets. 相似文献2.
Chris Salisbury Leigh Johnson Sarah Purdy Jose M Valderas Alan A Montgomery 《The British journal of general practice》2011,61(582):e12-e21
Background
In developed countries, primary health care increasingly involves the care of patients with multiple chronic conditions, referred to as multimorbidity.Aim
To describe the epidemiology of multimorbidity and relationships between multimorbidity and primary care consultation rates and continuity of care.Design of study
Retrospective cohort study.Setting
Random sample of 99 997 people aged 18 years or over registered with 182 general practices in England contributing data to the General Practice Research Database.Method
Multimorbidity was defined using two approaches: people with multiple chronic conditions included in the Quality and Outcomes Framework, and people identified using the Johns Hopkins University Adjusted Clinical Groups (ACG®) Case-Mix System. The determinants of multimorbidity (age, sex, area deprivation) and relationships with consultation rate and continuity of care were examined using regression models.Results
Sixteen per cent of patients had more than one chronic condition included in the Quality and Outcomes Framework, but these people accounted for 32% of all consultations. Using the wider ACG list of conditions, 58% of people had multimorbidity and they accounted for 78% of consultations. Multimorbidity was strongly related to age and deprivation. People with multimorbidity had higher consultation rates and less continuity of care compared with people without multimorbidity.Conclusion
Multimorbidity is common in the population and most consultations in primary care involve people with multimorbidity. These people are less likely to receive continuity of care, although they may be more likely to gain from it. 相似文献3.
Amy Waller Mariko Carey Danielle Mazza Serene Yoong Alice Grady Rob Sanson-Fisher 《The British journal of general practice》2015,65(634):e312-e318
Background
GPs are often a patient’s first point of contact with the health system. The increasing demands imposed on GPs may have an impact on the quality of care delivered. Patients are well placed to make judgements about aspects of care that need to be improved.Aim
To determine whether general practice patients perceive that the care they receive is ‘patient-centred’ across eight domains of care, and to determine the association between sociodemographic, GP and practice characteristics, detection of preventive health risks, and receipt of patient-centred care.Design and setting
Cross-sectional survey of patients attending Australian general practice clinics.Method
Patients completed a touchscreen survey in the waiting room to rate the care received from their GP across eight domains of patient-centred care. Patients also completed the Patient Health Questionnaire (PHQ-9) and self-reported health risk factors. GPs completed a checklist for each patient asking about the presence of health risk factors.Results
In total 1486 patients and 51 GPs participated. Overall, 83% of patients perceived that the care they received was patient-centred across all eight domains. Patients most frequently perceived the ‘access to health care when needed’ domain as requiring improvement (8.3%). Not having private health insurance and attending a practice located in a disadvantaged area were significantly associated with perceived need for improvements in care (P<0.05).Conclusion
Patients in general practice report that accessibility is an aspect of care that could be improved. Further investigation of how indicators of lower socioeconomic status interact with the provision of patient-centred care and health outcomes is required. 相似文献4.
Peter J Gill Braden O’Neill Peter Rose David Mant Anthony Harnden 《The British journal of general practice》2014,64(629):e752-e757
Background
Child health care is an important part of the UK general practice workload; in 2009 children aged <15 years accounted for 10.9% of consultations. However, only 1.2% of the UK’s Quality and Outcomes Framework pay-for-performance incentive points relate specifically to children.Aim
To improve the quality of care provided for children and adolescents by defining a set of quality indicators that reflect evidence-based national guidelines and are feasible to audit using routine computerised clinical records.Design and setting
Multi-step consensus methodology in UK general practice.Method
Four-step development process: selection of priority issues (applying nominal group methodology), systematic review of National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) clinical guidelines, translation of guideline recommendations into quality indicators, and assessment of their validity and implementation feasibility (applying consensus methodology used in selecting QOF indicators).Results
Of the 296 national guidelines published, 48 were potentially relevant to children in primary care, but only 123 of 1863 recommendations (6.6%) met selection criteria for translation into 56 potential quality indicators. A further 13 potential indicators were articulated after review of existing quality indicators and standards. Assessment of the validity and feasibility of implementation of these 69 candidate indicators by a clinical expert group identified 35 with median scores 8 on a 9-point Likert scale. However, only seven of the 35 achieved a GRADE rating >1 (were based on more than expert opinion).Conclusion
Producing valid primary care quality indicators for children is feasible but difficult. These indicators require piloting before wide adoption but have the potential to raise the standard of primary care for all children. 相似文献5.
Factors associated with enablement in general practice: cross-sectional study using routinely-collected data. 总被引:1,自引:0,他引:1
BACKGROUND: Quality-improvement activities are most often focused on clinical quality indicators. However, patient evaluations are important additional indicators of the quality of general practice consultations, including measures of satisfaction or enablement (that is, the extent to which the consultation enhances the patient's feelings of confidence and ability to cope). There is limited evidence concerning factors associated with enablement in UK general practice. AIM: To identify patient and practice characteristics associated with enablement scores following general practice consultations. DESIGN OF STUDY: Cross-sectional survey using a large routinely-collected dataset of patient evaluations of general practice (190,038 individual patient responses). SETTING: A total of 1031 UK general practices. METHOD: Relationships between health, demographic factors, evaluations of general practice care, and patient self-reported enablement were estimated using multiple regression. RESULTS: The primary predictor of enablement was positive patient evaluation of the GPs' communication. Reported continuity of care accounted for a lower proportion of the variance. Of the included patient demographic variables, ethnicity was a key predictor, with patients from minority ethnic groups reporting greater enablement once other factors were controlled. CONCLUSION: The current results provide support for the construct validity of the enablement measure. However, if enablement is to become a valid and useful measure of quality, it is necessary to understand the mechanisms by which enablement is increased in certain patients and practices. Detailed qualitative research may also be required to explain the relatively high scores of ethnic minority responders, despite lower overall satisfaction scores, and to understand why some items included in the enablement measure are regarded as 'not applicable' by a substantial minority of patients. 相似文献
6.
Harry PA Wagemakers Pim AJ Luijsterburg Edith M Heintjes Marjolein Y Berger Jan Verhaar Bart W Koes Sita MA Bierma-Zeinstra 《The British journal of general practice》2010,60(571):e56-e63
Background
Knee injuries may lead to pain and to functional limitations in the activities of daily living. Patients with knee injuries are frequently seen in general practice; however, the outcome and management in these patients is not known.Aim
To assess the outcome and management of knee injuries at 12 months'' follow-up in general practice.Design of study
A prospective observational cohort study with a 1-year follow-up.Setting
Primary health care.Method
Adult patients consulting their GP after knee injury (n = 134) participated in the cohort. A magnetic resonance imaging scan was carried out and patients were diagnosed as either no lesion or an isolated meniscal tear, an isolated collateral or cruciate ligament lesion, or a combination. Follow-up questionnaires were filled in up to 12 months'' follow-up.Results
At 12 months'' follow-up, 34 patients reported full recovery and 67 patients reported major improvement. At baseline, 37 patients (28%) were referred to physical therapy and 17 patients (13%) were referred to secondary care. During 1 year of follow-up, another 21 referrals to physical therapy and 11 referrals to secondary care took place. The pain severity decreased the most, and the Lysholm knee score increased in the majority of patients during the first 3 months after injury. In total, 18 arthroscopies were performed in 15 patients. One patient underwent an anterior cruciate ligament reconstruction.Conclusion
The vast majority of patients report clinically relevant recovery. There is no clear difference in outcomes between patients with meniscal tears or ligament lesions and patients without these diagnoses. 相似文献7.
Sivatharan Vedavanam Nicholas Steel Joanne Broadbent Susan Maisey Amanda Howe 《The British journal of general practice》2009,59(559):e32-e37
Background
Depression is a leading cause of disease and disability internationally, and is responsible for many primary care consultations. Little is known about the quality of primary care for depression in the UK.Aim
To determine the prevalence of good-quality primary care for depression, and to analyse variations in quality by patient and practice characteristics.Design of study
Retrospective observational study.Setting
Eighteen general practices in England.Method
Medical records were examined for 279 patients. The percentage of eligible participants diagnosed with depression who received the care specified by each of six quality indicators in 2002 and 2004 was assessed. Associations between quality achievement and age, sex, patient deprivation score, timepoint, and practice size were estimated using logistic regression.Results
There was very wide variation in achievement of different indicators (range 1–97%). Achievement was higher for indicators referring to treatment and follow-up than for indicators referring to history taking. Achievement of quality indicators was low overall (37%). Quality did not vary significantly by patient or practice characteristics.Conclusion
There is substantial scope for improvement in the quality of primary care for depression, if the highest achievement rates could be matched for all indicators. Given the lack of variation by practice characteristics, system-level and educational interventions may be the best ways to improve quality. The equitable distribution of quality by patient deprivation score is an important achievement that may be challenging to maintain as quality improves. 相似文献8.
Fiona Sampson Mark Pickin Alicia O'Cathain Stephen Goodall Chris Salisbury 《The British journal of general practice》2008,58(554):641-643
Following recent concerns about patients' inability to book appointments in advance, this study examined the relationship between the proportion of GP appointments reserved for same-day booking, and patient satisfaction with appointment systems. In a survey of 12,825 patients in 47 practices, it was found that a 10% increase in the proportion of same-day appointments was associated with an 8% reduction in the proportion of patients satisfied. Practices should be wary of increasing the level of same-day appointments to meet access targets. 相似文献
9.
Robert Fleetcroft Sheetal Parekh-Bhurke Amanda Howe Richard Cookson Louise Swift Nicholas Steel 《The British journal of general practice》2010,60(578):e345-e352
Background
General practices in the UK contract with the government to receive additional payments for high-quality primary care. Little is known about the resulting impact on population health.Aim
To estimate the potential reduction in population mortality from implementation of the pay-for-performance contract in England.Design of study
Cross-sectional and modelling study.Setting
Primary care in England.Method
Twenty-five clinical quality indicators in the contract had controlled trial evidence of mortality benefit. This was combined with condition prevalence, and the differences in performance before and after contract implementation, to estimate the potential mortality reduction per indicator. Improvement was adjusted for pre-existing trends where data were available.Results
The 2004 contract potentially reduced mortality by 11 lives per 100 000 people (lower–upper estimates 7–16) over 1 year, as performance improved from baseline to the target for full incentive payment. If all eligible patients were treated, over and above the target, 56 (29–81) lives per 100 000 might have been saved. For the 2006 contract, mortality reduction was effectively zero, because new baseline performance for a typical practice had already exceeded the target performance for full payment.Conclusion
The contract may have delivered substantial health gain, but potential health gain was limited by performance targets for full payment being set lower than typical baseline performance. Information on both baseline performance and population health gain should inform decisions about future selection of indicators for pay-for-performance schemes, and the level of performance at which full payment is triggered. 相似文献10.
Connolly A Iliffe S Gaehl E Campbell S Drake R Morris J Martin H Purandare N 《The British journal of general practice》2012,62(595):e91-e98
Background
Primary care services are often the main healthcare service for people with dementia; as such, good-quality care at this level is important.Aim
To measure the quality of care provided to people with dementia in general practice using routinely collected data, and to explore associated patient and practice factors.Design and setting
Observational, cross-sectional review of medical records from general practices (n = 52) in five primary care trusts.Method
A total of 994 people with dementia were identified from dementia registers. An unweighted quality-of-care score was constructed using information collected in the annual dementia review, together with pharmacological management of cognitive and non-cognitive symptoms. Multilevel modelling was carried out to identify factors associated with quality-of-care scores.Results
In total, 599 out of 745 (80%) patients with dementia had received an annual dementia review; however, a social care review or discussion with carers was evident in just 305 (51%) and 367 (61%) of those 599 cases, respectively. Despite high prevalence of vascular disease, over a quarter (n = 259, 26%) of all patients with dementia were prescribed antipsychotics; only 57% (n = 148) of these had undergone medication review in the previous 6 months. Those with vascular dementia who were registered with single-handed practices received poorer quality of care than those registered with practices that had more than one GP.Conclusion
Although the number of people with dementia with a record of an annual dementia review is high, the quality of these reviews is suboptimal. The quality score developed in this study could be used as one source of data to identify weaknesses in practice activity that need to be corrected, and so would be of value to commissioners and regulators, as well as practices themselves. 相似文献11.
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13.
Emma C Richards Thomas E Cowling Elinor J Gunning Matthew J Harris Michael A Soljak Naomi Nowlan Kanika Dharmayat Nur Johari Azeem Majeed 《The British journal of general practice》2015,65(641):e806-e812
Background
The NHS Choices website (www.nhs.uk) provides data on the opening hours of general practices in England. If the data are accurate, they could be used to examine the benefits of extended hours.Aim
To determine whether online data on the opening times of general practices in England are accurate regarding the number of hours in which GPs provide face-to-face consultations.Design and setting
Cross-sectional comparison of data from NHS Choices and telephone survey data reported by general practice staff, for a nationally representative sample of 320 general practices (December 2013 to September 2014).Method
GP face-to-face consultation times were collected by telephone for each sampled practice for each day of the week. NHS Choices data on surgery times were available online. Analysis was based on differences in the number of surgery hours (accounting for breaks) and the times of the first and last consultations of the day only between the two data sources.Results
The NHS Choices data recorded 8.8 more hours per week than the survey data on average (40.1 versus 31.2; 95% confidence interval [CI] = 7.4 to 10.3). This was largely accounted for by differences in the recording of breaks between sessions. The data were more similar when only the first and last consultation times were considered (mean difference = 1.6 hours; 95% CI = 0.9 to 2.3).Conclusion
NHS Choices data do not accurately measure the number of hours in which GPs provide face-to-face consultations. They better record the hours between the first and last consultations of the day. 相似文献14.
Scott Wilkes Alison Murdoch Nick Steen John Wilsdon Greg Rubin 《The British journal of general practice》2009,59(562):329-335
Background
GPs investigate approximately half of all infertile couples with semen analysis and endocrine blood tests. For assessment of tubal status, hysterosalpingography (HSG) is recommended as a first-line investigation for women not known to have comorbidities.Aim
To test whether providing GPs with open access to HSG results in infertile couples progressing to a diagnosis and management plan sooner than with usual management.Design of study
A pragmatic cluster randomised controlled trial.Setting
Seventy-one of 173 general practices in north-east England agreed to participate.Method
A total of 670 infertile couples presented to 33 intervention practices and 25 control practices over a 2-year period. Practices allocated to the intervention group had access to HSG for those infertile women who fulfilled predefined eligibility criteria. The primary outcome measure was the interval between presentation to the GP and the couple receiving a diagnosis and management plan.Results
An annual incidence of 0.8 couples per 1000 total population equated to each GP seeing an average of one or two infertile couples each year. Open access HSG was used for 9% of all infertile women who presented to the intervention practices during the study period. The time to reach a diagnosis and management plan for all infertile couples presenting was not affected by the availability of open access HSG (Cox regression hazard ratio = 0.9, 95% confidence interval [CI] = 0.7 to 1.1). For couples who reached a diagnosis and management plan, there was a non-significant difference in time to primary outcome for intervention versus control practices (32.5 weeks versus 30.5 weeks, mean difference 2.2 weeks, 95% CI = 1.6 to 6.1 weeks, P = 0.1). The intracluster correlation coefficient was 0.03 across all practices.Conclusion
Providing GPs with open access to HSG had no effect on the time taken to reach a diagnosis and management plan for couples with infertility. 相似文献15.
Agnes J Smink Cornelia HM van den Ende Thea PM Vliet Vlieland Johannes WJ Bijlsma Bart A Swierstra Joke H Kortland Theo B Voorn Steven Teerenstra Henk J Schers Joost Dekker Sita MA Bierma-Zeinstra 《The British journal of general practice》2014,64(626):e538-e544
Background
A stepped care strategy (SCS) to improve adequate healthcare use in patients with osteoarthritis was developed and implemented in a primary care region in the Netherlands.Aim
To assess the association between care that is in line with the SCS recommendations and health outcomes.Design and setting
Data were used from a 2-year observational study of 313 patients who had consulted their GP because of osteoarthritis.Method
Care was considered ‘SCS-consistent’ if all advised modalities of the previous steps of the SCS were offered before more advanced modalities of subsequent steps. Pain and physical function were measured with the Western Ontario and McMaster Universities Osteoarthritis Index (range 0–100); active pain coping with the Pain Coping Inventory (range 10–40); and self-efficacy with the Dutch General Self-Efficacy Scale (range 12–48). Crude and adjusted associations between SCS-consistent care and outcomes were estimated with generalised estimating equations.Results
No statistically significant differences were found in changes over a 2-year period in pain and physical function between patients who received SCS-inconsistent care (n = 163) and patients who received SCS-consistent care (n = 117). This was also the case after adjusting for possible confounders, that is, −4.3 (95% confidence interval [CI] = −10.3 to 1.7) and −1.9 (95% CI = −7.0 to 3.1), respectively. Furthermore, no differences were found in changes over time between groups in self-efficacy and pain coping.Conclusion
The results raised several important issues that need to be considered regarding the value of the SCS, such as the reasons that GPs provide SCS-inconsistent care, the long-term effects of the SCS, and the effects on costs and side effects. 相似文献16.
Hill JJ Asprey A Richards SH Campbell JL 《The British journal of general practice》2012,62(598):e314-e321
Background
UK revalidation plans for doctors include obtaining multisource feedback from patient and colleague questionnaires as part of the supporting information for appraisal and revalidation.Aim
To investigate GPs'' and appraisers'' views of using multisource feedback data in appraisal, and of the emerging links between multisource feedback, appraisal, and revalidation.Design and setting
A qualitative study in UK general practice.Method
In total, 12 GPs who had recently completed the General Medical Council multisource feedback questionnaires and 12 appraisers undertook a semi-structured, telephone interview. A thematic analysis was performed.Results
Participants supported multisource feedback for formative development, although most expressed concerns about some elements of its methodology (for example, ‘self’ selection of colleagues, or whether patients and colleagues can provide objective feedback). Some participants reported difficulties in understanding benchmark data and some were upset by their scores. Most accepted the links between appraisal and revalidation, and that multisource feedback could make a positive contribution. However, tensions between the formative processes of appraisal and the summative function of revalidation were identified.Conclusion
Participants valued multisource feedback as part of formative assessment and saw a role for it in appraisal. However, concerns about some elements of multisource feedback methodology may undermine its credibility as a tool for identifying poor performance. Proposals linking multisource feedback, appraisal, and revalidation may limit the use of multisource feedback and appraisal for learning and development by some doctors. Careful consideration is required with respect to promoting the accuracy and credibility of such feedback processes so that their use for learning and development, and for revalidation, is maximised. 相似文献17.
Trevor W Lambert Fay Smith Michael J Goldacre 《The British journal of general practice》2016,66(652):e848-e857
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. 相似文献
18.
Tjard RJ Schermer Alan J Crockett Patrick JP Poels Jacob J van Dijke Reinier P Akkermans Hans F Vlek Willem R Pieters 《The British journal of general practice》2009,59(569):e376-e382
Background
Spirometry is an indispensable tool for diagnosis and monitoring of chronic airways disease in primary care.Aim
To establish the quality of routine spirometry tests in general practice, and explore associations between test quality and patient characteristics.Design of study
Analysis of routine spirometry test records.Setting
Fifteen general practices which had a working agreement with a local hospital pulmonary function laboratory for spirometry assessment regarding test quality and interpretation.Method
Spirometry tests were judged by a pulmonary function technician and a chest physician. Proportions of test adequacy were analysed using markers for manoeuvre acceptability and test reproducibility derived from the 1994 American Thoracic Society spirometry guideline. Associations between quality markers and age, sex, and severity of obstruction were examined using logistic regression.Results
Practices performed a mean of four (standard deviation = 2) spirometry tests per week; 1271 tests from 1091 adult patients were analysed; 96.4% (95% confidence interval [CI] = 95.6 to 97.2) of all tests consisted of ≥3 blows. With 60.6% of tests, forced expiratory time was the marker with the lowest acceptability rate. An overall 38.8% (95% CI = 36.0 to 41.6) of the tests met the acceptability as well as reproducibility criteria. Age, sex, and severity of obstruction were associated with test quality markers.Conclusion
The quality of routine spirometry tests was better than in previous reports from primary care research settings, but there is still substantial room for improvement. Sufficient duration of forced expiratory time is the quality marker with the highest rate of inadequacy. Primary care professionals should be aware of patient characteristics that may diminish the quality of their spirometry tests. Further research is needed to establish to what extent spirometry tests that are inadequate, according to stringent international expert criteria, result in incorrect clinical interpretations in general practice. 相似文献19.
Samuel L Brilleman Sarah Purdy Chris Salisbury Frank Windmeijer Hugh Gravelle Sandra Hollinghurst 《The British journal of general practice》2013,63(609):e274-e282
Background
Comorbidity is increasingly common in primary care. The cost implications for patient care and budgetary management are unclear.Aim
To investigate whether caring for patients with specific disease combinations increases or decreases primary care costs compared with treating separate patients with one condition each.Design
Retrospective observational study using data on 86 100 patients in the General Practice Research Database.Method
Annual primary care cost was estimated for each patient including consultations, medication, and investigations. Patients with comorbidity were defined as those with a current diagnosis of more than one chronic condition in the Quality and Outcomes Framework. Multiple regression modelling was used to identify, for three age groups, disease combinations that increase (cost-increasing) or decrease (cost-limiting) cost compared with treating each condition separately.Results
Twenty per cent of patients had at least two chronic conditions. All conditions were found to be both cost-increasing and cost-limiting when co-occurring with other conditions except dementia, which is only cost-limiting. Depression is the most important cost-increasing condition when co-occurring with a range of conditions. Hypertension is cost-limiting, particularly when co-occurring with other cardiovascular conditions.Conclusion
Three categories of comorbidity emerge, those that are: cost-increasing, mainly due to a combination of depression with physical comorbidity; cost-limiting because treatment for the conditions overlap; and cost-limiting for no apparent reason but possibly because of inadequate care. These results can contribute to efficient and effective management of chronic conditions in primary care. 相似文献20.
Catherine A O'Donnell Maria Higgins Rohan Chauhan Kenneth Mullen 《The British journal of general practice》2008,58(557):e1-e11