Developing role of medical audit advisory groups.

OBJECTIVES--To investigate the approaches to audit of different medical audit advisory groups (MAAGs) and to consider the implications for evaluation of their activities and their developing role in the light of new priorities for clinical audit. DESIGN--Qualitative study based on semistructured interviews. SETTING--15 family health services authority (FHSA) districts in two English health regions. SUBJECTS--MAAG chairpersons and support staff and FHSA general managers and medical advisors in each district, totalling 68 subjects. MAIN MEASURES--Structures and activities of MAAGs; perceptions of the MAAG's role and its achievements compared with the initial brief in a health circular in 1990. RESULTS--The approaches of different MAAGs varied considerably: some concentrated on promoting audit and others were involved in a wider range of development activities. MAAGs assessed their progress in various different ways. The importance of collaborative working was recognised, but few interface audit projects had been undertaken. MAAGs had little contact with other quality assurance activities in the FHSA, and FHSA involvement in the MAAG strategy was variable, although MAAGs were taking steps to improve communication with the FHSA. CONCLUSIONS--Major differences exist in the approaches taken by MAAGs and the roles they fulfil, which will make evaluation of their effectiveness a complex task. Already MAAGs are responding to changing expectations about audit and pressure for closer links with management.     

The use of the FHSA (family health services authority) registration index for a health needs survey.

The FHSA patient registration index was used as a sampling frame for a population questionnaire survey. The main survey of 3,359 was preceded by a pilot study of 250. Ethical issues such as anonymity and release of data were addressed in order to obtain the approval of the ethical committee and LMC. The acceptability to GPs and the public of using FHSA Registration data was tested. The validity of the survey was indicated by the proportion of wrong addresses, the response rate and the representativeness of the sample and responders. Appropriate software is needed for selecting a random sample and producing address labels.     

Patients' Experiences of Health Checks in General Practice: a Sample Survey

The 1990 contract for general practitioners in the UK offeredincentives for them to organize health promo tion clinics andrequired them to perform ‘lifestyle’ checkups oftheir patients every 3 years, despite uncertainty about theimpact of such checks on patient health. To address this lackof appropriate evaluation, a follow-up study to assess benefitsin terms of patient behaviour and health resulting from theintroduction of lifestyle checkups in general practice in asample of more than 7000 patients aged 30–70 from 18 practicesin three FHSA areas (in south London, Surrey and Yorkshire)has been performed. Eighteen per cent of the random sample ofpatients reported having a health check in the previous year.A full health check comprising measurement of blood pressure,height and weight, urinalysis and questioning about smokinghabits, alcohol consumption, exercise, diet and family illnesseshad been given to 29% of respondents reporting a health checkof any kind. Respondents in less privileged socioeconomic groupswere more likely to have had a health check, but less likelyto have had a ‘full’ check. Reactions to the checkswere mainly positive; 81% regarded the check as helpful, andonly 6% reported it to be worrying and 6% a waste of time. Theimplications for the new health promotion banding system inthe UK are discussed.     

Leptospira hebdomadis associated with an outbreak of illness in workers on a farm in North Yorkshire.

Four cases of illness attributed to Leptospira hebdomadis occurred on a cattle farm in North Yorkshire. The clinical features were a febrile illness that resembled influenza; in one case there was a lymphocytic meningitis. This infection is probably more common than is recognised at present, and prevention of further cases may be possible if diagnosed promptly.     

Three is company

'Caring for people in Cornwall' is a project that involved GPs, the FHSA (Family Health Services Authority) and the HA (Health Authority) as three equal partners. Laurie McMahon explains how it evolved.     

Identifying Chinese populations in the UK for epidemiological research: experience of a name analysis of the FHSA register

Definition of Chinese. For the purposes of this study, Chinese refers to residents of the UK who either on the basis of name (face-to-face contact not made), or self-definition and appearance (contact made) had origins in China and included those born in the UK and others migrating to the UK via a third country (for example Vietnam, Singapore, Hong Kong etc). This is a pragmatic definition.There is a paucity of research on health in the UK Chinese community partly due to the difficulties of identifying and accessing study populations. For a survey of cardiovascular disease we aimed to identify and recruit all Chinese adults aged 25–64 y living in Newcastle-upon-Tyne, UK. One thousand, eight hundred and sixty-five potential subjects were identified using a variety of methods. Of the 1702 potential subjects identified from a name analysis of the 1991 FHSA register (FHSA group), 638 students in halls of residence were excluded and the remaining 1064 were invited to participate. Non-respondents were followed up. Of the 1064, 658 (65.5%) addresses were no longer valid, 21 (2%) were reclassified as non-Chinese and no contact was made with 18 individuals (1.6%). A further 163 subjects (non-FHSA group) came forward in response to publicity, giving a total of 530 Chinese actually identified in Newcastle. Three hundred and eighty subjects took part in the study. Compared to the 1991 Census, the recruitment procedure underestimated the total population size, particularly for men and younger ages. In the FHSA group, men were significantly more likely to be current drinkers, and women were more likely to smoke and have a lower educational attainment that the non-FHSA group. There were no other important differences in the distribution of CHD risk markers in the two groups. Our experience indicates that the FHSA register is suitable for identifying Chinese but should be used alongside other complementary methods to augment samples for ethnicity and health research.     

Counselling in primary care

A counselling scheme has been set up in general practices in Salisbury Health District by Wiltshire FHSA. Rose Wiles and colleagues give details of the findings of an audit of the scheme and Wiltshire FHSA's responses.     

Management ... working day of a health services manager. Manchester FHSA

Sue Beaumont is GP Fund Holding Development Manager for Manchester FHSA, covering a population of over 505,000 and over 100 practices in an inner-city area. Newly appointed after a seven-year absence from the NHS, she has an interesting perspective on the reforms.     

Distribution of knowledge is the distribution of power

Earlier this year the Journal published an article by Brian Watkin in which he criticised the contribution made to the NHS by many health authority members. Now Charlotte Williamson, a member of the North Yorkshire AHA, takes the debate a stage further. The specific remit of members, she argues, is to protect the interests of patients by ensuring resources are allocated in accordance with need, and proper standards of care are achieved.     

General practitioners' attitudes to variations in referral rates and how these could be managed

BACKGROUND: Hospital referral rates have received widespread attention forboth clinical and economic reasons. OBJECTIVES: This study was undertaken to find out the views of general practitionersin North Yorkshire on current arrangements for the feedbackof routine referral data, perceived factors that influencedtheir referral behaviour and changes that might help their referraldecisions. METHOD: Survey questions were chosen from the issues raised during semi-structuredinterviews with 11 selected practices. A postal questionnairewas sent to all 114 general practices in North Yorkshire. RESULTS: A 60% (68/114) response rate was obtained from the postal questionnaire.The majority of practices agreed that the referral informationsupplied by them was accurate (77%) and that the feedback ofthis data was useful (66%). Uncertainty of diagnosis/managementand patient pressure were the two most commonly agreed factorsthat were suggested as influencing referral behaviour. Trainingin procedures and use of clinical guidelines were the most popularchanges chosen as being helpful in referral decision making. CONCLUSIONS: The feedback of routine referral data is considered accurateand useful, and should continue. Expanding opportunities forthe training of general practitioners in specific skills andthe development of clinical guidelines for the management andreferral of commonly suggested areas would be helpful to generalpractitioners in making referral decisions. Keywords. Hospital referrals, information feedback, clinical guidelines.     

Unified commissioning of primary and community health care. The first year

Barking and Havering FHSA covers a population which exhibits symptoms of urban deprivation and which has been the victim of erosion in the quantity and quality of community and primary care services. Geoffrey Shepherd and Sharon Haffenden describe a unified commissioning project with the local health authority with the aim of improving services.     

The costs and benefits of asking patients for their opinions about general practice

BACKGROUND: Patient views are important in the evaluation of the qualityof health care. The use of surveys needs to be evaluated todetermine their cost-effectiveness and benefits. OBJECTIVES: To determine the costs of conducting patient opinion surveysin general practice and to find out how effective patient surveysare in stimulating changes which are beneficial for patientcare. METHOD: Postal questionnaire to all 102 medical audit advisory groups(MAAGs) and 98 family health services authorities (FHSAs) inEngland and Wales, followed by postal questionnaire to 302 generalpractices reported to have conducted surveys, sampled by thetype of questionnaire used. Numbers of MAAGs and FHSAs reportingsurveys in general practice; types of questionnaire used; estimatedcosts; changes made; and benefits identified were measured. RESULTS: Eighty-five (83%) MAAGs and 75 (77%) FHSAs responded. One hundredand fifty-four (96%) of MAAGs or FHSAs reported survey activity.Types of questionnaire used were 1) designed by the practice,2) designed by the MAAG or FHSA, possibly in collaboration witha practice, or 3) standard ‘off-the-shelf’. Onehundred and thirty-three (44%) practices responded. Total coststo a practice of conducting a survey ranged from nothing toover £2200. Questionnaires designed by the practice arelikely to be more costly than other designs. Some practiceshad surveys provided free of charge by MAAG or FHSA. Sixty-oneper cent of practices said changes had been implemented anda further 22% of practices said changes were planned. The mostcommon change was to appointment systems. Benefits were identifiedfor patients, staff, the practice, the MAAG or FHSA and theNHS. Surveys also brought benefits in relationships and understanding.Only 8.2% of practices felt the costs of surveys outweighedthe benefits. CONCLUSIONS: Many practices are surveying patients' opinions. Surveys canbe costly but MAAGs and FHSAs can provide expertise and resources.Surveys using any of the types of questionnaire are likely tolead to changes and identifiable benefits. Benefits of surveysare perceived by the majority of practices to outweigh the costs. Keywords. General practice, patient opinion, costs, benefits, questionnaire.     

Guidelines for low back pain: changes in GP management.

BACKGROUND: Management guidelines are aimed at reducing inappropriate practice and improving efficiency; however, the effectiveness of many guidelines has yet to be confirmed. This study targets GPs' management of back pain and its relationship with the recent management guidelines. OBJECTIVES: We aimed to investigate changes in GP management of low back pain, low back pain episode duration and time before consultation, over a 5-year period. METHOD: A case series report of 574 patient notes was collected from a large practice in North Yorkshire (January 1992-March 1997). In addition, 713 referral notes from 26 practices across North Yorkshire were collected. The patients were potential subjects for a larger randomized controlled trial evaluating the effectiveness of an exercise programme. Both groups of data were analysed by identifying trends over time and using log linear regression. RESULTS: Recommendation of activity or exercise was found to be a trend increasing over time. In contrast, recommendation to rest was found to be a trend decreasing over time. Activity or exercise was more frequently recommended to younger patients. There was evidence that individuals are seeking a GP consultation more quickly. CONCLUSIONS: The gap between GP practice and the recent guidelines appears to be reducing. However, many variations in practice still exist. Evidence of decreasing time before consultations may indicate that the level of self-care by low back pain patients is decreasing. Although management guidelines may have some effect, there is some way to go before back pain management is optimized.     

Investigation of spacial clustering of rare diseases: childhood malignancies in North Humberside.

STUDY OBJECTIVE--The aims of the study were (1) to test for uniformity of distribution of childhood leukaemias and other malignancies; and (2) to consider the aetiological implications of unusual distributions. DESIGN--A test for spacial clustering was applied using a method which allows for unequal distribution of the population at risk and avoids using census data to provide population denominators. When clustering was identified, four possible aetiological links which had already been suggested to the Leukaemia Research Fund Centre were examined in a local area. SETTING--The study was carried out in the Yorkshire Health Region in the north of England. PATIENTS--144 children under 15 years of age with a diagnosis of malignant disease known to the Yorkshire Regional Childhood Tumour Registry between 1974 and 1986 were included in the analysis. Of these 53 had leukaemias and nine had lymphomas. MEASUREMENTS AND RESULTS--Significant localised clustering was found in North Humberside, though not in the whole of the Yorkshire Health Region. A number of clustered cases were identified, some of whom were in a post code sector, Hull 10, to the west of Kingston-upon-Hull, about which concern had been expressed since 1985. There was however no evidence that disease clustering was confined to this area. Four previously suggested hypotheses about causation in this particular area were examined but the results were negative or inconclusive. CONCLUSIONS--The identification of spacial clustering must be seen as only the first step in a series of investigations; it can only rarely lead to aetiological conclusions by itself, but it can motivate and target other investigations.     

Cervical cytology.

1. Unless there are special clinical indications, regular cervical screening should begin at about the age of 20 and finish at 65. 2. Women aged 40 and over who have never had a smear should be actively encouraged to have a smear as soon as is practicable. 3. An Aylesbury spatula can be used, but the use of a cytobrush cuts down the proportion of smears reported as ''no endocervical cells seen''. 4. Most family health services authorities (FHSA) provide 3- or 5-yearly recall of women with normal smears and many practices have their own recall systems. District health authorities provide cytology and colposcopy services. The major part of the screening programme is undertaken in general practice. 5. The cervical screening policy of one district health authority is outlined. This is based upon the Intercollegiate Report issued by the Royal College of Obstetricians and Gynaecologists. 6. Different possible smear results are described together with appropriate patient management. Because these recommendations are likely to change in the light of new studies, general practitioners must be alert to the management advice offered by the cytology laboratory on abnormal smears. 7. For some women, FHSA recall may be more frequent than 3-yearly if instructed by the general practitioner. 8. Follow-up of abnormal smear results is the responsibility of the doctor who takes the smear.     

A survey of the cervical screening service in a London district, including reasons for non-attendance, ethnic responses and views on the quality of the service

A survey of 400 Ealing residents was conducted from the Department of Public Health in Ealing Health Authority to ascertain why the response to the call/recall letters issued by the Family Health Service Authority (FHSA) was at most 33%. Views about the service were also investigated. The findings were that satisfaction with the service was high and more women were covered than previously thought. However with close to 40% inaccuracies on the prior notification list (even after amendments by the GPs), few assumptions about the response to the call/recall system could be made until the FHSA mailing list is systematically reformed. A small but well defined group of older women were very infrequent, if ever attenders; their reasons were amenable to health education and encouragement by health professionals. Easily identifiable differences between ethnic minorities and women from U.K. backgrounds related to the choice of screening venues. However there were indicators of more fundamental problems of access to, and equity in the service in relation to certain ethnic minorities. Requests were made on approximately one third of completed questionnaires for further health checks which mainly related to general and cardiovascular fitness. Regular reviews of the service including feedback from the target group can yield valuable managerial, medical and quality assurance information.     

Impact of an interest in asthma on prescribing costs in general practice.

OBJECTIVE--To examine the effect on total prescribing costs and prescribing costs for respiratory drugs for practices with at least one general practitioner with a special interest in asthma. DESIGN--Postal questionnaire survey. SETTING--General practitioners in England and Wales. SUBJECTS--269 members of the General Practitioners in Asthma Group, of whom 103 agreed to participate. MAIN MEASURES--Individual practitioners' and their practices' PACT prescribing costs from the winter quarters of 1989-90 compared with average costs for their family health services authority (FHSA) and a notional national average of all FHSAs combined. RESULTS--The response rate was 57%; the average total prescribing costs for the practices of the 59 respondents were significantly lower than those of their respective FHSAs (mean difference 505 pounds per 1000 patients per quarter (95% confidence interval -934.0 to -76.2, p = 0.022) and lower than the national average. The average prescribing costs for respiratory drugs for the practices were significantly greater than those for their FHSA (195 pounds per 1000 patients per quarter (84.4 to 306.0, p = 0.001) and the national average. Both types of costs varied widely. CONCLUSION--An interest in asthma care in general practice is associated with higher average prescribing costs for respiratory drugs but no increase in overall prescribing costs compared with those for respective FHSAs and national averages. IMPLICATIONS--FHSAs and their medical advisors should not examine high prescribing costs for individual doctors or one therapeutic category but in the context of practice total costs.     

Effects of subsidising bus travel on the occurrence of road traffic casualties.

Between 1975 and 1 April 1986, public transport by bus in the metropolitan county of South Yorkshire, England, was increasingly subsidised. Trends in road traffic accident casualties between 1974 and 1983 in all the six provincial English metropolitan counties have been compared in order to examine the possible effect of this unique subsidy on the incidence of road traffic accident casualties. During that period the total number of casualties in South Yorkshire did not change significantly compared to the other metropolitan counties. However, the proportion of all casualties in South Yorkshire who were bus occupants did increase relative to other metropolitan counties, indicating either an increase in the amount of bus travel or a decrease in travel by other modes. There was a large increase in bus patronage in South Yorkshire relative to the other metropolitan counties, and the conclusion is that it is the transport policy in South Yorkshire which resulted in an actual increase in distances travelled by bus. Since bus is the safest form of road travel, it is concluded that the public transport subsidy in South Yorkshire has benefited the health of the local population by providing the social amenity of additional travel at the least additional health cost.