Investigation of benefits and costs of an ophthalmic outreach clinic in general practice.

BACKGROUND: With the advent of general practitioner fundholding, there has been growth in outreach clinics covering many specialties. The benefits and costs of this model of service provision are unclear. AIM: A pilot study aimed to evaluate an outreach model of ophthalmic care in terms of its impact on general practitioners, their use of secondary ophthalmology services, patients' views, and costs. METHOD: A prospective study, from April 1992 to March 1993, of the introduction of an ophthalmic outreach service in 17 general practices in London was undertaken. An ophthalmic outreach team, comprising an ophthalmic medical practitioner and an ophthalmic nurse, held clinics in the practices once a month. Referral rates to Edgware General Hospital ophthalmology outpatient department over one year from the study practices were compared with those from 17 control practices. General practitioners' assessments of the scheme and its impact on their knowledge and practice of ophthalmology were sought through a postal survey of all partners and interviews with one partner in each practice. Patient surveys were conducted using self-administered structured questionnaires. A costings exercise compared the outreach model with the conventional hospital ophthalmology outpatient clinic. RESULTS: Of 1309 patients seen by the outreach team in the study practices, 480 (37%) were referred to the ophthalmology outpatient department. The annual referral rate to this department from control practices was 9.5 per 10,000 registered patients compared with 3.8 per 10,000 registered patients from study practices. A total of 1187 patients were referred to the outpatient department from control practices. An increase in knowledge of ophthalmology was reported by 18 of 47 general practitioners (38%). Nineteen (40%) of 47 general practitioners took advantage of the opportunity for inservice training with the outreach team; they were more likely to change their routine practice for ophthalmic care or referral criteria for patients with cataracts or diabetes than those who did not attend for inservice training. The outreach scheme was popular with patients, for whom ease of access and familiarity of surroundings were major advantages. The cost per patient seen in the outreach clinics (48.09 pounds) was about three times the cost per patient seen in the outpatient department (15.71 pounds). CONCLUSION: The model of ophthalmic outreach care in this pilot study was popular with patients and general practitioners and appeared to act as an effective filter of demand for care in the hospital setting. However, the educational impact of the scheme was limited. Although the unit costs (per patient) of the outreach scheme compared unfavourably with those of conventional outpatient treatment, potential health gains from this more accessible model of care require further exploration.     

Psychiatric referral rates and the influence of on-site mental health workers in general practice.

Psychiatric referral rates vary widely between different general practices. To increase our understanding of this variation, we conducted a one-year prospective observational study of outpatient psychiatric referrals made by all general practices (622 referrals from 29 practices) within the catchment area of one inner-city psychiatric service. Contrary to our hypothesis, practices with higher allocations of on-site mental health workers did not have lower psychiatric referral rates. On the other hand, the highest referring practices had lower mental health worker allocations suggesting a possible influence upon referrals in this subgroup. A wide range of quantitative variables explained very little of the referral rate variation, implying that more subjective factors, such as general practitioner attitudes, may be influential in the decision to refer a patient to the psychiatrist.     

Do referral rates vary widely between practices and does supply of services affect demand? A study in Milton Keynes and the Oxford region.

Two commonly held beliefs about referral rates were investigated in this study: first that demand for services is determined by supply and secondly that there is wide variation between general practices in their referral rates. All referrals to specialist outpatient clinics were recorded during two 11-week periods by general practitioners in eight practices in the new town of Milton Keynes and in 17 practices elsewhere in the Oxford region. During the first period, only a limited outpatient service was available in the new town; for many specialist services, people had to be referred to hospitals outside the district. Referral rates from Milton Keynes were very similar to those from the rest of the region. By the second period the range of specialist facilities available locally had expanded considerably with the opening of the new district general hospital and during this period there was a statistically significant but rather small increase in referral rates from Milton Keynes. Variation in referral rates between general practices within each geographical group was greater than that between the two groups. Overall, there was about a three-fold variation between general practices in outpatient referral rates which is considerably less than that commonly thought to exist.     

Randomised controlled trial to compare GP-run orthopaedic clinics based in hospital outpatient departments and general practices

BACKGROUND: To reduce outpatient waiting times, a growing number of outpatient clinics for selected groups of patients are being provided by GPs with special interests (GPwSIs). AIM: To determine whether there are differences in patient satisfaction or clinical outcome among patients attending orthopaedic clinics provided by GPwSIs in hospital or community settings. DESIGN OF STUDY: Randomised controlled trial. SETTING: Hospital outpatient departments or general practices. METHOD: Three hundred and twenty-one patients with minor orthopaedic problems were referred by GPs to the orthopaedic surgery department of the University Hospitals of Leicester NHS Trust; 168 patients were randomised to care by GPwSIs in practices, and 153 were randomised to care by the same GPwSIs in clinics held at hospital outpatient departments. Patients completed the SF-36v2 and satisfaction questionnaires at their first appointment, and again 3 months later. RESULTS: There was no significant difference between the sites in changes in health. After the first clinic attendance, patients attending practice-based clinics were more satisfied with access to appointments and information received. CONCLUSION: For selected orthopaedic referrals seen by GPwSIs, there were no significant differences in clinical outcomes between practice-based and hospital-based clinics, but some features of practice-based clinics tend to be preferred by patients.     

Musculoskeletal clinic in general practice: study of one year''s referrals.

BACKGROUND. A musculoskeletal clinic, staffed by a general practitioner trained in osteopathy, medical acupuncture and intralesional injections, was set up in an inner London general practice in 1987. AIM. A retrospective study was undertaken of one year's referrals to the clinic in 1989-90 to determine how general practitioners were using the clinic in terms of problems referred; consultation patterns of patients attending the clinic and 12 months after initially being seen; and how access to the clinic influenced referrals to relevant hospital departments. METHOD. Day sheets were studied which recorded information on demographic characteristics of patients referred to the clinic and their problems, diagnoses made, duration of symptoms, number and range of treatments given, and recurrence of problems. Use of secondary referral sources was also examined. RESULTS. During the study year 154 of 3264 practice patients were referred to the musculoskeletal clinic, and attended a mean of 3.5 times each. Of all the attenders 64% were women and 52% were 30-54 years old. Eighty one patients (53%) presented with neck, back or sciatic pain. A specific traumatic, inflammatory or other pathological process could be ascribed to only 19% of patients. Regarding treatment, 88% of patients received osteopathic manual treatment or acupuncture, or a combination of these treatments and 4% received intralesional injections. Nine patients from the clinic (6%) were referred to an orthopaedic specialist during the year, two with acute back pain. Referrals to orthopaedic specialists by the practice as a whole were not significantly lower than the national average, although the practice made fewer referrals to physiotherapy and rheumatology departments than national figures would have predicted. Seventeen patients (11%) returned to the clinic with a recurrence of their main complaint within a year of their initial appointment; second courses of treatment were usually brief. CONCLUSION. The clinic encouraged a relatively low referral rate to musculoskeletal specialists outside the practice. However, a need was identified for better communication about the potential of the approaches used in order that referrals to secondary specialists, particularly orthopaedic specialists, could be further reduced.     

Outcome of general practitioner referrals to specialist outpatient clinics for back pain.

In 1983-84 general practitioners in the Oxford region kept records of their referrals to outpatient clinics over a period of six months. Five years later in 1988-89 the general practice notes of 182 patients referred for back pain were studied to determine the outcomes of their referral. The actions initiated in the outpatient clinics were compared with the general practitioners' main reason for referral recorded at the time of referral. Of the 182 patients 136 (74.7%) received specialist treatment following the outpatient referral despite the fact that general practitioners had given treatment as the main reason for referral in only 28.6% of cases. Patients' mean consultation rate for back pain declined from 4.2 consultations per annum to 0.9 (P less than 0.001) over the five year period, but there was a small but significant increase in consultations for other problems. Five years after the referral 33.3% of patients were still consulting their general practitioner for back pain. The referral system for patients with chronic back pain could be rationalized to reduce the need for re-referrals and multiple follow-up outpatient consultations. There is a need to improve communications between general practitioners, specialists and patients about the purpose of referral, the likely effects of treatment and the scope for prevention. A survey of the outcome of referrals for common conditions, such as back pain, is a useful first step in the development of referral guidelines.     

Social workers and their clients: a comparison between primary health care and local authority settings

A social work attachment scheme to several general practitioners was established. Data from the first 300 referrals to the scheme were compared with data from a previous study of referrals to the `intake' teams of the social services department of the same London borough. In addition, data about the activities of the social workers in the `attachment' were collected, and the work was found to be predominantly short-term.

The populations referred to social workers in both settings were found to be similar in age and sex. Although general practitioners in the area referred only a few clients to social services departments, the clients in both groups were generally in poor health.

The psychiatric morbidity of those referred to the attached social workers was significantly higher, however, than those referred to the intake team (p < 0·01), and their problems were also more likely to need psychological help rather than practical measures. These differences were considered to be due mostly to the different types of referral agencies operating in the two settings and to their perceptions of the social worker's role.

The findings support the argument for closer liaison between medical and social services in the community: the attachment of social workers to general practices proved to be particularly valuable in the management and treatment of patients with emotional and mental illness.

     

Psychiatric services in primary care: specialized or not?

We compare referrals made to a psychiatric service by two comparable general practices. One practice made its referrals through conventional channels; the other referred patients to a multi-professional team who saw patients at a clinic held on the practice premises. The members of the team and the general practitioners in the second practice also met regularly to discuss matters of mutual interest. More patients were referred by this method, which also made greater use of the multiple disciplines involved in psychiatric care.

Patients referred through conventional channels were more likely to have had previous contact with the psychiatric service, were more likely to be admitted to hospital and spent 70 per cent more time as inpatients.

These results confirm the findings of other workers in demonstrating that there are tangible benefits in a multidisciplinary specialist team working in primary care.

     

General practitioner referral rates to district psychiatry and psychology services.

The number of referrals made to a district psychiatry service by each of the local general practitioners over a five year period was counted and a large variation in general practitioner referral rate was found. Ten referral letters from each of the general practitioners were independently assessed for the amount of detail included and a mean score for each general practitioner obtained. A significant negative correlation was found between referral rate and amount of detail in referral letters, that is low referrers wrote very detailed letters. The procedure was repeated over an 18 month period including referrals to the district psychology service. Referral rate to the psychologists was positively correlated with detailed referral letters, that is those who referred many patients to the psychologists wrote detailed letters. This study has indicated a wide variation in the use of the psychiatry and psychology services by general practitioners which cannot be explained solely on the basis of a general referral tendency. It is likely that constructive liaison between psychiatrists and general practitioners, especially those who refer a large number of patients, could enhance the care of patients with psychiatric disorder in general practice.     

Liaison psychiatry in general practice: a comparison of the liaison-attachment scheme and shifted outpatient clinic models.

Most psychiatrists who visit health centres use the shifted outpatient clinic model, the main aim of which is to improve secondary care by providing it in the primary care setting. For five years we have employed a liaison-attachment scheme in which support and advice from the psychiatrist enables general practitioners to improve their care of patients with psychiatric and psychological problems. One of the advantages of the latter model is that the psychiatrist can contribute to the care of patients not seen by the specialist psychiatric service and also to the development of the primary care team. The scheme is cost effective as psychiatrists can advise on the care of far more patients than they could see in formal referrals, fewer patients are taken on for a course of psychiatric treatment that could be provided by general practitioners and the skills of general practitioners and their trainees are enhanced. It is hoped that more general practitioners will adopt this pattern of working so that it can be fully developed and evaluated.     

Effect of information about waiting lists on referral patterns of general practitioners.

In a two year trial general practitioners in the West Midlands were provided with extended waiting time information for hospital consultation and treatment in general surgery. Selected general practitioners were sent monthly bulletins on comparative times to wait for both outpatient appointment and inpatient treatment throughout the region. Their referrals to consultant general surgeons were monitored, alongside those of a matched control group not receiving such information. Differences were found between the two groups which indicate the willingness of general practitioners to change their referral practice when adequate information is available. In addition, patients referred to their local hospital had longer waiting times than patients matched for clinical condition and district of origin who were sent to hospitals where it was indicated that a shorter wait might be expected.     

Rheumatology in general practice — a survey in World Rheumatism Year 1977

Rheumatological complaints accounted for 10·6 per cent of new presentations in this general-practice survey. Spinal problems formed almost half of this total and led to a greater degree of disability than other locomotor system disorders. Active participation in the treatment of pain by the practitioner's use of manipulation and injection techniques is shown to be quite feasible in general. Forty-six per cent of all hospital referrals were simply requests for physiotherapy, and we suggest that physiotherapy departments should offer open access and so lead to a marked reduction in over-strained rheumatology consultant outpatient clinics.     

Links between mental health care professionals and general practices in England and Wales: the impact of GP fundholding.

BACKGROUND: Fundholding general practitioners are able to determine the type of contracts they place with providers of mental health care, and are able to employ some categories of mental health care professionals directly. The impact of this on the care of the mental health of patients in non-fundholding practices is not yet fully known. AIM: A survey was undertaken of 100 fundholding general practices and 100 similarly sized non-fundholding practices in order to investigate the changes in mental health provision made by general practitioners. METHODS: A sample of 100 fundholding general practices in England and Wales was randomly chosen from the list supplied by the Association of Fundholders and matched to a similarly randomly chosen sample of non-fundholding practices. Postal questionnaires were sent to the senior partner and to the practice manager in each practice. RESULTS: The number of mental health care professionals who are either employed by or attached to general practices, or who visit the general practice on a regular basis appears to have increased substantially since 1991. This increase was particularly marked in fundholding practices. The results suggest that general practitioners with specific links to particular mental health care providers were more satisfied with the service provided by the mental health care team, and more likely to increase referrals to that service in the last 2 years, than general practitioners without such links. There was little evidence to suggest that increasing the number of mental health care professionals in primary care had brought about a major reduction in referrals to psychiatrists. CONCLUSION: General practitioners, particularly fundholders, are increasing their links with mental health professionals, and community psychiatric nurses, psychiatrists, psychologists and counsellors are spending more time either based in general practice or visiting regularly. While the shift of resources to primary care, particularly to fundholders, may increase the treatment options available to patients with less severe illnesses, this may have the effect of reducing the services available for the long-term and severely mentally ill.     

Resource implications of a knee referral

Introduction: The latest government targets state that by the end of 2005 the maximum waiting time for an outpatient appointment will be 3 months. These recommendations will not only increase the size of the outpatient clinics, but also the resources required thereafter. The purpose of this study was to analyse the outcome of new patient referrals to one knee outpatient service in order to quantify the resources required to investigate and treat these patients. Method: All new patients attending one consultant's knee outpatient service in the time period January 1st 1997 to December 31st 1997 were prospectively entered into a database recording patient details, source of referral and diagnosis. Eighteen months after the time period a cohort of 200 patients was randomly selected and the case notes were analysed. The number of outpatient appointment episodes, MRI scans, physiotherapy referrals and surgical episodes generated were recorded for each patient. Results: Analysis of the initial database records show that a total of 662 new knee referrals were seen in 1997. Fifty-two percent (341) were made up of the five most common diagnoses, these being osteoarthritis, anterior knee pain, anterior cruciate ligament injury, medial ligament injury and medial meniscus injury. Retrospective analysis of the 200 patient notes revealed that these patients required a total of 499 outpatient episodes, 43 MRI scans, 180 courses of physiotherapy and 93 surgical episodes (53 elective and 40 emergency). These figures can be used to predict the resources that would be required by all new patients seen in an outpatient knee service in a year. Discussion: Each new patient that enters the cycle of investigation followed by treatment must be met by extra resources. If this does not occur the net result will be that although government targets may be met, the time taken to complete each patient episode will become longer. It is imperative that before an agreement is made to see new patients the resources required to manage them are in place.     

One counsellor, two practices: report of a pilot scheme in Cambridgeshire.

BACKGROUND. Despite limited evidence of their effectiveness, counsellors are increasingly being employed as part of the primary health care team. Evaluation of counsellor services is therefore important. AIM. In 1990 the Cambridgeshire Family Health Services Authority initiated a pilot scheme to evaluate the role of counsellors in general practice and to help the authority determine its policy towards claims by general practitioners for reimbursement through the ancillary staff scheme. METHOD. Two group practices were identified and an external evaluator appointed. The evaluator and the general practitioners developed their aims and objectives for counselling in the general practice context, the number of counsellor hours per week and the type and process of referral. An experienced counsellor was appointed to work in both practices. Information was gathered over two years about doctors' reasons for referral, counsellor's initial assessment, patient outcome at the end of treatment, the patients' and practice teams' opinions about the counselling service, and patient outcome a year after counselling. RESULTS. A total of 293 patients were referred in the first two years of the scheme, of whom 75% were women. The main reasons for referral were that the general practitioners considered the patients to be suffering from anxiety/stress (33%), interpersonal difficulties (33%) and depression (20%). Almost all referrals (98%) were considered by the counsellor to be appropriate. The counsellor was able to provide an assessment for the 248 patients who attended and either take on the case for short-term counselling (69%) or suggest referral to a more appropriate service (25%) (6% withdrew). The expected maximum of six sessions of 45 minutes duration per referral was achieved in 87% of cases. The service was valued by patients and doctors. It coped effectively with a high proportion of patients with problems who did not reappear as demand elsewhere in the practice, and achieved a reduction in dose of psychotropic drugs among those seen. CONCLUSION. This study has shown the value of clarifying referral criteria and the intended role of the counsellor prior to the counsellor's introduction. This ensures effective use of a scarce resource and a high level of satisfaction among doctors and patients.     

Children referred for specialist care: a nationwide study in Dutch general practice.

BACKGROUND: Insight into referral patterns provides general practitioners (GPs) and specialists with a frame of reference for their own work and enables assessment of the need for secondary care. Only approximate information is available. AIM: To determine how often, to which specialties and for what conditions children in different age groups are referred, as well as how often a condition is referred given the incidence in general practice. METHOD: From data of the Dutch National Survey of Morbidity and Interventions in General Practice, 63,753 new referrals (acute and non-acute) were analysed for children (0-14 years) from 103 participating practices (161 GPs) who registered. Practices were divided into four groups. Each group of practices participated for three consecutive months covering a whole year altogether. We calculated referral rates per 1000 children per year and referability rates per 100 episodes, which quantifies the a priori chance of a condition being referred for specialist care. RESULTS: The referral rate varied by age from 231 for children under 1 year old to 119 for those aged 10-14 years (mean 159). The specialties mainly involved were ENT, paediatrics, surgery, ophthalmology, dermatology and orthopaedics. Referrals in the first year of life were most frequently to paediatricians (123); among older children the referral rate to paediatricians decreased (mean 36). Referrals to ENT specialists were seen particularly in the age groups 1-4 (71) and 5-9 (53). For surgery, the referral rate increased by age from 19 to 34. Differences between boys and girls were small, except for surgery. The highest referral rates were for problems in the International Classification of Primary Care (ICPC) chapters: respiratory (28); musculoskeletal (25); ear (24) and eye (21). Referability rates were, in general, low for conditions referred to paediatrics and dermatology and high for surgery and ophthalmology. The variation in problems presented to each specialty is indicated by the proportion of all referrals constituted by the 10 most frequently referred diagnoses: from 35% for paediatrics to 81% for ENT; for ophthalmology, five diagnoses accounted for 83% of all referrals. CONCLUSIONS: The need for specialist care in childhood is clarified with detailed information for different age categories, specialties involved and variation in morbidity presented to specialists, as well as the proneness of conditions to be referred.     

Comparison between primary care physiotherapy education/advice clinics and traditional hospital based physiotherapy treatment: a randomized trial.

BACKGROUND: Studies have shown that patients prefer to received physiotherapy services in the primary care setting, but none has made direct comparisons between hospital and primary care based physiotherapy. AIM: This pragmatic randomized trial set out to compare general-practice-based physiotherapy education and advice clinics with traditional physiotherapy treatment in an acute hospital setting. METHOD: The study involved 130 patients referred to physiotherapy services by 43 general practitioners over a one-year period. Patients were included in the study if they were at work, independent in all activities of daily living and would have routinely been referred to the hospital physiotherapy department for treatment. Patients were randomly allocated to one of two intervention groups: general practice education/advice, or treatment and education/advice at the local hospital. Patients completed a questionnaire prior to their first physiotherapy appointment and again 6 weeks later. RESULTS: A disappointing number of patients failed to attend either the first or subsequent appointments. The post-intervention scores revealed improvements in patients' problems, with the advice group exhibiting a slightly better outcome than the hospital group, as measured by the Nottingham health profile, the anxiety component of the hospital anxiety and depression rating scale, pain and problem size visual analogue scales, and measures of patient satisfaction. Advice group patients also had less attendances than the hospital treatment group. The general practitioners surveyed commented favourably on the advice clinics. CONCLUSIONS: The findings of this study justify the concept of general-practice-based physiotherapy education and advice clinics.     

Primary care access to computed tomography for chronic headache

Background

The diagnostic yield of neuroimaging in chronic headache is low, but can reduce the use of health services.

Aim

To determine whether primary care access to brain computed tomography (CT) referral for chronic headache reduces referral to secondary care.

Design of study

Prospective observational analysis of GP referrals to an open access CT brain scanning service.

Setting

Primary care, and outpatient radiology and neurology departments.

Method

GPs in Tayside and North East Fife, Scotland were given access to brain CT for patients with chronic headache. All referrals were analysed prospectively over 1 year, and questionnaires were sent to referrers to establish whether imaging had resulted in or stopped a referral to secondary care. The Tayside outpatient clinic database identified scanned patients referred to the neurology clinic for headache from the start of the study period to at least 1 year after their scan.

Results

There were 232 referrals (55.1/100 000/year, 95% confidence interval = 50.4 to 59.9) from GPs in 59 (82%) of 72 primary care practices. CT was performed on 215 patients. Significant abnormalities were noted in 3 (1.4%) patients; there were 22 (10.2%) non-significant findings, and 190 (88.4%) normal scans. Questionnaires of the referring GPs reported that 167 (88%) scans stopped a referral to secondary care. GPs referred 30 (14%) scanned patients to a neurologist because of headache. It is estimated that imaging reduced referrals to secondary care by 86% in the follow-up period.

Conclusion

An open access brain CT service for patients with chronic headache was used by most GP practices in Tayside, and reduced the number of referrals to secondary care.     

Does the North Staffordshire slot system control demand of orthopaedic referrals from primary care?: A population-based survey in general practice

BACKGROUND: Attempts to manage general practice demand for orthopaedic outpatient consultations have been made in several areas of the NHS, with little robust evidence on whether or not they work. AIM: To evaluate the effect of the North Staffordshire 'orthopaedic slot system' on the demand for general practice referrals to orthopaedic outpatients. METHOD: A prospective study of 12 general practices in the slot system, 24 controls, and the 63 other general practices in North Staffordshire. Comparison periods were the baseline year (0); the first calendar year (1); and the first half of the second calendar year (2). A multifactor linear regression model was used. RESULTS: Mean referral rate decreased 22% in the slot group in period 1, and was maintained in period 2 (9.40, 7.29, 7.31 referrals per 10,000 population per month for periods 0, 1 and 2, respectively). The control and other groups showed a small decrease in period 1, but in period 2 higher referral rates were observed. The reduction in referrals of 20-40% in participating practices compared to other practices equates to 2-4 referrals per 10,000 patients per month. CONCLUSIONS: Our study suggests that practices willing and able to take up an offer of a slot system for managing their orthopaedic referrals will be able to significantly reduce referral rates for their patients when compared to similar practices who do not. Further research on the generalisability, effectiveness and cost-effectiveness of such systems is warranted.