Primary care teams and the elderly in Northern Ireland

The results of a questionnaire were used to examine how primary care workers set about the management and surveillance of their elderly patients. The majority of practices had attached visitors (76 per cent) and attached district nurses (59 per cent), while 61 per cent of general practitioners worked in health centres. Over half of the responding practices had agesex registers. Few of the practices (14 per cent) had screened their elderly patients in the last five years and maintained an `at-risk' register. Twenty per cent of practices held a regular meeting concerning their elderly patients but only half of these reviews involved the available health visitors and district nurses.

At least half of the general practitioners and district nurses plus three quarters of the health visitors felt dissatisfied with the care of the elderly.

A single and systematic review of elderly patients conducted jointly by general practitioners, health visitors and district nurses would do much to improve the care of this group of patients and the morale of these workers.

     

Immunization, practice records and the white paper

The accuracy of all immunization records for a cohort of two to three year olds, registered with one general practice, was investigated. Information was obtained from practice notes, the practice computer, the district health authority records and the parents of those children whose records indicated they had outstanding immunizations. The combined results revealed a rate for completed immunization schedules of 72%, but the rate recorded by the district health authority was only 40%. All the records were defective because the systems for exchange of data were not functioning properly. The government's white paper on primary health care links practice income to performance, and immunization rate is one index of this. On the basis of the district health authority records, this practice would be wrongly penalized.     

Telephone messages received by seven general practices

Telephone calls were recorded in seven general practices in Aylesbury in a study of communications received from the hospitals, local health authority (L.H.A.), social services department, and other sources, but excluding calls from patients.

Analysis of 855 telephone calls revealed patterns of communication with the staff of the practices which have not previously been recorded. The general practitioners were central in communications from all sources except the local health authority, while calls to health visitors came overwhelmingly from the local health authority. Community nurses received only 36 (four per cent) of all the calls despite the interests expressed by hospital nursing staff in their responses to a postal questionnaire. A hypothesis is advanced to explain this discrepancy between interest and action.

     

General practitioners and social help for the handicapped

A study was undertaken by the Greater London Association for the Disabled in consultation with the Royal College of General Practitioners, to explore the depth of knowledge of the Chronically Sick and Disabled Persons Act and statutory and voluntary social provision, of 22 general practitioners in 16 practices served by one area social services office in a London borough.

The doctors were mainly middle-aged, of British or Irish birth and training and had no language barrier. The majority lived in or near their practices. Half the practices were groups or partnerships, half were singlehanded. Only in three groups was there any attached district nursing staff and in only one was there an attached health visitor. More than half the general practitioners had reception staff only during surgery hours. Four practices had no reception staff during National Health Service surgery hours, two of which had no reception staff at all. In no practice was there any privately employed nursing staff. All the practices had private patients.

Nine of the 22 doctors in the study had never heard of the Chronically Sick and Disabled Persons Act, and a further five had not mentioned the Act to their patients. Fifty per cent had no knowledge of the extent of functional disability in their practice. More than half the doctors knew no more of the social services than that home helps and meals-on-wheels were available, while six doctors knew of no provision at all. Knowledge and use of the voluntary services was almost non-existent. No meetings with team members were held, other than in the group practices with attached staff, and the team members were largely unknown to most of the doctors.

Attempts were made through various channels to extend the knowledge of the general practitioners of the services provided by both statutory and voluntary agencies, and to introduce them and their receptionists to their team, but little use was made of the opportunity.

     

GPs'' compliance with health and safety legislation and their occupational health needs in one London health authority.

This survey assessed general practitioners' (GPs') knowledge of and compliance with, health and safety legislation and occupational health guidance in one London health authority. The response rate was 85%. Although the majority of practices were aware of the most important piece of legislation--The Management of Health and Safety at Work Regulations, 1992--less than one in ten practices had carried out the required systematic risk assessments. Compliance with other health and safety legislation and related employment issues was also poor. The health of GPs and their staff may be at risk and these general practices may be vulnerable to prosecution by the Health and Safety Executive.     

Patterns of work in general practice in the Bromley health district

The results of a survey of patterns of work in general practice over five days in one health district were linked to family practitioner committee data on individual general practitioners. Characteristics of doctors and practices were mostly unrelated to various aspects of workload. However, referral rates for pathological tests and to outpatient departments and claims for cervical cytology screening were significantly higher for younger principals than for older doctors, while younger doctors prescribed less frequently. Women general practitioners had significantly lower personal list sizes and claims for night visits and temporary residents than their male colleagues but saw only 10% fewer patients and made significantly more claims for cervical cytology screening. It was also found that UK graduates made more requests for pathological tests than doctors graduating in the Indian sub-continent. A correlation was found between list size and consultation rate, though the list size only explained a relatively small part of the variation in the rates.

The results have been fed back to doctors in the area and it is hoped that this will increase awareness of the patterns of work in general practice.

     

Health surveillance project among single homeless men in Bristol

The establishment of a health surveillance system for the single homeless is described. Health checks were performed in two Salvation Army hostels by a district nurse supported by general practitioners and other workers from one health centre. High levels of morbidity were discovered and the residents were largely treated by the primary health care team. Those residents who were referred to other agencies were shown to have a high attendance rate. An open access clinic was later set up by the district nurse in one of the hostels. This was well received by residents and staff and reduced the call out rate for the general practitioners.

In some parts of the UK, special medical centres for the single homeless have been established on the premiss that it is unrealistic to expect general practitioners to provide an adequate service. However, this study describes an effective service based on primary care which is acceptable to homeless people while being relatively cheap and easy to administer. We recommend the development of a peripatetic service as outlined in this study, offering health care at hostels, day centres and other places where the homeless are to be found.

     

Case against targeting long term non-attenders in general practice for a health check.

A study was undertaken to describe the consequences of implementing that part of the 1990 contract for general practitioners which requires them to offer health checks to all patients aged 16-74 years not seen within the previous three years. A random sample of 679 patients who had not attended for three years and 379 patients who had attended in this period were identified from 30 practice lists (including eight inner city practices) in five family health services authority areas. All patients were sent an invitation to a health check by their own practice and an attempt was made by the research team to conduct a home interview. The results showed that a considerable proportion of non-attenders were not in a position to take advantage of such an invitation; 17% of those at inner city practices were known to have received the invitation, 68% in practices elsewhere. Interviewed non-attenders (76% of those known to have received their invitation) had sociodemographic characteristics similar to the comparison group of interviewed attenders, although women aged 55-74 years were over-represented. At interview, non-attenders reported relatively less use of accident and emergency services and preventive health care and scored significantly better on all six dimensions of the perceived health status measure. Overall, 3% of all identified non-attenders in the inner city practices and 13% elsewhere accepted the invitation to a health check. Low levels of morbidity were found at health checks for those who had and who had not attended their general practitioners in the previous three years.(ABSTRACT TRUNCATED AT 250 WORDS)     

Patients presenting with acute myocardial infarction to a district general hospital: baseline results and effect of audit

The Cardiovascular Health Strategy recommended that patients presenting with acute myocardial infarction receive thrombolysis within ninety minutes of alerting medical or ambulance services. The aim of this prospective study was to describe the management of patients with acute myocardial infarction (AMI) presenting to a district general hospital in Donegal. All patients with a confirmed diagnosis of acute myocardial infarction, excluding those from the Donegal Area Rapid Treatment Study (DARTS) practices, admitted to Letterkenny General Hospital (LGH) from 31.08.99 to 31.08.01 were included in the study. 349 patients were included in the study; average age of 68 ranging from 30 to 96 years and 69% were male. Of the 349 patients, 101 (29%) were located more than 30 miles from LGH at the time of onset of symptoms. The median time taken from the onset of symptoms to calling for help was 119 minutes. The median time from hospital arrival to patients being admitted to CCU was 90 minutes. Thrombolytic therapy was administered in 31% of patients; for these patients the median call to needle time was 200 minutes. Call to needle times differed significantly between rural (median 227.5 minutes n = 64) and urban patients (median 175 minutes n = 37, p < 0.05, Mann-Whitney). Hospital delay times decreased throughout the study period (p > 0.05, Mann-Whitney). The study extends the findings from previous research by investigating the individual time delay components from onset of symptoms to treatment in AMI patients. Delay times exceed the recommended call to needle and door to needle times suggesting the need for interventions to reduce these times.     

Creating a death register for general practice.

General practitioners complete approximately 26% of death certificates themselves but have considerable difficulty obtaining prompt and accurate information about their other patients who die. A random survey of district health authorities in England revealed that all were able to compile death lists but none included general practitioner details. This paper reviews the flow of information on patient deaths and describes a project to assess the feasibility of providing Newcastle general practitioners with comprehensive death registers. With the collaboration of the family health services authority and the district health authority, and with data from the regional perinatal mortality survey the creation each week of complete lists of patient deaths, broken down by general practitioner, is feasible. Death registers allow general practitioners to undertake audit of the quality of death certification and of the care of the recently deceased, and to improve the continuing care of the bereaved.     

How do general practices manage requests from patients for ''same-day'' appointments? A questionnaire survey.

Same-day appointment requests are common and can be problematic for general practices that run appointment systems. In a questionnaire survey sent to 90 general practices in one health authority area (response rate 88%), a variety of management systems existed for dealing with same-day appointment requests. Managing the requests was found to be a significant cause of stress for many general practitioners. Registrars, locums, and practice nurses play only a small part in meeting patient demands and few practices operate telephone triage to help manage these requests.     

Primary and community health services in Newcastle upon Tyne--a joint statement of intent.

In the absence of a single primary health care authority (except in Scotland) district health authorities and family practitioner committees must cooperate in planning health services for the community. Equally, in the field, the potential for teamwork between salaried district health authority nursing staff and the independent general practitioners remains largely unrealized. Yet the government has restated its commitment to the development of primary health care teams as the best means of delivering health care in the community. In Newcastle upon Tyne the local medical committee and the community health services management team have set out their shared aspirations for future development in a joint 'Statement of intent'. This statement, since endorsed by the district health authority and family practitioner committee, includes a number of key principles as a basis for future joint working. These principles emanate from an understanding of the complementary nature of general practice and district health authority community services, and firmly support the primary health care team approach. This statement of intent could serve as a useful model for collaboration and planning of services elsewhere in the country.     

The development of a district community psychology service

A survey was carried out to assess the difficulties encountered by general practitioners within a health district in the management of patients with emotional problems, and their attitudes to the involvement of clinical psychologists in primary health care.

Based on the response to this survey a district community psychology service has been established. This is an adjunct to hospital-based services and attempts to overcome some of the shortcomings of traditional psychotherapeutic services.

     

重庆市九龙坡区2005—2007年医院消毒效果分析

目的了解医院消毒质量变化,分析评价消毒效果。方法每年对医疗机构进行1～2次采样检测,按照卫生部《医院消毒卫生标准》和《消毒与灭菌效果的评价方法与标准》判定样品是否合格,计算合格率,以卫生统计学方法分析消毒质量变化。结果共监测9所医院,检测样品3099份,合格率为82．1％．其中2006年（86．1％）和2007年（85．7％）显著高于2005年（67．3％）。分类样品中,合格率最高为医疗器械,为95．4％;其次是物体表面,为90．3％;医务人员手次之,为78．9％;室内空气最低,为35．2％。2005—2007年,分类样品年份比较,空气合格率2007年最高为53．7％,2005、2006和2007年间相互比较,差异具有统计学意义。医务人员手合格率2006年为81-3％,高于2005年的72．4％。医疗器械合格率2005年为100％,2006—2007年呈下降趋势。结论九龙坡区消毒效果合格率虽呈逐年上升趋势,但总体合格率不高,分类合格率不平衡。消毒措施有待加强,消毒质量有待提高。     

Involvement of the primary health care team in coronary heart disease prevention.

BACKGROUND. Recent years have seen a vast increase in the amount of health promotion activity undertaken in general practice. AIM. This study set out to identify the level of general practitioner and nurse involvement in activities aimed at coronary heart disease prevention and to examine variations in involvement. METHOD. A questionnaire survey was undertaken of a sample of general practitioners across England and the nurses who worked in their practices. RESULTS. Of 1696 randomly selected general practitioners 64% completed a questionnaire, of 928 practice nurses 71% responded and of 682 health visitors and 679 district nurses 52% and 40% responded, respectively. Of the general practitioners 94% reported that they were involved in assessing lifestyle risk factors in the routine consultation and regular assessments most commonly involved blood pressure testing and inquiry about smoking status. Eighty six per cent of practices were reported by the practice nurse as having well person clinics; these clinics were usually run by the practice nurse. Clinics for the management of specific lifestyle risk factors were also usually run by practice nurses, although many doctors were involved in hypertension clinics and cholesterol clinics. Health visitors and district nurses had a low level of involvement in this practice based clinic activity. Involvement of general practitioners and practice nurses in coronary heart disease prevention was associated with training in health promotion and positive attitudes towards prevention and health promotion. The level of involvement of practice nurses in health promotion was associated with the support received from primary health care facilitators, family health services authorities and district health authorities. CONCLUSION. Members of the primary health care team appeared to have their own distinct area of preventive activity. However, this division did not appear to be a result of organized teamwork and deployment of skills and expertise according to a clearly defined management protocol. Instead it seemed to be a product of general practitioner contract and management arrangements which tended to encourage an approach to general practice health promotion which revolved around the practice nurse and which hindered the development of a broader team based approach to planning and delivery of health promotion in relation to the needs of the practice population.     

Drinking patterns in general practice patients

Patients from 47 group practices recruited from the Medical Research Council's general practice research framework participated in a study involving the collection of information about smoking, drinking, exercise and dieting and weight. This paper is concerned with the data on alcohol consumption obtained in the first stage of the study in which a self-administered questionnaire, the health survey questionnaire, was distributed by hand or by post to patients registered with the participating practices.

Of the 25496 men who completed the questionnaire, 83.6% stated that they had been drinking in the previous three months compared with 69.2% of the 36657 women. For both sexes, abstinence rates were significantly lower in the younger age groups (P<O.001). Of the men, 7.6% admitted to a weekly alcohol consumption of 35 units or more and 2.7% women were drinking 21 units per week or more.

Of the 1948 male excessive drinkers 45.9% expressed concern about their drinking through a positive CAGE response and/or self assessment of a drinking problem, while for the 989 female excessive drinkers the figure was 44.1%. A positive response to these questions was strongly related to alcohol consumption and was more frequent among women than men at most levels of consumption.

     

Provision of health promotion clinics in relation to population need: another example of the inverse care law?

The new contract encourages health promotion in general practice. The aim of this study was to explore the pattern of provision of health promotion clinics across one family health services authority and to relate this to possible indicators of health need in the practice population. Single-handed practices were less likely to be running health promotion clinics. The proportion of practices running clinics increased with increasing numbers of partners. Practices located in wards where the standardized mortality ratio was greater than 100, and practices receiving deprivation payments were less likely to be offering health promotion clinics. This was explained by the presence of most single-handed practitioners in deprived, historically unhealthy wards. If effective, health promotion clinics will have tended to benefit populations in Bedfordshire at lower risk of ill-health. Other shortcomings of the clinic-based health promotion model are discussed.     

Applying community-oriented primary care methods in British general practice: a case study.

BACKGROUND: The '75 and over' assessments built into the 1990 contract for general practice have failed to enthuse primary care teams or make a significant impact on the health of older people. Alternative methods for improving the health of older people living at home are being sought. AIM: To test the feasibility of applying community-oriented primary care methodology to a relatively deprived sub-population of older people in a relatively deprived area. DESIGN OF STUDY: A combination of developmental and triangulation approaches to data analysis. SETTING: Four general practices in an inner London borough. METHOD: A community-oriented primary care approach was used to initiate innovative care for older people, supported financially by the health authority and practically by primary care academics. RESULTS: All four practices identified problems needing attention in the older population, developed different projects focused on particular needs among older people, and tested them in practice. Patient and public involvement were central to the design and implementation processes in only one practice. Innovations were sustained in only one practice, but some were adopted by a primary care group and others extended to a wider group of practices by the health authority. CONCLUSION: A modified community-oriented primary care approach can be used in British general practice, and changes can be promoted that are perceived as valuable by planning bodies. However, this methodology may have more impact at primary care trust level than at practice level.     

Audit of the management of pelvic inflammatory disease in general practice

There has been a change in the causative organisms of pelvic inflammatory disease over recent years - Chlamydia trachomatis is now the commonest infecting organism. Pelvic inflammatory disease is often managed in general practice and it is important that each episode is treated adequately in order to prevent recurrent infection, with its short term morbidity and long term risk of infertility and ectopic pregnancy.

In an attempt to document the current management of pelvic inflammatory disease in general practice, a questionnaire was sent to all 143 general practitioners in the Torbay area health authority. The response rate was 78.3%. Investigation methods and treatment regimens varied, with almost half (46.4%) of the respondents taking endocervical specimens but only 25.0% providing antibiotic therapy against C. trachomatis. Only 39.3% of the doctors considered investigation or referral of the male partner.

It is concluded that general practitioners are willing to participate in clinical audits of this kind and that the management of pelvic inflammatory disease in general practice is often incomplete.

     

Minimum data set necessary to promote the care of the elderly in general practice

A preliminary data set was designed to allow uniform information collection, to initiate structured intervention and thereby to promote anticipatory care of the elderly. A questionnaire inviting comment on the data set was sent to 116 general practitioners in training practices and 40 consultants in geriatric medicine in the northern region and also to the 18 professors in general practice in the United Kingdom. The response rates from the three groups were 76%, 55% and 67% respectively.

There was good agreement between the three groups regarding the content of the data set suggesting that it may be possible to introduce uniform information collection which in turn would standardize records of the elderly and aid computerization.

The need for periodic screening of the elderly was considered necessary by 37% of general practitioners, 59% of consultants and 33% of professors. The cause of such low interest in screening and its effect on computerized care and surveillance of the elderly are discussed.