Patient participation groups in general practice in the National Health Service

General practice remains the organizational hub of first level health services in the United Kingdom. Patient participation groups are probably the most well known model for public participation in this setting and, although still not widespread, they have been a slowly expanding area of development for almost three decades. This paper sets out to critically asses patient participation groups in general practice by considering the context of their development and reviewing the research literature about groups. Critical issues needing more study and key methodological challenges are then discussed.
Patient participation groups have been a somewhat shifting and contested phenomenon, embracing trends and changing as policy priorities have changed over the years. There is some evidence to think that they might have potential as a local element within a public participation strategy in the National Health Service. However, the field studies are very limited and more research of a better quality is needed. The state of knowledge is not adequate to be able to say with any confidence if or how such groups should be developed. A better understanding is needed of the public's perspectives on this and other models of participation. There are many other questions to do with patient participation groups' purpose, equitable access, and effectiveness that need to be addressed. The methodological challenges include issues of how to involve all stakeholders in the research process; and how to study less tangible aspects of general practice organization, such as culture and power, that effect the public's participation.     

Patient satisfaction with availability of general practice: an international comparison.

OBJECTIVE: To identify associations between the characteristics of general practitioners and practices, and patients' evaluations of the availability of general practice. DESIGN: Written surveys completed by patients. SETTING: General practice care in nine European countries: Denmark, Germany, The Netherlands, Norway, UK, Belgium (Flanders and Wallonia), Switzerland, Slovenia and Spain. STUDY PARTICIPANTS: 15996 adult patients consecutively visiting the general practitioner (response rates per country varied between 47 and 89%). MAIN MEASURES: The Europep instrument to assess patients' evaluations of five aspects of the availability of general practice care: (1) getting an appointment, (2) getting through on the phone, (3) being able to speak to the practitioner on the telephone, (4) waiting time in the waiting room, and (5) providing quick services for urgent health problems. Each general practitioner recorded age, sex, number of years in the practice, number of practitioners and other care providers in the practice, and urbanization level of the practice. RESULTS: Patients' more positive evaluations were associated with fewer general practitioners in the practice, except for quick services for urgent health problems (range of conditional overall odds ratios, 1.69-2.02). In addition, a number of significant unconditional overall odds ratios were found, particularly those related to the number of general practitioners' working hours and the number of care providers in the practice. None of the associations was found consistently in all countries. CONCLUSION: Patients favour small practices and full-time general practitioners, which contradicts developments in general practice in many countries. Policy makers should consider how the tensions between patients' views and organizational developments can be solved.     

Patient empowerment in the United States: a critical commentary

Whilst there is no consensus amongst analysts regarding how best to define 'patient empowerment', at the very least, this concept entails a re-distribution of power between patients and physicians. Empowered patients attempt to take charge of their own health and their interactions with health care professionals. Empowerment can occur at different levels (micro, meso, and macro) and patients have different ideas about what it means to 'take charge' and 'be empowered'. Some patients simply want to be given information about their conditions whilst others want to have full control over all medical decision-making. Some empirical evidence suggests that active patient participation in health care is associated with better patient outcomes. This field is ripe for future studies which both help to develop theoretical models of patient empowerment and articulate the conditions under which patient empowerment occurs.     

Patient evaluations of accessibility and co‐ordination in general practice in Europe

Objective  To determine whether patient evaluations of the accessibility to general practice and co‐ordination with other care providers were associated with characteristics of general practice organizations. Background  In 1998 patients across Europe perceived that small general practices have better accessibility than large practices. Since then a number of changes in primary care have had impact on accessibility and co‐ordination of care. Design, setting and participants  The study was based on data from the European Practice Assessment study, an observational study in 284 general practices in 10 countries in 2004. Main outcome measures  Patient evaluations of general practice were measured with the 23‐item Europep instrument, from which seven items on accessibility and co‐ordination were selected in a principal factor analysis. Six practice characteristics were examined: percentage of female general practitioners, mean age of physicians, mean number of physician hours worked per week, number of general practitioners, number of care providers, urbanization level. Mixed regression models were applied, in which patients were clustered within practices, and practices within countries. Results  Practices with a higher numbers of care providers received less positive patient evaluations (b = −0.112, P = 0.004). The other practice characteristics were not related to patient evaluations. Only a small proportion of the total variation in patient evaluations of accessibility and co‐ordination (1.8%) was explained by characteristics of the general practice organizations. Conclusions  General practices have become larger in most developed countries in recent years, but patients seemed to prefer general practice organizations with fewer health professionals.     

Communication in general practice: differences between European countries

BACKGROUND: Based on differences in national health care system characteristics such as the gatekeeping role of GPs (at the macrolevel) and on diverging GP and patient characteristics (at the microlevel), communication may differ between countries. Knowledge of the influence of these characteristics on doctor-patient communication will be important for setting European health care policies. OBJECTIVES: Our objectives were (i) to compare doctor-patient communication in general practice between European countries; and (ii) to investigate the influence of the gatekeeping system and GP and patient characteristics on doctor-patient communication in general practice. METHODS: Fifteen patients per GP (in total 2825 patients) of 190 GPs in six European countries were included. Participating countries were The Netherlands, Spain, the UK (gatekeeping countries), Belgium, Germany and Switzerland (non-gatekeeping countries). Data were collected by means of patient and GP questionnaires and observation of videotaped consultations, and analysed by one-way and multilevel, multivariate analysis. RESULTS: Differences in communication between countries were found in: affective and instrumental behaviour; biomedical and psychosocial talk; GPs' patient-directed gaze; and consultation length. The study showed that GPs' gatekeeping role (with registered patients) was less important for doctor-patient communication than was expected. Patient characteristics such as gender, age, having psychosocial problems, and familiarity between the doctor and the patient were the most important in explaining differences in communication. CONCLUSION: The gatekeeping role of GPs is hardly important in explaining doctor-patient communication. The relationship is more complex than expected. Patient and GP characteristics are more important. Cultural factors should be included in future studies.     

Health professionals' views of the effectiveness of nutrition care in general practice setting

Aim: The current qualitative study aimed to explore the perceptions of key health professionals relating to the effectiveness of nutrition care provided in the general practice setting. Methods: Twenty‐eight health professionals across a range of disciplines (general practitioners (n = 11), practice nurses (n = 3), dieticians (n = 5), naturopaths (n = 5) and exercise physiologists (n = 4)) individually participated in a semistructured telephone interview, guided by an inquiry logic informed by the literature. Interviews were transcribed verbatim and analysed thematically using a constant comparison approach. Results: Health professionals, including general practitioners, perceived that nutrition care provided in the general practice setting was mostly ineffective at improving patient nutrition behaviour. This was reported to be due to nutrition care competency deficits among general practitioners, a general practice reimbursement system that encourages practices inconsistent with quality nutrition care, and a low prioritisation of nutrition care in general practice. Tensions were apparent between health professional groups, which may be hindering the successful implementation of interdisciplinary nutrition care for patients with chronic disease in this setting. Conclusion: Without systematic changes to Australian primary health care model, the demand on general practitioners as primary providers of nutrition care will continue, therefore mandating support for general practitioners providing care in this context. Further research is required to identify strategies to improve nutrition care and opportunities to facilitate integrated health care provided to the general public within the general practice setting.     

Electronic records suggest suboptimal management of chronic kidney disease in general practice

Objective: To examine electronic records of GP management of chronic kidney disease. Design: Cross‐sectional study. Setting: Thirteen general practices. Participants: Fifteen thousand four hundred and fiftteen active patients aged 50 years and over. Main outcome measure: Recorded estimated glomerular filtration rate (eGFR) and diabetes, and rate of prescribing of angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers (ACE/ARBs). Results: Six thousand and fifty‐nine (39%) patients had hypertension and 1859 (12%), diabetes. Two thousand six hundred and eighty‐nine (17%) patients were recorded with eGFR < 60 mL min^–1 (1.73 m²)^–1, while 3344 (22%) did not have an eGFR result recorded. Hypertension, diabetes and eGFR <60 mL min^–1 (1.73 m²)^–1 were shown to be significantly related to prescribing of ACE/ARBs; however, 31% of known diabetics and 23% of diabetics with an eGFR < 60 mL min^–1 (1.73 m²)^–1 are not recorded as receiving ACE or ARB therapy. Forty‐two per cent of patients with eGFR < 60 mL min^–1 (1.73 m²)^–1, are also not recorded as receiving ACE or ARB therapy. There was a 23% variation in the rates of prescribing of ACE/ARBs by practice for patients with diabetes and eGFR < 60 mL min^–1 (1.73 m²)^–1. Conclusion: The overall recording of eGFR and the recorded prescribing of ACE or ARB therapy in known diabetics and patients with eGFR < 60 mL min^–1 (1.73 m²)^–1appear suboptimal. Also, the variations in prescribing between practices require further investigation.     

Acute maxillary sinusitis in general practice: The relation between clinical picture and objective findings

Objective: The value of symptoms and clinical findings for the diagnosis of acute maxillary sinusitis in general practice is unclear. We investigated the relation between clinical picture and objective findings.

Methods: For 113 adult patients suspected by their general practitioner (GP) of having maxillary sinusitis, history and clinical examination data were related to roentgenograms, echograms and punctate results.

Results: History and examination data of the GPs showed a similar pattern for patients with and without positive punctate results. Even 22 patients with fluid and pathogenic bacteria in the sinus could not clearly be distinguished clinically. The probability of fluid in the sinus ranges from very low for X-ray results without demonstrable abnormalities, to about 60% in case of X-rays showing fluid levels.

Conclusion: Our findings demonstrate that the group of patients suspected of having maxillary sinusitis cannot be further subdivided on the basis of history and examination. Since acute rhinitis and acute sinusitis appear to be manifestations of the same clinical entity, for these patients the diagnosis acute rhinosinusitis is preferable. The patients can be roughly classified on the basis of the X-ray as to the presence of fluid and pathogenic bacteria in the sinus. The question is now whether such diagnostic classification is relevant with a view to treatment.     

广州市全科医学教育社区卫生服务实践基地卫技人员调查分析

目的:了解广州市全科医学教育社区卫生服务实践基地卫技人员队伍现状,为促进全科医学教育师资队伍建设提供依据.方法:采用问卷调查的方式对广州市全科医学教育社区卫生服务实践基地的在岗卫技人员进行普查.结果:广州市19家全科医学教育社区卫生服务实践基地共有卫技人员1849名,平均每家拥有卫技人员97人,公卫医师占6.00%;卫技人员中25～54岁占80.53%;大专以下学历人员占66.47%;高级职称、中级职称、初级、无职称人员分别占5.25%,17.85%,67.65%,9.25%;医(仅全科医师)护比为1∶0.95.结论:广州市全科医学教育社区卫生服务实践基地卫技人员队伍中,护士和公卫医师数量不足,学历、职称偏低,人力资源结构有待改善.     

Patient safety in primary care: incident reporting and significant event reviews in British general practice

Over the past 20 years, healthcare has adapted to the ‘quality revolution’ by moving away from direct provision and hierarchical control mechanisms. In their place, new structures based on contractual relationships are being developed coupled with attempts to create an organisational culture that shares learning and that scrutinises existing practice so that it can be improved. The issue here is that contractual arrangements require surveillance, monitoring, regulation and governance systems that can be perceived as antipathetic to the examination of practice and subsequent learning. Historically, reporting levels from general practice have remained low; little information is shared and consequently lessons are not shared across the general practice community. Given large‐scale under‐engagement of general practitioners (GPs) in incident reporting systems, significant event analysis is advocated to encourage sharing of information about incidents to inform the patient safety agenda at a local and national level. Previous research has concentrated on the secondary care environment and little is known about the situation in primary care, where the majority of patient contacts with healthcare occur. To explore attitudes to incident reporting, the study adopted a qualitative approach to GPs working in a mixture of urban and rural practices reporting to a Welsh Local Health Board. The study found that GPs used significant event analysis methodology to report incidents within their practice, but acknowledged under‐reporting. They were less enthusiastic about reporting externally. A number of barriers exist to reporting, including insufficient time to report, lack of feedback, fear of blame, and damage to reputations and patient confidence in a competitive environment. If incident reporting processes are perceived as supportive and formative, and where protected time is allocated to discuss incidents, then GPs are willing to participate. They also need to know how the information is used, and whether lessons are being learnt from errors.     

Does the health status of chronically ill patients predict their judgements of the quality of general practice care?

Patients' health status as well as patients' judgements of care are used for assessing patients' perspectives, but the relation between those two concepts is unclear. In this study we explored whether health status predicts patients' judgements of the quality of general practice care. Hand-distributed and mailed surveys were performed by 28 general practitioners in The Netherlands. Chronically ill patients were approached when visiting the general practice or drawn from the practice registers. Health status was measured by WONCA/COOP charts, and patients' judgements by the CEP, a previously validated questionnaire. The response rate was 63% (n=762). When controlled for other patient characteristics, a poor overall health predicted less positive judgements of medical care, information, counselling, relation and communication, continuity of care and the organization of appointments (p[lessthan]0.01). Poor mental well-being predicted less positive judgements of the cooperation between care providers and a stronger need for more care (p[lessthan]0.001). The four other aspects of health status did not predict the patients' judgements. Judgements about the premises and the availability for emergencies were not predicted by health status. It can be concluded that a multidimensional approach should be used for interpreting the relations between patients' health status and their judgements of general practice care.     

Development and validation of the short version of the diabetes obstacles questionnaire (DOQ-30) in six European countries

Background: Patients with type 2 diabetes reveal different obstacles in living with the disease. The EGPRN initiated a qualitative research EUROBSTACLE to create a broadly conceptualized diabetes-related quality of life (DR-QoL) instrument. It led to the development of the diabetes obstacle questionnaire (DOQ), a five-point Likert-scaled measure, consisting of 78 items in eight scales.

Objectives: To develop and validate a short, easy-to-use version of the DOQ.

Methods: A cross-sectional study with the DOQ was carried out. Participants answered the DOQ and GPs added some clinical data from their medical records. Data of 853 patients from Belgium, France, Estonia, Serbia, Slovenia, and Turkey were included in the analysis. The selection of items for the short version of the DOQ was achieved with exploratory factor analysis (EFA). Construct validity was proved with EFA and Pearson correlations between the DOQ and the new DOQ-30. Internal reliability was established with Cronbach’s alpha.

Results: DOQ-30 resulted in 30 items in nine subscales. It explained 49.8% of items’ variance. It shows a considerable good internal reliability and construct validity.

Conclusion: The DOQ-30 is a five-point Likert-scaled broadly conceptualized measure of DR-QoL. It addresses a variety of obstacles, such as social, psychological, cognitive and behavioural. The DOQ-30 is ready for implementation in general practice and research in Europe as a valuable instrument to assess DR-QoL.     

Variation in the use of point-of-care ultrasound in general practice in various European countries. Results of a survey among experts

Background: Before implementing point-of-care ultrasound in general practice in Denmark, we sought inspiration from other countries/regions.

Objectives: To collect information about the use and organizational aspects of point-of-care ultrasound in general practice in different European countries/regions.

Methods: Fifteen key persons with knowledge about the use of ultrasound in general practice in Austria, Catalonia, Denmark, Finland, Germany, Greenland, Iceland, the Netherlands, Norway, Scotland, Sweden, and Switzerland were included. Participants received a link to a web-based questionnaire. The primary outcome measures were educational aspects regarding the use of point-of-care ultrasound; clinical application and use; financial aspects; and main barriers to using ultrasound in general practice.

Results: In eight out of 12 countries/regions there were national societies for the use of ultrasound in general practice. The respondents from three countries/regions reported that the use of ultrasound was integrated into undergraduate medical education. In nine of the countries/regions, there was formalized training for general practitioners, but only three reported this to be part of the specialization to become a general practitioner. In seven out of 12 countries/regions, general practitioners received payment for ultrasound scans. However, the payment and the requirements for reimbursement differed between countries. Lack of time, lack of training, and financial aspects were important common barriers across countries/regions.

Conclusion: There were significant differences regarding the use and organizational aspects of point-of-care ultrasound in general practice in Europe. Lack of time and training as well as financial aspects were important barriers to the use of point-of-care ultrasound in general practice.

KEY MESSAGES

• Point-of-care ultrasound is used differently in different countries/regions.

• Significant differences exist between countries/regions regarding the organization of national societies for the use of point-of-care ultrasound in general practice.

• Respondents cited financial aspects, time use and lack of skills as the greatest barriers to general practitioners’ use of point-of-care ultrasound.

     

广东省全科医学教育社区实践基地卫生人力资源现状研究

目的:了解广东省全科医学教育社区实践基地卫生人力资源现状,为促进实践基地建设提供参考依据.方法:拟定统一的调查表,由各实践基地统一填报,并分为经济发达及欠发达地区进行统计分析.结果:广东省全科医学教育社区实践基地共87所,职工7233人,其中卫技人员占84%,硕士研究生占1.1 %,本科占26.5%;师级及以上占56.3%;临床医学和护理专业占58.6%,预防医学专业占3.1%;全科医学培训率28.2%.经济发达地区高学历高职称所占比例、接受全科医学培训率均高于欠发达地区.结论:广东省全科医学教育社区实践培训网络逐步形成,但部分实践基地规模小,学历偏低、职称不高,专业结构尚需改善.     

Ending the doctor-patient relationship in general practice: a proposed model

BACKGROUND: The doctor-patient relationship in general practice is often viewed by practitioner and patient alike as a long-term 'personal' relationship. Little, however, is known about how such relationships are ended in general practice. METHODS: This paper uses theoretical insights obtained from the sociology and social psychology of social relationships, together with the authors' own empirical work on the removal of patients from GPs' lists, to develop a theoretical model of ending the doctor-patient relationship in general practice. RESULTS: Ending the relationship involves 'breakdown' and 'termination'. 'Breakdown' in the relationship occurs when one party decides that the other has acted in such a way as to threaten that party's identity as a 'good' patient or doctor. 'Termination' may be patient initiated, doctor initiated or by mutual consent. CONCLUSIONS: It is proposed that further research is needed to delineate the rules and rituals governing entry into and maintenance of the doctor-patient relationship in general practice as well as those that govern its ending.     

A standardised instrument for patient evaluations of general practice care in Europe

Objective: International comparisons of health care systems may provide important insights, but they require internationally standardised and validated instruments. This paper describes the validity and reliability of the EUROPEP instrument for patient evaluation of general practice care. Methods: Surveys were performed in 16 countries among patients who visited the general practice (n=23892), using the 23-item EUROPEP questionnaire. Data were analysed with respect to content validity, reliability, criterion validity, construct validity and sensitivity of the instrument. Results: The item response among responders was good or acceptable for most items. Two internally consistent dimensions were identified, 'clinical behaviour' (17 items) and 'organisation of care' (6 items). The answers to the 23 questions predicted the overall attitudes regarding the general practitioner. Higher age, more visits to the GP and better health status predicted more positive evaluations of care, as was expected beforehand. Differences between countries were significant but moderate for most of the questions. In specific countries problems with respect to validity and reliability were found. Conclusions: An internationally standardised and validated instrument for patients' evaluations of general practice care is now available for international comparisons. Future research should improve its validity to solve the problems that were found in some countries. Eur J Gen Pract 2000;6:82–7.     

Patient factors in the implementation of decision aids in general practice: a qualitative study

Background  Decision aids (DAs) have been developed to help patients make treatment decisions. Research shows that they are effective in increasing patients' knowledge of treatment options without raising anxiety or conflict. However, they have not been routinely adopted for use in general practice in the UK and there are few reports addressing strategies to introduce them.
Objective  To examine patients' views about a variety of DAs for different conditions (heart disease, osteoporosis, osteoarthritis and breast cancer) in order to inform a strategy to introduce them into general practice.
Setting and participants  General practice patients over the age of 18 years being or having been treated for one of the conditions above.
Methods  Qualitative study involving 12 focus groups with 77 patients evaluating decision aids relevant to their conditions. A semi-structured interview guide was used to generate discussions about the applicability of the DAs in routine general practice.
Results  Patients welcomed DAs for their educational and informational content. Reactions to the DAs were influenced by patients' own personal desires for involvement. The main concerns were that the use of DAs would potentially shift the onus of decision making responsibility on to the patient and about the practical challenges to implementation.
Conclusions  Clinicians will need to make explicit to patients that DAs are an adjunct to routine care and not a replacement, and therefore do not represent a derogation of responsibility. DAs need to be used as an integral part of the communication and support process for patients who want them.