Evaluating general practice fundholding in the United Kingdom

GP fundholding was the most radical element in the package ofreforms introduced into the British National Health Servicein April 1991. Despite initial hostility from the British MedicalAssociation, this scheme has become increasingly popular withGPs, such that it now covers one-third of the UK population.GP fundholding has generated considerable interest internationallyand the British Government has hailed It as a great success.When the organizational changes were first implemented formalevaluation was not encouraged by the government. Nevertheless,some hearth services researchers have carried out evaluativestudies on the impact of GP fundholding. This paper discussesthe problems faced by those attempting to evaluate hearth carereforms, using the studies on fundholding to illustrate thedifficulties. A summary of the main findings from these studiesreveals extensive gaps in current knowledge about the impactof the scheme. Claims that the introduction of GP fundholdinghas resulted in improvements in efficiency, responsiveness andquality of care are in general not supported by the evidence.     

Attitudes to the training of general medical practitioners in Nigeria

Nigeria has pioneered a vocational training programme for general medical practitioners. The first major evaluation and review of the curriculum took place in July 1988 when over 50 trainees, supervisors and faculty board members attended a conference at Ibadan University. The opportunity was taken to assess by questionnaire the views of the participants on a range of issues related to health care in Nigeria and of the training and supervision of general medical practitioners. Sixty-six per cent of potential respondents provided completed questionnaires. A large proportion of respondents felt the need for some revisions in the curriculum and for a greater emphasis on small group training. The results indicated scepticism about the role of high technology medicine and private medical practice in meeting the health needs of Nigerians. There were some differences between the trainees and their supervisors and faculty board members in the responses obtained. The programme in Nigeria and the attitudes of those taking part demonstrate a vigorous and visionary approach to health care. It is hoped that this experience will be a useful and important example of what can be achieved in a country with potential for development.     

Promoting clinically effective practice: general practitioners' awareness of sources of research evidence

BACKGROUND: Practitioners are being encouraged to base their clinical practice on research evidence. In order to do this, they must be aware of and use the sources of evidence. METHODS: A questionnaire survey was undertaken to establish GPs' awareness of research evidence in their clinical practice and, in fundholding practices, its influence on purchasing plans. Questionnaires were sent to 360 lead fundholders in North Thames Region and 440 of a random sample of the remaining general practitioners in the region for comparison. RESULTS: Questionnaires were returned by 62% of lead fundholders and 63% of GPs in the random sample. There was limited use of the electronic sources of clinical effectiveness. There was greater reported awareness of published sources of research evidence and fundholding GPs were significantly more likely to have referred to publications summarizing research evidence. CONCLUSIONS: GPs seem to make more use of published clinical effectiveness sources than the electronic databases. Consequently, they need educational and technical support if they are to make full use of the available sources of research evidence available in other media.      

Attitudes towards the content of general practice teaching

In a study of attitudes towards the content of general practice teaching, it was found that there was good agreement between fifth year medical students and their general practitioner tutors. The social aspects of illness were considered the most important by students and both groups emphasized the value of seeing patients in their homes with time for discussion of cases. These findings are discussed in the context of the development of teaching in general practice at Glasgow University.     

The patient's view of general practice fundholding: results of a cross-sectional survey

We report the results of a survey of patients' awareness, attitudes and satisfaction regarding fundholding and related developments in primary care, and compare the responses of patients in fundholding and non-fundholding practices. (Six total fundholding general practices and two non-fundholding general practices in West Berkshire were included.) An anonymous postal questionnaire was sent to 1150 patients with joint pain aged 17-80, of whom 715 (63%) returned completed questionnaires. Few (17%) fundholding respondents had received information from their practice about fundholding or (36%) were aware of new or different services being offered but the majority had heard of fundholding and were able to describe it accurately. Satisfaction with GP services was high in both types of practice, but fundholding patients reported higher levels of satisfaction with getting a referral to a hospital specialist (FH: 81% vs. NFH: 63%), and with the length of time between referral and treatment (FH: 81% vs. NFH: 59%). A majority of patients in both types of practice wanted to be involved in decisions about the services available to them but only a third of patients thought that fundholding would make this easier. Fundholding patients were more likely to report being given enough choice about treatments available to them (51%) than their non-fundholding counterparts (35%). Fundholding patients had not perceived a reduction in quality of care as a result of budgetary pressures and were more satisfied with the process of referral to secondary care than their counterparts in non-fundholding practices. Patients in both types of practice felt that it was important to be involved in decisions about the services available to them, but few thought that this would be more likely as a result of fundholding. Provision of information to patients is a prerequisite for their involvement, but judging by the number of patients receiving any information about fundholding from their practices this aspect of the reforms does not seem to have been implemented.     

Prevention and health promotion in clinical practice: the views of general practitioners in Europe

BACKGROUND: Disease prevention and health promotion are important tasks in the daily practice of all general practitioners (GPs). The objective of this study was to explore the knowledge and attitudes of European GPs in implementing evidence-based health promotion and disease prevention recommendations in primary care, to describe GPs' perceived barriers to implementing these recommendations and to assess how GPs' own health behaviors affect their work with their patients. METHODS: A postal multinational survey was carried out from June to December 2000 in a random sample of GPs listed from national colleges of each country. RESULTS: Eleven European countries participated in the study, giving a total of 2082 GPs. Although GPs believe they should advise preventive and health promotion activities, in practice, they are less likely to do so. About 56.02% of the GPs answered that carrying-out prevention and health promotion activities are difficult. The two most important barriers reported were heavy workload/lack of time and no reimbursement. Associations between personal health behaviour and attitudes to health promotion or activities in prevention were found. GPs who smoked felt less effective in helping patients to reduce tobacco consumption than non-smoking GPs (39.34% versus 48.18%, P < 0.01). GPs who exercised felt that they were more effective in helping patients to practice regular physical exercise than sedentary GPs (59.14% versus 49.70%, P < 0.01). CONCLUSIONS: Significant gaps between GP's knowledge and practices persist in the use of evidence-based recommendations for health promotion and disease prevention in primary care.     

Catching waves: the historical geography of the general practice fundholding initiative in England and Wales

General practitioner fundholding is often represented as one of the more successful elements of the 1989/90 Conservative reforms of the UK National Health Service (NHS). Successive annual 'waves' of fundholding practices were approved from 1990 through to 1997 and, over time, the initiative came to involve some 50% of UK general practitioners. Fundholding is known to have had a strong regional geography that changed with evolving fundholding eligibility criteria. Further, there have been persistent allegations that fundholding tended to occur disproportionately in areas of higher social status. Past studies of fundholding have tended to consider single waves or the overall impact of the initiative rather than its development over time. They have also tended to work at a single geographic scale or through single-region case studies when exploring the statistical regularities underlying the uptake of fundholding. Using multilevel analysis, this paper seeks to enhance understanding of fundholding through an examination of the interaction of district health authority and practice characteristics across all implemented waves for all general medical practices in England and Wales. We conclude that wave mattered on a national scale, that deprivation was relatively unimportant and that there were certain types of area that exhibited persistent but unexpected high uptake.     

Types of work stress and implications for the role of general practitioners.

This study investigated a wide range of job-related characteristics which had the potential of acting as stressors for General Practitioners (GPs). Three hundred and four GPs completed a detailed questionnaire which sought audit information including practice workload factors, coping approaches and attitudinal information including sources of stress and the value of management training. Ten independent factors were identified as underpinning GP stress and using multi-variate analysis, it was shown that each of these factors is predicted by a separate and distinct set of variables. This finding suggests that it is inappropriate to simply talk about GP stress since it is a multi-dimensional concept. This finding has important implications for identifying potentially successful mechanisms of coping and support.     

Pneumococcal vaccination by general practitioners: an evaluation of current practice.

During the first two years following registration of the 23-valent pneumococcal vaccine in Belgium, the numbers of doses administered were 166 and 211 per 10,000 inhabitants, representing a vaccination coverage of nearly 20% of the recommended target population as defined by the High Council for Public Health. The time course of vaccine use showed a seasonal variation with up to 74 and 85% of the doses administered from September through November in 1996 and 1997, respectively. Vaccination practices by general practitioners and the profile of the patients who received the pneumococcal vaccine were studied during the September through December period each year. Among the 18,236 patients included, 82% were above 60 years of age (mean age 69.5 years). The main indications for vaccination were chronic bronchopulmonary disease (41%) and cardiovascular disorders (26%). Age as the sole criterion was mentioned for only 17% of vaccine recipients. Sixty percent of the patients received influenza vaccine concomitantly. The intensity of the mass media campaign correlated with the public awareness of the national recommendations. These observations provide insight into current practices for pneumococcal vaccination in Belgium and suggest opportunities for future vaccination campaigns.     

全科服务团队模式的实践与探讨

组建以全科医师为骨干的全科服务团队，是上海近3年来深化社区卫生服务内涵建设的重要步骤。用竞争的方式组建全科服务团队，开展以基本医疗为主的六位一体综合服务，实行中心、站点、居民家庭的三站式服务，以全科团队为独立核算单位，采取中心购买服务的形式。调动了医护人员的积极性，更好地发挥社区卫生综合服务的效能。     

Perceptions of psychological problems in general practice: a comparison of general practitioners and psychiatrists.

All general practitioners and psychiatrists working in a single health district were sent a questionnaire on their perceptions of the prevalence of psychological problems among patients consulting in general practice. One hundred and twenty-one GPs (75%) and 10 (83%) psychiatrists responded. GPs and psychiatrists agreed that up to 20% of consulting patients were likely to be clinically depressed; they also agreed on the most appropriate management, although GPs tended to be more conservative than psychiatrists would advise on making use of hospital services. GPs, however, believed non-specific psychological problems to be significantly less common than did psychiatrists. This expectation may help explain the reported failure of GPs to diagnose all psychological problems identified by formal psychiatric instruments.