The biopsychosocial model of general practice: rhetoric or reality?

BACKGROUND: For more than 20 years, general practitioners have been encouraged to adopt a 'biopsychosocial' model of health care, that is, encompassing physical, psychological and social aspects. AIM: A study was undertaken to explore the extent to which general practitioners' views about the acceptable boundaries of their work are consistent with a biopsychosocial model. METHOD: A semi-structured postal questionnaire was sent to all 494 members of the Royal College of General Practitioners in Mersey Region who were general practitioner principals. The general practitioners were asked to list up to three topics presented by patients that they considered to be appropriate, and up to three topics that they considered to be inappropriate, to a general practitioner's knowledge and skills. The general practitioners were asked to rate, on a five-point scale of appropriateness, each of a list of 12 topics about which patients might have problems and present. Responses were analysed by sex and age of respondents. RESULTS: The response rate was 42%. Acute physical problems were most often listed appropriate by respondents, followed by chronic physical and psychological problems. The topics most often considered inappropriate were bureaucracy and social issues. Among the list of 12 specified topics, respondents considered terminal care and hypertension to be more appropriate than housing issues, spiritual worries, welfare rights or political issues. The sex of respondents did not relate to differences in results. Respondents aged 35 years and over generally considered topics presented by their patients to be more appropriate than did their younger colleagues. CONCLUSION: The general practitioner respondents in this study appeared to hold the view that general practitioners should work to a bio(psycho) rather than a biopsychosocial model of health care.     

Use of general practitioner beds in Leicestershire community hospitals.

BACKGROUND. The shift in care from secondary to primary services is likely to place greater demands on community hospitals. Before changes in the provision of community hospitals can occur, baseline data are needed, outlining their current use. AIM. A study was undertaken to obtain baseline data describing the use of general practitioner beds in Leicestershire community hospitals. METHOD. A three-month prospective, observational study was carried out between February and May 1992 using data from a questionnaire completed by nurses and general practitioners and from patient hospital records. Study patients comprised all patients admitted to general practitioner beds in all eight Leicestershire community hospitals. RESULTS. A 100% questionnaire response rate was obtained giving data on 685 hospital admissions. Around 70% of admissions were of patients aged 75 years and over. Of admissions, 35% were for acute care, 31% for respite care, 22% for rehabilitation, 7% for terminal/palliative care and 5% for other reasons. Fifteen per cent of patients had been transferred from a consultant bed. Of those not transferred, 91% were admitted by their usual general practitioner or practice partner and for 96% of these patients this was the general practitioner's first choice for care. There was significant variation in both the age mix and care category mix of patients between individual hospitals. Medical deterioration in an underlying condition and family pressure on the general practitioner or carers' inability to cope each contributed to around half of all admissions. Of all admissions, 38% lived alone, and 18% of carers were disabled. Incontinence was reported for 35% of patients, and 26% of all patients were of a high nursing dependency. There was low utilization of community services before admission and 33% received none. There was variation between individual hospitals in use of local and district general hospital investigations, specialist referral and types of therapy. Of 685 admissions 11% died during their stay. Of those discharged, 76% went to their own or a relative's home, 10% to a residential or nursing home and 9% were transferred to an acute bed. Nine percent of discharges were postponed and 10% were brought forward. On discharge to non-residential care, 26% of patients received no community services. CONCLUSION. Shifting resources from secondary to primary care is a priority for purchasers. Both the introduction of the National Health Service and community care act 1990, and acute units having increasing incentives for earlier discharge, are likely to place greater demands on community hospital beds. Not all general practitioners have the option of community hospital beds. Before access to general practitioner beds can be broadened, existing beds should be used appropriately and shown to be cost-effective. Purchasers therefore require criteria for the appropriateness of admissions to general practitioner beds, and the results of a general practitioner bed cost-benefit analysis.     

Views of pregnant women on the involvement of general practitioners in maternity care.

BACKGROUND: The reorganization of maternity services in England following the report Changing childbirth is likely to impinge upon general practitioners' contribution to maternity care. Professionals and managers are increasingly expected to take account of patients' views when reorganizing services. AIM: This study aimed to elicit women's views about the involvement of general practitioners in maternity care and to establish the extent of continuity provided by general practitioners. METHOD: A prospective cohort postal questionnaire survey was undertaken in the Bath health district to elicit the views of pregnant women about the general practitioner's role in maternity care, the continuity provided, patient satisfaction and the general practitioner-patient relationship. Responses were rated on five-point Likert scales. Women completed questionnaires at 24 and eight weeks before the birth and at two and eight weeks after the birth. RESULTS: Of 164 women entering the study (28 of whom were booked for home delivery and 136 for hospital delivery), 116 (71%) completed all four survey questionnaires. Of respondents 68% agreed that general practitioners play an important role in routine antenatal care and 53% that they have an important role in normal labour. These opinions appeared to be stable over time. Most women (73%) were cared for throughout their pregnancy by one general practitioner whom they knew well; such continuity was desired by nearly all the women in the study. Approximately three quarters of women were satisfied with the antenatal, postnatal and overall care provided by their general practitioner. Over half of respondents (56%) wished to get to know the doctor who would be present at the birth: the general practitioner was involved in 19 labours (16%), being present at the birth for only nine women. Women delivering at home were significantly more likely to agree with the statement that they knew the doctor present at the birth compared with those women delivering at hospital. Most women (91%) had their final six-week postnatal check with their general practitioner. CONCLUSION: Most women in this study believed that general practitioners are important in maternity care, providing continuity of antenatal and postnatal care but not of intrapartum care. These beliefs might be an indicator of the future situation in the United Kingdom when more women give birth at home and under non-consultant care. The vocational training and continuing education of general practitioners should accommodate their possible future roles in maternity care.     

Women's preferences for sex of doctor: a postal survey

A random sample of 512 women were sent a questionnaire to determine whom they see and whom they would prefer to see for primary and preventive health care, including screening for breast and cervical cancer. The response rate was 86%.The majority of women had had at least one cervical smear test, most of them carried out by a general practitioner. Two thirds of the women had had a physical breast examination, but only one third had been shown breast self-examination techniques – again the general practitioner was the health professional most often involved.The women''s preferences for who to see for primary and preventive health care were problem/procedure specific. Less than one in 10 said they would prefer to see a female general practitioner for general health problems, compared with nearly six out of 10 for women''s health problems. Similarly, almost 60% would prefer to see a female health professional for cervical screening and for breast screening by physical examination and instruction in self-examination. Just under half of all the respondents – two fifths of the over 45 years age group and half of the younger women – said they would prefer a female doctor for breast screening by mammography.A female general practitioner was the first choice for cervical screening for the highest proportion of women (41%) and the proportion was even higher among women from the manual classes and among older women from the nonmanual classes. More women general practitioners might increase compliance rates for cervical screening among these high risk groups.     

Why do patients change their general practitioner? A postal questionnaire study of patients in Avon.

The aim of this confidential postal questionnaire study was to determine why patients change their general practitioner. Among 1423 patients who changed their general practitioner without changing their address the reason most commonly given for leaving a general practitioner was distance (41%)--three quarters of these patients mentioned only distance. Just over one third of respondents (35%) mentioned dissatisfaction with the personal care given by the general practitioner and 36% mentioned dissatisfaction with practice organization. Specific patient requirements, such as a woman doctor, were not commonly mentioned. Convenience was the commonest reason given for choosing a new doctor (53%), with recommendation or reputation mentioned by 36% of respondents and positive expectations of service by 37%. The proportion of patients that changed from any one practice was small. This type of survey may prove a useful method for family health services authorities to identify practices with a higher than normal level of patient dissatisfaction.     

Use of the consultation satisfaction questionnaire to examine patients'' satisfaction with general practitioners and community nurses: reliability, replicability and discriminant validity.

BACKGROUND: Primary health care services are the most frequently used in the health care system. Consumer feedback on these services is important. Research in this area relates mainly to doctor-patient relationships which fails to reflect the multidisciplinary nature of primary health care. AIM: A pilot study aimed to examine the feasibility of using a patient satisfaction questionnaire designed for use with general practitioner consultations as an instrument for measuring patient satisfaction with community nurses. METHOD: The questionnaire measuring patient satisfaction with general practitioner consultations was adapted for measuring satisfaction with contacts with a nurse practitioner, district nurses, practice nurses and health visitors. A total of 1575 patients in three practices consulting general practitioners or community nurses were invited to complete a questionnaire. Data were subjected to principal components analysis and the dimensions identified were tested for internal reliability and replicability. To establish discriminant validity, patients' mean satisfaction scores for consultations with general practitioners, the nurse practitioner, health visitors and nurses (district and practice nurses) were compared. RESULTS: Questionnaires were returned relating to 400 general practitioner, 54 nurse practitioner, 191 district/practice nurse and 83 health visitor consultations (overall response rate 46%). Principal components analysis demonstrated a factor structure similar to that found in an earlier study of the consultation satisfaction questionnaire. Three dimensions of patient satisfaction were identified: professional care, depth of relationship and perceived time spent with the health professional. The dimensions were found to have acceptable levels of reliability. Factor structures obtained from data relating to general practitioner and community nurse consultations were found to correlate significantly. Comparison between health professionals showed that patients rated satisfaction with professional care significantly more highly for nurses than for general practitioners and health visitors. Patients' rating of satisfaction with the depth of relationships with health visitors was significantly lower than their ratings of this relationship with the other groups of health professionals. There were so significant differences between health professional groups regarding patients' ratings of satisfaction with the perceived amount of time spent with health professionals. CONCLUSION: The pilot study showed that it is possible to use the consultation satisfaction questionnaire for both general practitioners and community nurses. Comparison between health professional groups should be undertaken with caution as data were available for only a small number of consultations with some of the groups of health professionals studied.     

Patients' choice of general practitioner: influence of patients' fluency in English and the ethnicity and sex of the doctor.

Asian patients' use of general practitioner services and, in particular, their interaction with doctors is not well researched. However, difficulty in communication and in the case of women, reluctance to be examined by a male doctor has been reported. This study, based on interviews with 241 Caucasian, Pakistani and Indian patients attending a general practice in Bradford, examined the relationship between choice of general practitioner and the patient's fluency in English and the general practitioner's ethnicity and sex. Both Pakistani and Indian patients, particularly women, had poor fluency in English and the use of interpreters was confined to women (11% of Pakistani women and 4% of Indian women). The linguistic and broad cultural concordance between the patient and the general practitioner was more important in the choice of doctor than the sex of the general practitioner. It was also found that while 62% of Pakistani women objected to being examined by a male doctor, this was true for only 21% of Indian women.     

Why do patients consult the general practitioner? Determinants of their decision.

In order to obtain more information about the reasons why patients consult their general practitioner 1000 patients completed a questionnaire in the waiting rooms of eight general practices. After the consultation the patients received a second questionnaire. The aim of the study was to determine why people decide to consult their general practitioner about one complaint but not about a second complaint. Both questionnaires were based on the health belief model, augmented by three other factors: the perceptions patients have of their own abilities to cope with their condition (efficacy of self care), their knowledge about the complaint and their need for information. The results showed that two of the additional factors (efficacy of self care and need for information) as well as most of the factors of the health belief model (efficacy of general practitioner care, perceived severity of complaint and cues to consult) were important determinants of consulting the general practitioner. The results suggest that patients sometimes expect information from their general practitioner rather than medical treatment. Furthermore, as the perceived efficacy of general practitioner care is also an important determinant, unnecessary consultation or unnecessary delay in treatment could be prevented by offering patients information about the potential effectiveness of medical care or self care for specific conditions. Implications for general practitioners' daily practice and future research are discussed.     

Factors that influence general practitioners' choice of hospital when referring patients for elective surgery.

To describe the factors that influence general practitioners' choice of hospital when referring patients for elective surgery in three specialties, a postal questionnaire was distributed in January 1991 to 449 doctors who had referred patients to one of six hospitals in the North Western Regional Health Authority. Responses were received from 260 general practitioners (58%). Of the respondents 95% selected 'local and convenient' as a factor that commonly influenced their choice of hospital for at least one specialty and 65% mentioned this across all three specialties. Seventy four per cent mentioned patient preference as influencing choice for at least one specialty and 57% across all three specialties. Only 32% of doctors mentioned waiting times for appointment across the three specialties and 26% waiting times for surgery across the three specialties. When asked to select the single most important factor 'local and convenient' was selected by 33% of general practitioners for a least one specialty, the general standard of clinical care by 28% and waiting time for appointment by 23%. Patient preference was only selected by 6% of doctors as the most important factor. It is of note that 33% of general practitioners perceived there to be no choice of hospital for at least one specialty and 14% thought this to be the single most important influence on choice for at least one specialty. Approximately half the general practitioners (49%) considered it always or often appropriate to give their patients a choice. Most general practitioners received waiting time information from hospitals in their own health district but fewer received such information from hospitals outside their district.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coordinating and standardizing long-term care: evaluation of the west of Scotland shared-care scheme for hypertension.

BACKGROUND. The long-term management of patients with chronic conditions such as hypertension presents problems for the health services. Shared care addresses these by coordinating care and defining responsibilities. AIM. This study set out to investigate the feasibility, acceptability and cost effectiveness of shared general practitioner-hospital care for well-controlled hypertensive patients in an urban area by comparing three matched groups of patients. METHOD. A total of 554 outpatient clinic attenders, considered suitable for shared care by their consultant, were randomly allocated to shared care or follow up in the outpatient clinic; a third group of 277 patients was selected from a nurse practitioner clinic. Main outcome measures were the proportion of patients in the second year of follow up who had undergone a complete review (blood pressure measurement, serum creatinine level result and electrocardiograph report), acceptability to patients and general practitioners as assessed by questionnaire, and cost per complete review in year two (National Health Service and patient costs). RESULTS. After two years 220 (82%) shared care patients had had a complete review compared with 146 (54%) outpatient clinic attenders and 202 (75%) nurse practitioner clinic attenders. Blood pressure control was similar in each group. Of 297 general practitioners invited, 85% wished to participate in the study; 61% of questionnaire respondents subsequently wanted shared care to continue while 25% were unsure. Half of the patients receiving shared care preferred this method of follow up. The rank order of cost-effectiveness ratios was shared care, nurse practitioner care and conventional outpatient care, relative differences being most marked when only patient costs were considered. CONCLUSION. Shared care for hypertension is feasible in an urban setting, acceptable to the majority of participants and is a cost-effective method of long-term follow up.     

Attitudes to and perceived use of health care services among Asian and non-Asian patients in Leicester.

A random sample of 449 Asian patients and 447 non-Asian patients were interviewed at home in their preferred language using a personally administered questionnaire comparing attitudes to and perceived use of health care services in Leicester. The overall response rate was 89.6%. There were differences in the responses of the Asian and non-Asian populations. With respect to communication, language as a barrier appears to be a diminishing problem among Asian patients in Leicester. However, Asian patients reported finding it more difficult to gain access to their general practitioners than non-Asian patients. More Asian than non-Asian patients would have preferred direct access to consultants and most respondents from both populations felt they should be able to request a hospital opinion from their general practitioner. More Asian patients disliked management of illness by telephone than non-Asian patients, the latter feeling that telephone advice could save them a trip to the surgery, or their general practitioner a home visit. However, both groups regarded home visiting as essential. Asian patients disliked deputizing services more than non-Asian patients, and there was some support for 24 hour surgeries, particularly among the Asian population, with doctors working in shifts. As Asian patients appear to differ from non-Asian patients with respect to attitudes and perceived need for health care services, this type of survey may form the basis for the more rational planning of health care delivery to ethnic minority patients in the future.     

General practitioners' beliefs about their role in the prevention and treatment of accidents involving children.

This questionnaire survey set out to determine the perceptions of family doctors in north Staffordshire regarding their role in the prevention and treatment of childhood accidents. Of 277 doctors sent questionnaires, 207 (75%) replied. Only 23% of respondents considered that they did enough child accident prevention work; lack of time was mentioned as a limiting factor by 66%. Child health surveillance clinics and home visits were considered by 60% and 59% of respondents, respectively, to be appropriate occasions on which to give prevention advice. However, only 12% of respondents frequently gave safety advice while visiting a child. Significantly more older general practitioners (over 44 years) gave advice during a visit than younger doctors. Among doctors with a health visitor who was practice rather than geographically based significantly more gave advice on a home visit and discussed safety issues with their health visitors. Significantly more general practitioners in practices more than five miles from the nearest accident and emergency department offered to provide treatment for children following an accident than those in practices nearer to a hospital. Child accident prevention has recently been targeted as an important area for health promotion in primary care. However, this district based survey has identified a relatively low profile for the subject in the everyday activities of the general practitioner. The need for further research to determine the precise role of the family doctor in the prevention and treatment of children's accidents is highlighted.     

Adolescent patients in an Inner London general practice: their attitudes to illness and health care

A postal questionnaire was sent to 121 patients aged 16-20 years identified from the age-sex register of an Inner London practice; 87 replied. Information was sought about adolescents' perceptions and experience of illness and health care, and their attitudes to preventive medicine. Few of the girls reported that they were in good health; 59 per cent of girls and 23 per cent of boys had visited their general practitioner in the previous three months. Thirty per cent of girls and 15 per cent of boys felt that there was something wrong with their health and in particular that they were overweight. Smoking and drinking were common. Adequate contraception was being practised by most girls.

Detailed interviews with 18 of the respondents identified a number of family problems and difficult relations with staff in hospitals. Most of them considered that good health was not merely a matter of luck.

Adolescents are usually described as being a most healthy group, but this study of an inner city practice suggests that adolescents themselves do not share this view.

     

Urban public attitudes to the treatment of psychological problems and depression in general practice

A previous national study of public attitudes to depression indicated that only 17% spontaneously mentioned their general practitioner as someone who could help with depression, in contrast to 79% of respondents being willing to consult their G.P. in a similar U.K. survey. The present study undertook to examine the public perception of an urban sample to the treatment of depression in general practice and the factors associated with expressed unwillingness to consult. A random sample from the electoral register was drawn and 54 (89%) of 61 subjects selected were interviewed. While 85% of respondents were satisfied with their general practice care, only 24% to 52%, depending on the context and wording of the question, said that they would seek help from their general practitioner for depression. Factors associated with an expressed reluctance to consult were being male, dissatisfied with general practitioner care and believing that general practitioners were not qualified to treat depression.     

An evaluation of a nurse-led ear care service in primary care: benefits and costs.

BACKGROUND: Nurses trained in ear care provide a new model for the provision of services in general practice, with the aim of cost-effective treatment of minor ear and hearing problems that affect well-being and quality of life. AIM: To compare a prospective observational cohort study measuring health outcomes and resource use for patients with ear or hearing problems treated by nurses trained in ear care with similar patients treated by standard practice. METHOD: A total of 438 Rotherham and 196 Barnsley patients aged 16 years or over received two self-completion questionnaires: questionnaire 1 (Q1) on the day of consultation and questionnaire 2 (Q2) after three weeks. Primary measured outcomes were changes in discomfort and pain; secondary outcomes included the effect on normal life, health status, patient satisfaction, and resources used. RESULTS: After adjusting for differences at Q1, by Q2 there was no statistical evidence of a difference in discomfort and pain reduction, or differential change in health status between areas. Satisfaction with treatment was significantly higher (P = 0.0001) in Rotherham (91%) than in Barnsley (82%). Average total general practitioner (GP) consultations were lower in Rotherham at 0.4 per patient with an average cost of 6.28 Pounds compared with Barnsley at 1.4 per patient and an average cost of 22.53 Pounds (P = 0.04). Barnsley GPs prescribed more drugs per case (6% of total costs compared with 1.5%) and used more systemic antibiotics (P = 0.001). CONCLUSIONS: Nurses trained in ear care reduce costs, GP workload, and the use of systemic antibiotics, while increasing patient satisfaction with care. With understanding and support from GPs, such nurses are an example of how expanded nursing roles bring benefits to general practice. Nurses trained in ear care reduce treatment costs, reduce the use of antibiotics, educate patients in ear care, increase patient satisfaction, and raise ear awareness.     

Child care in the new towns in the UK

New towns with large populations of children present ideal opportunities to study and implement extended primary care services for children. It appears that workload in most new towns is higher than in established communities. Often, the demanding nature of new town practice seems to have precluded innovations in primary care services for children. This report, which is general-practice orientated, can only indicate some aspects of child care in new towns which require further scrutiny. General practitioners are strongly divided in their views as to how they can act most effectively in child health, but there is no doubt that there is a chance in our new towns to nurture the idea of expanding the general practitioner's role in child care.     

Fundholding in the south Thames Region.

BACKGROUND: The general practice fundholding scheme is now at the forefront of the National Health Service (NHS) reforms and should lead to the more efficient use of services by making general practitioners more aware of the financial consequences of their clinical decisions. However, there is a concern that adverse effects may also occur. AIM: To monitor the changes occurring in a sample of fundholding and non-fundholding practices between 1992 and 1995, including providing care nearer to patients, the mixed economy of care, the efficiency and costs of fundholding, and the commitment of fundholders. METHOD: Fifteen first-wave practices, four second-wave practices, and four non-fundholding practices in the former South East Thames Region took part in the study. Information was collected using interviews, questionnaires, prescribing data, and annual fundholders' income and expenditure accounts. RESULTS: Consultant clinics were set up in 10 different practices in 15 different specialties, and paramedical clinics in 12 different practices. Physiotherapy and mental health clinics constituted over 90% of the paramedical hours. Fundholders had private arrangements with an individual consultant or practitioner for approximately half of the contracted hours in both types of clinics. Fundholders had lower overall prescribing costs than non-fundholders, but the overall costs for prescribing for all groups had risen by about one third over three years. CONCLUSION: While outreach clinics may help to provide for the needs of patients with common conditions, they may lead to the fragmentation of services. The provision of primary care by those who are not NHS employees needs careful consideration. Recent policies for general practice have emphasized its role in disease prevention and in coordination of care for chronic illness. Fundholding also promotes two additional roles, the purchasing of care and the development of in-house facilities. Combining these different functions presents a considerable challenge.     

Women's knowledge of taking oral contraceptive pills correctly and of emergency contraception: effect of providing information leaflets in general practice.

BACKGROUND. About one third of all pregnancies are unplanned and 20% of all pregnancies end in abortion. More than 170,000 legal abortions are performed in the United Kingdom annually. Nearly all general practitioners provide contraceptive advice; the most commonly used form of reversible contraception is the oral contraceptive pill. AIM. The aim of this study was to determine factors associated with women's knowledge of taking the contraceptive pill correctly and of emergency contraception, and to investigate if their knowledge could be improved in general practice by providing women with Family Planning Association information leaflets. METHOD. An uncontrolled intervention study was performed in one rural and one urban English general practice, using a self-completion questionnaire that was initially administered to women attending their general practitioner for oral contraception over six months from 1 October 1992. The questionnaire asked for: sociodemographic information; knowledge of how late women can be taking an oral contraceptive pill and still be protected against unplanned pregnancy; for how many days after being late with a pill they need to use other precautions; sources and methods of emergency contraception; and for how long the methods are effective after the primary contraceptive failure. After completing the questionnaire women were given two leaflets: one about how to take their prescribed contraceptive pill correctly and one about emergency contraception. Three to 12 months later the same questionnaire was administered in the same manner. RESULTS. Of 449 women completing the first questionnaire, 233 (52%) completed the second questionnaire. Initially 71% of 406 women taking an oestrogen/progestogen combined pill knew about the '12-hour rule' and 17% knew about the 'seven-day rule'; giving women information about the pill they were taking increased the extent of knowledge about these rules among 212 respondents to 82% (P < 0.01) and to 25% (P < 0.05), respectively. The proportion of respondents who knew that they could obtain emergency contraception from their own general practitioner, from any general practitioner and from family planning clinics all increased after they had received the leaflets (from 84% to 92%, from 34% to 47% and from 82% to 90%, respectively, all P < 0.01). There were significant improvements in the proportion of women knowing the duration of effectiveness of emergency contraception. However, after receiving the leaflet on emergency contraception the majority of women still did not know for how long after unprotected intercourse the high-dose combined pill and the intrauterine contraceptive device were effective (80% and 93% of 233 women, respectively). Improvements in knowledge depended upon women's social class, previous use of emergency contraception and with which practice they were registered. CONCLUSION. Providing women with leaflets about taking the contraceptive pill correctly and about emergency contraception appears to improve significantly their extent of such knowledge. If such practice was adopted elsewhere this increased knowledge might reduce the number of unplanned pregnancies in the UK. The effect of general practitioners personally providing such leaflets, with or without verbal instruction, warrants further study.     

General practitioner beds in Finland — lessons for the UK?

The Finnish Primary Health Care Act of 1972 aimed to provide comprehensive health care to the population. One consequence was an increase in the number of beds for the use of general practitioners, so that there are now 2.2 general practitioner beds per thousand population. Use of these beds varies with the location of the health station in which they are situated, but in rural areas approximates to that of general practitioner hospitals in the United Kingdom. Despite integration of general practitioner beds into overall planning, some potential benefits of these facilities have not been realized. For the UK, with traditions of personal general practice and continuity of care, the Finnish system offers one model of community care which may have medical and economic advantages.     

Prevention in general practice: the views of doctors in the Oxford region.

A postal questionnaire was sent to all 1291 general practitioners in the Oxford region to determine the pattern of preventive care and their beliefs about its effectiveness. Replies were received from 1014 doctors (79%). Doctors' attitudes to their role in prevention and health promotion were very positive and a large majority claimed to discuss health related topics with their patients when indicated. Fewer respondents said they made a point of discussing smoking habits (64%), alcohol intake (26%), diet (12%), or exercise (11%) as a matter of routine with all their adult patients. Most general practitioners said they usually offered simple advice, leaflets, or other aids when they had identified a problem, but few said they would refer these patients to the practice nurse. With the exception of cervical screening (45%), few respondents said they maintained statistics on the distribution of risk factors in their practice population. Despite considerable enthusiasm for their role in preventive health care, before the imposition of the new contact most general practitioners in the Oxford region had not yet embraced the model of prevention which the contract aims to encourage: systematic screening for risk factors and lifestyle advice for all patients.