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.

     

The role of practice manager—changes in attitudes promoted by the Royal College of General Practitioners

Because of the roles traditionally required of them, and because of the insularity of ancillary staff in general medical practice, many senior ancillary staff may not have been giving their doctors the most effective support of which they are capable. This is changing as a result of the change-promoting activities of the North of England Faculty of the Royal College of General Practitioners.

A survey of ancillary staff and general practitioners in the North of England has shown that the Royal College of General Practitioners has assisted ancillary staff to a greater consensus of more progressive views about the emerging role of practice manager than is the case amongst general practitioners. The results also show that differences in the size of practices have determined whether or not a need for a practice manager is perceived.

The focus of interest created by this faculty of the Royal College of General Practitioners has resulted in the formation of special interest groups of senior ancillary staff in the North of England. These groups form a valuable resource for exploration and innovation to discover more effective means of organising and managing general medical practice.

     

Evaluation of a data base sheet in an A4 medical record system

The medical record system used by the author's general practice is in the A4 format and includes a structured summary sheet of their own design. In an evaluation of this data base sheet, the aims were twofold: to measure the extra time required to complete the A4 data base sheet during an interview with a patient against the time for an inspection of existing medical records alone; to quantify the usefulness of the data base sheet to the doctor seeking immediate access to relevant information about the patient's medical, family and social history.

Compilation of a structured A4 data base sheet took an average time of five and a half minutes per patient. Examination of NHS medical records took an average time of three minutes per record, and only 4 per cent of these records included any form of completed summary sheet. The data base sheet, which took only another two or three minutes to complete, was found to be a practicable document that provides immediate access to a wide range of relevant information for effective (and efficient) patient management.

     

The organization of cervical screening in general practice

Well organized cervical screening in general practice can have considerable clinical and financial rewards. Yet in a randomized survey of general practitioners in the United Kingdom only 43% operated a system for cervical screening which allows previously untested women to be identified and invited for testing.

A younger age of general practitioner, a more rural practice, a larger practice size, employment of a practice nurse, a belief in the effectiveness of cervical screening and a positive view of the time spent on screening were all strong predictors of an organized approach to cervical screening within a practice. Being female or having a female partner was not statistically associated with systematic screening. The results demonstrate a need for education within general practice which emphasizes the relevance and significance of cervical screening and the essential contribution that can be made by each individual general practitioner to the success of the whole cervical screening programme.

     

Continuing education — a new approach

Many teachers of general practice in this country and abroad have called upon colleagues in practice to take upon themselves a larger share of continuing education within this branch of the profession.

One response to this call, reported in this article, was a five-day intensive course for 29 established general practitioners, held at the Eastbourne Postgraduate Medical Centre, 1980. The course was planned entirely by a team of seven general practitioners who had gained their teaching experience as vocational training course organizers. The course and its evaluation are described. We offer it as a new approach to continuing education which some of our general practitioner colleagues may prefer to conventional courses, but we do not suggest that our approach should replace well-tried and successful methods.

     

Seeing the same doctor

It is not known how many general practices are organised so that patients usually see the same doctor (separate list practice) or how many are arranged so that patients are encouraged to see any partner (combined list practice).

A survey was carried out in Wiltshire which obtained an 85 per cent response to a questionnaire. This showed that a majority of general practitioners working in partnership in Wiltshire no longer organise their practices so that they care for a defined list of patients.

     

General practice in Croatia, Yugoslavia

The position and importance of general practice in the Yugoslavian Health Service is being reviewed in a study of the working conditions, the composition and relationship of the primary health care team, the workload, and the opinions of the patients in Croatia, Yugoslavia.

We found that many practices had barely half the recommended equipment, that the average workload was 40 patients a day, and that many general practitioners expected others to improve their organisation rather than undertaking it themselves.

Those general-practitioner teams which we rated highly were also the most popular with patients. The job satisfaction of nurses varied and was highest when the doctors in the team did not have a high need for status for themselves.

We consider general practice to be of crucial importance in the total system of health care in our country and believe that general practitioners should have the same status as specialists.

     

The management of vaginal discharge in general practice

A group of general practitioners in active practice were asked to report how they preferred to manage the symptoms of vaginal discharge presented by a woman in her twenties. Subsequently the same practitioners reported their management of such patients in their practice.

A shortfall was found for all practitioners between their declared intention and their actual practice.

This method of analysis offers a way of working towards a consensus in clinical care and also of auditing medical performance in general practice.

     

Diagnosis and general practice.

This discussion paper presents the case for a rigorous diagnostic research agenda within primary care. In view of unique aspects of primary care medicine and the relatively unselected nature of the populations encountered by general practitioners, it is clear that diagnostic research undertaken in other settings may be inapplicable. Most diagnostic studies adopt designs that seek to compare items, or clusters of items, of clinical information against a gold standard. In order to enhance the feasibility and rigour of such research within primary care, suggestions are made about priorities and specific key methodological issues. It is essential that the information generated by primary care diagnostic research should be reliable, valid, useful, and useable within general practice. The ultimate objective must be the identification of specific items, or small clusters of items, of clinical information of high discriminant ability among the groups of patients encountered in general practice.     

What is narrative therapy and what is it not? The usefulness of Q methodology to explore accounts of White and Epston's (1990) approach to narrative therapy

Objective. ‘What is narrative therapy and how do you do it?’ is a question that is repeatedly asked of narrative therapy, with little consistent response. This study aimed to explore and distil out the ‘common themes’ of practitioner definitions of White and Epston's approach to narrative therapy. Design. This was an Internet‐based study involving current UK practitioners of this type of narrative therapy using a unique combination of a Delphi Panel and Q methodology. Method. A group of experienced practitioners were recruited into the Delphi Poll and were asked two questions about what narrative therapy is and is not, and what techniques are and are not employed. These data combined with other information formed the statements of a Q‐sort that was then administered to a wider range of narrative practitioners. Findings. The Delphi Panel agreed on a number of key points relating to the theory, politics and practice of narrative therapy. The Q‐sort produced eight distinct accounts of narrative therapy and a number of dimensions along which these different positions could be distinguished. These included narrative therapy as a political stance and integration with other approaches. Conclusions. For any therapeutic model to demonstrate its efficacy and attract proponents, an accepted definition of its components and practice should preferably be established. This study has provided some data for the UK application of White and Epston's narrative therapy, which may then assist in forming a firmer base for further research and practice. Copyright © 2010 John Wiley & Sons, Ltd. Key Practitioner Message: ? Narrative therapy and how it is carried out remain unclearly defined, which limits studies of the efficacy of this approach. ? Experienced practitioners of narrative therapy were able to identify a set of core concepts, values and techniques over which there was some consensus. ? This study also identified the different ‘positionings’ of narrative therapy that have contributed to its opacity and have highlighted the diversity in therapist practice.     

Norfolk general practice: a comparison of rural and urban doctors

A postal questionnaire was sent to all Norfolk practitioners, allowing a comparison to be made between rural general practice and urban practice in Norwich and Great Yarmouth. However, when Norfolk town and country doctors were compared, little difference was found in their personal or practice characteristics. In respect of their workload rural doctors, as expected, carried out more procedures overall but, somewhat surprisingly, did not make more home visits. Both sets of doctors had similar views on their present and future role in general practice.

When Norfolk doctors collectively were compared with general practitioners nationally their service appeared to be of a high standard. The only uncertainty surrounded the effects of the greater clustering of Norfolk surgeries, together with the levels of home visiting and their attendant effects on patient accessibility.

     

Medical screening of 1500 patients in a dental surgery: a prospective study.

Communication between medical and dental practitioners about patients they have in common enhances total patient care, but such communication rarely occurs. This may be due to lack of appreciation by doctors of the medical risks to certain patients undergoing dental treatment. To ascertain a relevant medical history, prospective medical screening was performed on 1500 new patients attending a general dental practice using a standard health questionnaire followed by an interview between the patient and dentist. There were 382 (25.5%) patients with a current or past medical history of relevance to dentistry, 90 (6.0%) were taking medication of potential importance and 105 (7.0%) considered they had an intolerance to certain drugs. The screening provided a patient data base for medical and medico-legal purposes. A total of 376 (25.1%) questionnaires were filled out incorrectly and 63 of these (16.8%) had major misinformation about medical history. A small but important group deliberately misled the dentist either from fear of refusal of treatment or embarrassment about their medical history. Therefore interviews are an essential adjunct to written health questionnaires in eliciting accurate information. Formal screening of new patients is essential in general dental practice. Furthermore, general medical practitioners need to become aware of the common risks to patients undergoing dentistry. Better formal and informal communication between general medical and dental practitioners is recommended for the benefit of their mutual patients.     

Group-based care: does it change problem behaviour?

As a result of disappointing experiences in managing problem behaviour presented by patients in general practice, a system of team or group-based care was developed at the Ommoord Health Centre in Rotterdam, the Netherlands.

However, despite all the care given by social workers, general practitioners, physiotherapists and other members of the primary health care team, the problem behaviour of about half the patients was unaltered.

This report concerns the aims and methods of our group meetings and the conditions such as empathy, sincerity and non-possessive warmth which we regard as essential in dealing with problem behaviour. The conditions necessary for improvement, such as independence and responsiveness by patients, are also considered. During our group meetings the team deals with the emotions which patients are experiencing at the time, and patients are encouraged to discover as much as possible about their own possibilities for both influencing and making choices in their lives. Some examples of this type of care are given.

Patients react positively to the group-based care approach and some reduction in the consultation rate and in the prescribing of tranquillizers by general practitioners has been shown.

     

The choice of practice location

A ten per cent sample survey of all general practitioners in England and Wales in 1969-70 included two questions about the choice of practice location. The most common reasons given were the absence of any real alternatives (in the immediate post-war period), the influence of family or friends, the existence of medical contacts in the area, and favourable points about the practice itself.

In considering possible future moves, general practitioners would pay closest attention to the educational facilities of an area, its rural or coastal location, its social and cultural amenities, and the practice conditions. The conclusion is drawn that financial incentives are unlikely to contribute much towards a more equal distribution of general-practitioner manpower. More thought should be given to recruitment to the medical profession in under-doctored areas through the development of the highest professional standards and facilities in such places.

     

Implementation of quality assurance and medical audit: general practitioners'' perceived obstacles and requirements.

BACKGROUND. The introduction of quality assurance and medical audit has been an important development in general practice. However, the introduction of such programmes does not necessarily mean they are implemented by general practitioners. AIM. A study was undertaken to describe the problems and requirements perceived by general practitioners in relation to the implementation of quality assurance and medical audit in general practice. METHOD. Interviews were carried out with a stratified sample of 120 Dutch general practitioners. Knowledge, acceptance and application of quality assurance and medical audit activities were investigated, and perceived problems and requirements in implementing quality assurance and audit activities were explored. RESULTS. General practitioners in the Netherlands were generally positive towards quality assurance activities, but had little experience of carrying out such activities. The most frequently mentioned obstacles to implementing quality assurance activities concerned lack of time, colleagues' negative attitudes and fear of assessment and criticism by colleagues. Requirements for implementing quality assurance included having regular meetings with colleagues about quality assurance, having information on the aims and methods of quality assurance, having data from other practices with which to compare performance, having support in data collection, in audit in the practice and in setting up local peer review, and having financial support. The most important factor predicting the actual application of quality assurance activities was found to be knowledge of specific quality assurance activities. CONCLUSION. Well-designed programmes for the implementation of quality assurance and medical audit, using a variety of different interventions, have to be developed. Such programmes should include the training of professionals in the concepts and methods of quality assurance as well as the provision of financial support for quality assurance activities.     

Self-observation in general practice—the bleep method

Recent trends in general practice towards working in multi-disciplinary teams from purpose-built premises have emphasised the need to study the ways in which doctors and other staff spend their working time.

This paper describes a well-established work-study technique (activity sampling), which has been adapted to enable doctors to assess how they use their time. The method needs no observer and is cheap to operate. Five general practitioners undertook to record their surgeries for two separate weeks using the bleep method of activity sampling. The results they obtained show that the technique is both practicable in normal working conditions and is capable of providing information highly relevant to the management of general practice.

     

Deliberate self-poisoning: implications for pyschotropic drug prescribing in general practice

Several surveys have confirmed that the majority of patients who take an overdose of drugs have seen their general practitioner within the preceding few weeks; as many as a third attend within the previous week.

We studied 130 patients who had taken an overdose and interviewed 122 of the general practitioners. We found that they had identified many interpersonal problems and had usually prescribed psychotropic drugs.

We question the wisdom of this response and suggest other ways of handling such problems in general practice.

     

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

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

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

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

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

     

Social work in general practice

A questionnaire seeking details of working arrangements and problems encountered was circulated to social workers working in general practice.

The main difficulties were: insufficient preparation for the scheme, poor communication between general practitioners and social workers, and the inadequate provision of facilities for social workers in practice premises.

Most of the respondents had not experienced big difficulties. Two thirds had enjoyed a rewarding professional experience, which is a testimonial to interdisciplinary co-operation.

     

General practitioners and the independent contractor status

Primary medical care can be provided either by a bureaucratic hierarchical organization or alternatively by independent contractors. Most members of the caring professions in medicine, nursing, and social work are employed in bureaucracies, whereas general medical practitioners, general dental practitioners, opticians, and pharmacists are independent contractors.

The independent contractor status has recently been heavily attacked from within the medical and nursing professions, and also from outside. It has been suggested that contracting for services is an inappropriate and anomalous way of arranging medical care, which should now be stopped. However, this process of contracting for services can be analysed, using perspectives from some of the behavioural sciences, to reveal hidden depths in the independent contractor status which suggest that the provision of primary medical care is best carried out by independent contractors.