Computerized family practitioner committee records — a data base for general practitioners

In the primary care environment the role of preventive medicine is assuming increasing importance and general practitioners need accurate and up-to-date information about their practice population. Computerization of family practitioner committee registers should provide a readily accessible data base from which data about groups of patients within the practice area can easily be extracted. This paper describes a study carried out in Northumberland, which set out to establish the type of information which would be of interest to general practitioners and how it could be produced.

It was found that a data base holding only registration data was of limited value to general practitioners, although useful for identifying target groups for screening programmes and showing demographic trends within the practice. The doctors felt that the inclusion of medical data would make the register a far more effective resource.

     

Cervical screening in general practice: call and recall

Regular universal screening for cervical cancer is associated with a considerable reduction in the disease. However, opportunistic screening has tended to reach groups at low risk and miss those at high risk from the disease. This study assessed the cost-effectiveness of a call and recall system for cervical screening which was set up in one general practice.

The practice age-sex register and records were used to monitor the screening status of women patients. Of the eligible population aged 36-60 years 70% were found to have been screened in the previous five years. The remainder were offered an appointment for a cervical smear and 57% attended following this invitation. Three smears out of 110 undertaken were reported as showing marked dyskaryosis or cervical intraepithelial neoplasia grade III. The estimated cost per case identified was £366.

A call system in general practice can increase the uptake of cervical screening among women at risk. It is a relatively cost-effective method of preventing cervical cancer.

     

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.     

Patterns of work in general practice in the Bromley health district

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

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

     

One practice's review of its use of a general practitioner hospital

For a period of six months a record was kept of every attendance at a general practitioner hospital by a patient from a four-partner practice with a list of 10,500 patients.

During the six-month period one in 17 of the practice population was x-rayed; one in 50 attended the physiotherapy department, and the rate for general practitioner surgery consultations was one per person.

I believe that in semi-rural North Yorkshire the general practitioner hospital has a continuing role to play and such a hospital can provide a better and more comprehensive service to patients, and give professional satisfaction and stimulation to the primary health care team.

     

Paediatric developmental screening: a survey of general practitioners

A questionnaire survey of 293 general practitioner trainers in England to investigate paediatric screening yielded a response rate of 86%. Paediatric screening sessions were being held by a practice member in the practices of 54% of respondents. In one-third of these practices the practice member was acting in the capacity of clinical medical officer. Of responding trainers 28% held sessions personally and these doctors did not differ significantly from the remainder in terms of sex, seniority, hospital paediatric experience or membership of the Royal College of General Practitioners. About one-third of the doctors holding sessions had spent six months or more working in hospital paediatric departments. First-hand experience of paediatric screening was gained by 60% of the current trainees.

Sixty-one per cent of trainers agreed with the view that developmental screening is an appropriate task for all general practitioners, while 71% saw it as an appropriate task for themselves. Eight-six per cent of trainers agreed that doctors should be paid for this service if trained for it, and 56% that they should be paid regardless of training.

Comparative figures were determined from a parallel survey of 333 non-training general practitioners of whom 225 (68%) replied. Paediatric screening sessions were held in the practices of 34% of respondents and personally by 21%.

It is concluded that there is a high level of interest in paediatric screening among general practitioners, but that there is a need for further expansion in postgraduate paediatric training.

     

Comparison of the work of a nurse practitioner with that of a general practitioner

The work of a nurse practitioner was compared with that of a general practitioner. Both were equally available to the same patient population over the same period. The nurse practitioner saw a similar age and sex distribution of patients to the doctor but saw different types of problems. More of the patients she saw were for followup of chronic diseases, health advice and screening measures while fewer were acutely ill. The doctor dealt with four times as many patients. The nurse practitioner managed 78% of her consultations without referral to a doctor, and 89% without resorting to prescribed drugs. There was a high level of patient satisfaction with her work and 97% of the patients who saw the nurse would choose to consult her again. The role of the nurse practitioner in our practice has developed differently from a similar post in another setting, thus emphasizing the need for flexibility when defining the role.

Nurse practitioners are a valuable extra resource for the development of new areas of care, rather than a cheaper substitute for a general practitioner.

     

Chlamydial cervicitis: a research study from general practice

Chlamydia trachomatis was isolated from the cervix in five out of 294 women at routine cervical cytology screening. Significant sera antibody titres were obtained from six out of 115 isolate-negative women similarly screened. The antibody response increased in proportion to the past frequency and severity of cervical pathology and sexually transmitted disease.

It is suggested that the true incidence of chlamydial genital infection in general practice will be five times as high as the current cervical isolation rate.

     

Specialization in general practice

Ideas about general practitioner specialism may have been hampered in the past because of the three models of general practitioner specialism — in the hospital service, the fee-earning specialoid or the general practitioner obstetrician — none of which is satisfactory.

However, general practitioner specialism can be justified in guaranteeing standards by concentrating groups of patients, accepting responsibility, and planning care. Medico-political changes may be needed to achieve improvement in clinical standards.

     

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.

     

The paediatric training required by the general practitioner: A report by a Joint Working Party of The British Paediatric Association and The Royal College of General Practitioners

This report has been written because special programmes of training for general practice are being developed in many parts of the country and there are questions about the paediatric component of training which need to be discussed nationally.

An important part of this report is devoted to listing educational objectives which should be attained in paediatrics by the general practitioner at the end of his training.

     

Why standards?

My experiences of growing up in a general practitioner's home and practice led me to want to be a general practitioner myself.

The early 1950s were critical years for general practice. Three developments — the foundation and work of the College, the introduction of vocational training, and the development of postgraduate medical centres — have led to its revival.

The next main change may well be the interest in, and development of, clinical standards. In my opinion this ought to be done by general practitioners themselves rather than by society via the Ombudsman.

     

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.

     

Use of the Michigan alcoholism screening test in general practice

The Michigan alcoholism screening test was used to assess the prevalence of alcohol problems in 142 patients aged between 18 and 60 years consulting a general practitioner. Previous and/or current alcohol problems were identified in 33% of men and 4% of women. Unemployment was found to be significantly associated with alcohol problems in the men of the study group. The higher proportion of patients with alcohol problems requesting consultation compared with those without such problems did not appear to be associated with a specific presenting complaint.

Screening for alcohol problems should be undertaken in all patients consulting a general practitioner if early detection and intervention are to be achieved.

     

A community study of diabetes in Oxfordshire

A mailed questionnaire was used to identify people with diagnosed diabetes in a population of approximately 14,000. A response rate of 90 per cent was obtained and the prevalence of diabetes was found to be 0.8 per cent. The questionnaire method compared favourably with other methods of identifying diabetics in the area.

Eighty-two diabetics were interviewed and examined for diabetic complications and 55 of these completed a questionnaire on their attitudes to diabetes and its care.

The medical records of all 108 diabetics identified were examined. A greater proportion of patients who attended either a general practice mini-clinic or a hospital diabetic clinic had examination for complications recorded than patients attending their general practitioner in ordinary surgery time. Patients attending on demand were seen less often and had fewer observations recorded when they came.

Comparison of measures of control between hospital and general practice patients showed that hospital patients tended to be more tightly controlled even though most were on insulin and likely to have more severe diabetes.

Half of non-insulin diabetics and a quarter of those on insulin considered that their diabetes should be managed solely by their general practitioner.

This was a pilot study and caution should be exercised in interpreting results from comparatively small numbers. The study has since been extended to a larger population. f10sl60

     

Inviting infrequent attenders to attend for a health check: costs and benefits.

A total of 114 patients who had not attended their general practitioner in the previous three years were identified by searching a sample of 1488 records (12.8% of the practice list). An invitation for a health check was sent, in keeping with the requirements of the new general practitioner contract. Seventeen out of 94 patients invited (18%) attended. Surgery staff spent 28 hours and the practice doctors spent 15 hours on arranging and carrying out the investigation. The group responding to the invitation were in general healthy; the only new finding of remediable disease was mild hypertension in one man. The smoking rate and alcohol consumption rate were low. Of 13 patients who needed tetanus immunization, five refused it and five failed to return. All three women who were overdue for a cervical smear failed to return to have it done. It is concluded that screening infrequent attenders is not an efficient use of medical time.     

General practice screening clinic for Bangladeshi families.

AIM. A screening clinic for Bangladeshi families was established in order to improve the health care provided by one general practice to its Bangladeshi patients. METHOD. The clinic was run by a general practitioner, a health visitor and a Bangladeshi health worker. Patients were invited to attend household by household. The composition of each household was recorded using a genogram. Details of family illness, housing and employment were noted. A medical history was taken from each individual. Every adult was screened for diabetes and risk factors for coronary heart disease; cervical cytology was offered to women. The immunization status of all patients was recorded and adults were immunized. Children were referred to the child health clinic for immunizations. The clinic concluded with a health education session focusing on smoking, exercise and diet. RESULTS. Over a two year period, 58% of the Bangladeshi families registered with the practice attended the clinic, a total of 207 people. Meeting Bangladeshi patients household by household was an effective and apparently efficient way of providing basic screening and health education. It allowed the practice to learn about the structure of its Bangladeshi families, the social problems faced by their community, and the areas in which their health care could be improved. CONCLUSION. This clinic provides a model which could be adapted for use with other ethnic or 'hard-to-reach' groups. It may also prove an effective way of screening all families in general practice.     

Comparison of outcome of low-risk labour in an isolated general practice maternity unit and specialist maternity hospital

The outcome of labour of 185 low-risk pregnancies at an isolated general practitioner maternity unit was compared with that for 185 comparable low-risk pregnancies at a specialist maternity hospital. No difference was found in mode of delivery or in the proportion of women requiring no analgesia, although significantly more women in the general practice group received analgesia beyond nitrous oxide. There was a significantly higher level of intervention in labour in the maternity hospital group in the form of fetal monitoring and augmentation of labour. The duration of first stage of labour was longer and meconium staining less frequent in the general practice group. Fourteen (7.6%) of the general practice group were transferred in labour to the specialist unit.

The results suggest that where considerations for selection of low-risk pregnancy permit, the general practice maternity unit can provide a distinctive style of intrapartum care with minimum intervention.

     

Prophylactic cytological investigation for cervical cancer in relation to stage at diagnosis: a study of 420 women in Denmark

Despite widespread cervical smear testing 500-600 cases of cancer of the cervix are still diagnosed each year in Denmark, with over 200 deaths. The distribution of the different stages of cancer among 420 women who were diagnosed during 1983 was correlated with the number of previous cervical smears, whether done purely for screening reasons or for minor gynaecological problems. Of the women with cancer 56% had never been screened, and among these 42% were diagnosed at stage 1; 19% had been screened once; 61% of them at stage 1. The remainder (25%) had been screened at least twice, and 81% of them were diagnosed at stage 1. Among the patients who had been screened at least twice, with the last screening not more than three or five years ago, about 90% were diagnosed at stage 1 and the rest at stage 2.

The introduction of cervical smear testing will thus mean a considerably better stage distribution among cases which develop invasive cancer of the cervix, and both case fatality and mortality rates will be reduced by organized programmes, which have better participation rates than disorganized use of cervical smears.

     

Should performance indicators in general practice relate to whole practices or to individual doctors?

In a study of referrals to East Anglian hospitals 737 referrals in six specialties from three general practices were examined to see how accurately the hospital computer master index had identified the referring practice, the referring general practitioner and the doctor with whom the patient was registered. Although the practice was accurately identified by the hospital computer in 97% of referrals, the identification of the referring doctor and the patient's registered general practitioner were less reliable (72% and 49% respectively). It is concluded that at present the practice rather than the individual doctor may be the appropriate unit of analysis for studies of general practitioners' referral rates. This may be true for other performance indicators where information on a doctor's case mix and workload is not available. The results of this study emphasize that problems may arise if data relating to individual general practitioners are interpreted out of context of the practice and the way in which it is organized.