Family practitioner committee records — a neglected resource. 3. Three inner city areas compared

Data from the family practitioner committees of three inner city areas — Kensington, Chelsea and Westminster; Lambeth, Lewisham and Southwark; and Manchester — were compared. The information about general practitioners over one year included number of principals, distribution by partnership size and numbers working from health centre premises. Data about practices covered the five years 1979—83, with figures for mean list size, registrations and removals, temporary residents and claims for various items of service. Comparisons between the three areas showed great differences for which no convincing explanation could be found. The possibility that people living in these areas have different primary care health services suggests that comparisons should be made nationally; this requires family practitioner committees to be fully computerized and to collect their data in the same way.     

Practice activity analysis: collaboration between general practitioners and a family practitioner committee.

The Brent and Harrow family practitioner committee has supported a scheme to enable general practitioners to collect data relating to their practice activity. This paper reports on the operation of the scheme involving 76 general practitioners from 22 practices and the findings. Practice nurse activity was also included. The family practitioner committee undertook an analysis of the data and provided each participating general practitioner with a print-out of his or her consultation rates over a range of activity, enabling general practitioners to make comparisons both with their partners and with the averages for all the practices participating in the scheme. The essential aim is to provide structured information which enables general practitioners to look more objectively at their activity. The family practitioner committee gave an assurance that the figures would not be used to criticize individuals.     

Family practitioner committee records — a neglected resource 2. Drawing the profile of an area

Capitation and item of service fees paid by a family practitioner committee can be analysed to produce a profile of the area which covers list sizes, age structure and mobility of the population and the extent of various practice activities. Such an analysis was made for Kensington, Chelsea and Westminster, an area for which it was particularly appropriate to consider these variables in terms of partnership size and doctor's age. Practices with one or two principals had lower rates of claiming for items of service than the larger partnerships, and within these smaller groupings it was the practices with elderly doctors that had the lowest rates. The findings indicate a problem associated with elderly doctors but wider conclusions are not necessarily justified. Profiles produced in the way described should be available for local planning but must be interpreted with caution.     

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.

     

Assessing the outcome of making it easier for patients to change general practitioner: practice characteristics associated with patient movements.

BACKGROUND. The government white paper, Promoting better health, suggested that primary health care services should be made more responsive to patient needs and that competition, brought about by the freer movement of patients between practices, could act as a mechanism for improving the quality of the services provided. Policy changes reflecting these aims were introduced with the 1990 contract for general practitioners. AIM. A study was carried out to estimate the volume of patient movement between practices not attributable to a patient's change of address or to a major change in the practice they had left, and to investigate which practice characteristics patients moved towards and which they moved away from when changing general practitioner. METHOD. Data on 2617 patient movements during June 1991 were collected from five family health services authorities. These patient movements were analysed in relation to data on practice characteristics obtained from family health services authority records. RESULTS. The estimated volume of movement of patients between practices was small (1.6% of the registered population per year). The majority of movements were between group practices; a quarter of the movements recorded were to single-handed general practitioners. However, the ratio of the number of movements from group practices to single-handed general practitioners compared with those from single-handed general practitioners to group practices was 1.37 (95% confidence interval 1.19 to 1.57). In choosing single-handed general practitioners these patients were willing to forgo access to a woman general practitioner, extended services and greater hours of general practitioner availability. Among the subset of movements between group practices, patients were more likely to gain access to a practice nurse, longer surgery hours and a woman general practitioner as a consequence of their move. CONCLUSION. The scale of patient movement observed did not indicate any substantial mechanism by which the new policy of encouraging consumerist behaviour on the part of primary care users could effect desired changes in primary care practice. Among the patient movements observed, the evidence suggests that when choosing a practice potential patients were not deterred by the fact that a practice was single-handed. The public's perception of the factors contributing to a high quality of service may conflict with the official characterization of good practice and high quality services in primary health care.     

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.

     

Are postal questionnaire surveys of reported activity valid? An exploration using general practitioner management of hypertension in older people.

BACKGROUND: Postal questionnaire surveys are commonly used in general practice and often ask about self-reported activity. The validity of this approach is unknown. AIM: To explore the criterion validity of questions asking about self-reported activity in a self-completion questionnaire. METHOD: A comparison was made between (a) the self-reported actions of all general practitioner (GP) principals in 51 general practices randomly selected within the nine family health services authorities of the former northern regional health authority, and (b) the contents of the medical records (case notes and computerized records) of patients classified as hypertensive from a 1 in 7 random sample of all patients registered in these practices and aged between 65 and 80. Data were gathered from the GPs by self-completion postal questionnaires. Six comparisons were made for two groups of items: first, target and achieved blood pressure; secondly, patient's weight, smoking status, alcohol consumption, exercise and salt intake. The frequency with which the data items were recorded in patient records was compared with the GPs' self-reported frequency of performing the actions. RESULTS: No relationship was found between achieved blood pressure and stated target levels. For each of the other actions, more than half of the responders reported that they usually or always performed the activity. For four of these (smoking, weight, alcohol and exercise), a significant association was noted, but the size of this varied considerably. CONCLUSIONS: There is a variable relationship between what responders report that they do in self-completion questionnaires, and what they actually do as judged by the contents of their patients' medical records. In the absence of prior, knowledge of the validity of questions on reported activity, or of concurrent attempts to establish their validity, the questions should not be asked.     

A review of family planning services by general practitioners in a health board region

In 1994 the North Eastern Health Board published a study, which ascertained the range of family planning services provided by General Practitioners (GPs) in the area. This study highlighted some service and training needs, which have since been addressed. This study has been repeated to evaluate service developments. All GPs on the NEHB mailing list were sent a pre-piloted questionnaire about the range of family planning services they provide, their referral patterns should they not provide the service themselves and their comments on how the health board could assist in the enhancement of family planning services. The data were analysed using the software package JMP and statistical analysis was carried out using either the Chi-square test or Fishers exact test. There was a response rate of sixty six percent. There has been a decrease in the number of GPs in single-handed practices (24% vs 50% in 1994) and an increase in the number of practices who employ a practice nurse. Almost one third of GPs providing family planning services are women (18% in 1994) and over half of GPs hold a family planning certificate (33% in 1994). The range of services provided has increased and more GPs are now fitting intrauterine contraceptive devices (19% vs 14%). This study highlights significant developments in the family planning service and indicates that general practice is capable of providing a fully comprehensive service.     

GP referral to an eating disorder service: why the wide variation?

BACKGROUND: Early detection and management of patients with eating disorders is thought to improve prognosis, yet little is known about the factors associated with referral of these patients to treatment centres. AIM: To calculate general practitioner (GP) referral rates to a specialist eating disorder service and determine the association between referral rate and general practice and practitioner factors. METHOD: Referral rate was calculated from a database of routine referrals to St George's Hospital Eating Disorder Service from January 1990 to May 1996 and correlated with practice and practitioner details obtained from medical directories and health authority data. RESULTS: There was a wide variation in referral rates. A higher referral rate was found to be associated with practice size, proximity to the clinic, female GPs, GPs having the MRCGP qualification, being United Kingdom qualified, and offering full contraceptive services. Fundholding was associated with lower rates of referral. CONCLUSION: Patients with eating disorders may be at a disadvantage in certain practices. Educational interventions could be targeted towards low referrals.     

Evaluation of the use of general practice age-sex registers in epidemiological research.

AIM. This study set out to show how well samples from general practice registers compare with census data, to describe those characteristics of the population and of the register that influence the response to postal surveys, and to demonstrate how general practice records can be used to assess non-response bias. METHOD. The data for this study were obtained from a large postal survey about low back pain among the general adult population aged 20-59 years in eight areas of the United Kingdom, using general practice age-sex registers as the sampling frame. RESULTS. The overall response rate was 59%. In the areas chosen, general practice registers yielded samples of size and age-sex composition close to that predicted from national census data. Responses were more likely to be obtained from women, from older age groups and from practices where the sample lists had been inspected for errors. The use of computerized registers and a letter of recommendation from the general practitioner had no effect on the response rate. Inspection of the general practice records of subsamples of respondents and non-respondents to determine consultation rates suggested that there was little response bias in respect of the subject of the survey. CONCLUSION. General practice registers can provide a suitable sampling frame for epidemiological purposes. Inaccuracies in the register can be reduced to some extent by careful inspection, but an irreducible minimum remain. Information held in general practice records can be useful in assessing response bias in health surveys.     

Psychiatric referral rates and the influence of on-site mental health workers in general practice.

Psychiatric referral rates vary widely between different general practices. To increase our understanding of this variation, we conducted a one-year prospective observational study of outpatient psychiatric referrals made by all general practices (622 referrals from 29 practices) within the catchment area of one inner-city psychiatric service. Contrary to our hypothesis, practices with higher allocations of on-site mental health workers did not have lower psychiatric referral rates. On the other hand, the highest referring practices had lower mental health worker allocations suggesting a possible influence upon referrals in this subgroup. A wide range of quantitative variables explained very little of the referral rate variation, implying that more subjective factors, such as general practitioner attitudes, may be influential in the decision to refer a patient to the psychiatrist.     

Incidence and management of oral conditions in general practice.

Despite a high community prevalence, little is known about the occurrence of oral conditions in general practice. In an observational study, 354 new cases of oral complaints were recorded in 35 participating practices during a period of six months (cumulative incidence = 6.7 per 1000 per year). The incidence was highest in children under five years of age (21% of all cases). The conditions diagnosed most frequently were aphthous ulceration, oral candidiasis, and herpes simplex infection. Most oral conditions were minor ailments, and could be dealt with by the general practitioner alone.     

The doctor's deputizing service in a single-handed practice

The out-of-hours calls received by a doctor's deputizing service on behalf of a single-handed general practitioner were studied over the course of one year.

It was found that the overall rate of call (66.3 per 1,000 patients per year) and the rate of night call (10 per 1,000 patients per year) differed little from the rates found by general practitioners who did their own out-of-hours calls. The main users of the service were children under five and women. The time when the service was used least was between 23.00 and 07.00.

It is concluded that employing a deputizing service did not necessarily increase the rate of out-of-hours calls, but that the rate was influenced by the age/sex structure of the practice list. The most economical time to employ the service was found to be from 23.00 to 07.00.

     

Differences between general practices in hospital admission rates for self-inflicted injury and self-poisoning: influence of socioeconomic factors.

BACKGROUND. Self-inflicted injury and self-poisoning are major causes of hospital admission of young adults throughout the United Kingdom, while in Scotland, suicide is the leading cause of death each year in persons aged 15 to 40 years. General practitioners are in a unique position in that they may have contact with the patient before the attempted suicide and later play a supportive role along with other health service and social work professionals. AIM. This study set out to examine the differences between 72 general practices in Tayside in the hospital admission rates for self-inflicted injury/poisoning among their patients, and the extent to which these differences were related to the socioeconomic conditions prevailing in the patients' areas of residence and in the areas in which practices were located. The study also aimed to examine the agents of self-inflicted injury/poisoning most commonly used by different age groups. METHOD. Details of admissions to hospitals in Tayside for self-inflicted injury/poisoning, from 1991 to 1993 inclusive, were obtained from a national, hospital inpatient discharge summary scheme, loaded onto a microcomputer and analysed using standard commercial software. Data from the 1991 census at the postcode sector level and death registrations summaries were obtained from the office of the registrar general for Scotland. The deprivation categories used were based on 1991 census data. RESULTS. In the study period, 52% of hospital admissions for self-inflicted injury/poisoning were of patients aged 30 years or over. Overall, the number of admissions of females exceeded that of males by 26%. Annual hospital admission rates for self-inflicted injury/poisoning per 1000 registered patients averaged over the Tayside practices correlated closely with the male unemployment rate in, and deprivation category of, the postcode sector in which the practice was located. Rates ranged from an average of 1.1 admissions per 1000 registered patients per year in sectors with less than 5% male unemployment of 4.6 where male unemployment was 15% or over. Similarly, the admission rates ranged from 1.1 per 1000 registered patients per year in the most affluent sectors to 3.3 in the most deprived sectors. The proportion of older patients who used sedatives, hypnotics and tranquillizers to poison themselves was greater than that of younger patients; analgesics, such as paracetamol, were the agents most commonly used for self-poisoning by the younger age groups. CONCLUSION. The routine monitoring at national level of hospital admission rates for self-inflicted injury/poisoning, using established computerized information systems, would enable the identification of those practices that have a relatively high proportion of such admissions. This would provide a starting point for the identification of pilot sites for the development of protocols for offering multi-agency support to high-risk groups of patients.     

Non-acute abdominal complaints in general practice: diagnostic value of signs and symptoms.

BACKGROUND. Although many patients are evaluated initially by their general practitioner, clinicians' accuracy at diagnosing organic gastrointestinal disease has not been studied in a primary care setting. Different spectra of severity of disease in general practice and hospital populations may lead to different values for diagnostic tests in these two populations. AIM. This study set out to determine the diagnostic value of history and physical and laboratory items for organic and neoplastic disease in general practice patients with nonacute abdominal complaints. METHOD. The one-year prospective, observational study was carried out in 1989 in 80 general practices in Limburg, the Netherlands. The study subjects were 933 patients (aged 18-75 years) presenting to their general practitioner with new non-acute abdominal complaints of minimum duration two weeks, and with whom the doctor had a diagnostic problem. Patients were physically examined by their general practitioner and asked to complete pre-structured questionnaires. Basic laboratory tests were carried out. Patients were followed up for at least one year by researchers and then a diagnosis was determined by an independent panel of three general practitioners using patient records, blinded for the results of the questionnaires. Sensitivity, specificity and odds ratios were calculated for clinical items. Stepwise forward logistic regression analysis was undertaken to identify independent predictors of organic gastrointestinal disease. RESULTS. Of the 933 patients 14% had organic gastrointestinal disease. No clinical item had both high sensitivity and specificity. Logistic regression analysis showed only eight independent predictors of organic disease: male sex, greater age, epigastric pain, no specific character to pain, pain affecting sleep, history of blood in stool, no pain relief after defecation and abnormal white blood cell count. When the model was programmed to predict neoplasms five items were found: male sex, greater age, no specific character to pain, weight loss and erythrocyte sedimentation rate greater than 20 mm hour-1. CONCLUSION. In a general practice population with non-acute abdominal complaints some clinical findings can be used as predictors for organic and neoplastic gastrointestinal disease.     

Views of general practitioners in the Oxford region on microcomputing and collaboration with health authorities and family practitioner committees

A postal questionnaire was sent to the senior partners of all 353 general practices in the Oxford region to investigate their interest in microcomputing and in pooling data with other general practitioners, health authorities and family practitioner committees. The response rate was 58%. Twenty per cent of responders already used a microcomputer and a further 59% intended to purchase a microcomputer for the practice. Nearly all the practices with an interest in microcomputing wanted to use it to produce age-sex registers, to establish recall groups and for repeat prescribing. Approximately 90% of interested practices reported that they would be prepared to link their data with family practitioner committees or health authorities, while 76% were interested in collaborating with other general practitioners for research. The results show that general practitioners will require support in utilizing the data that they produce.     

General practitioner reaccreditation: use of performance indicators.

There has been increasing debate about reaccreditation of general practitioners over the last few years with contributions from the General Medical Services Committee, the Royal College of General Practitioners and the National Association of Health Authorities and Trusts. The implications of proposals in terms of cost, logistics and organization are discussed in this paper, in light of experience with the introduction of summative assessment for general practitioner registrars (trainees) and a programme of training practice visits in West Midlands Region. A model for reaccreditation for all general practitioners is proposed which is professionally led and sensitive to the needs of patients and health service managers. The basic proposition is that publicly owned family health services authority data could be used as initial performance indicators for professional competence. The model is dependent on the rebuttal of the null hypothesis: there is no link between the competence of a general practitioner and his or her achievements in the suggested performance indicators. If the performance indicators (educational commitments, prescribing data, health promotion activity and immunization targets, and service elements) can be shown to correlate with possession of the attributes for independent practice as defined by the General Medical Council, then a relatively inexpensive and simple system of reaccreditation could be envisaged. General practitioners who are recorded as achieving set performance indicator targets would be accorded automatic reaccreditation. Only substandard practitioners would be required to be assessed further by a visiting team of local general practitioner peers and, if appropriate, a remedial education strategy introduced. This method would complement the General Medical Council scheme for assessing an individual doctor's persistent poor performance, which could then be invoked as a last resort.