Features of primary care associated with variations in process and outcome of care of people with diabetes.

BACKGROUND: There is now clear evidence that tight control of blood glucose and blood pressure significantly lowers the risk of complications in both type I and type II diabetes. Although there is evidence that primary care can be as effective as secondary care in delivering care for people with diabetes, standards in primary care are variable. Previous studies have shown that practice, patient or organisational factors may influence the level of care of patients with diabetes. However, these studies have been conducted in single geographical areas and involved only small numbers of practices. AIM: To determine the standard of diabetes care in general practice and to determine which features of practices are associated with delivering good quality care. DESIGN OF STUDY: A questionnaire survey and analysis of multi-practice audit data. SETTING: Three health authorities in England, comprising 169 general practices. METHOD: This study was conducted with a total population of 1,182,872 patients and 18,642 people with diabetes. Linkage analysis was carried out on data collected by a questionnaire, routinely collected health authority data, and multi-practice audit data collected by primary care audit groups. Practice annual compliance was measured with process and outcome measures of care, including the proportion of patients who had an examination of their fundi, feet, blood pressure, urine, glycated haemoglobin, and the proportion who had a normal glycated haemoglobin. RESULTS: Median compliance with process and outcome measures of care varied widely between practices: fundi were checked for 64.6% of patients (interquartile range [IQR] = 45.3-77.8%), urine was checked for 71.4% (IQR = 49.7-84.3%), feet were checked for 70.4% (IQR = 51.0-84.4%), blood pressure for 83.6% (IQR = 66.7-91.5%), and glycated haemoglobin was checked for 83.0% of patients (IQR = 69.4-92.0%). The glycated haemoglobin was normal in 42.9% of patients (IQR = 33.0-51.2%). In multiple regression analysis, compliance with measures of process of care were significantly associated with smaller practices, fundholding practices, and practices with a recall system. Practices with more socioeconomically deprived patients were associated with lower compliance with most process measures. Practices with a greater proportion of patients attending hospital clinics had lower compliance with process and outcome measures. Being a training practice, having a diabetes mini-clinic, having more nurses, personal care, and general practitioner or nurse interest in diabetes were not associated with compliance of process or outcome of care. CONCLUSIONS: Despite recent evidence that complications of diabetes may be delayed or prevented, this study has highlighted a number of deficiencies in the provision of diabetes care and variations in care between general practices. Provision of high quality diabetes care in the United Kingdom will present an organisational challenge to primary care groups and trusts, especially those in deprived areas.     

General practitioner turnover and migration in England 1990-94.

BACKGROUND: In tandem with fears about a GP workforce crisis, increasing attention is being focused on the supply and distribution of primary care services: on general practitioners in particular. Differential turnover and migration across health authority boundaries could lead to a maldistribution of GPs, yet comprehensive studies of GP turnover are non-existent. AIM: To quantify general practitioner (GP) turnover and migration in England from 1990 to 1994. METHOD: Yearly data from 1 October 1990 to 1 October 1994 were collected on GPs in England practising full time, including average yearly turnover, rates of entry to and exit from general practice, and net migration among GPs. All were calculated at the family health service authority (now the new health authorities) level. RESULTS: Average yearly GP turnover ranges from 2.9% in Shropshire to 7.8% in Kensington, Chelsea and Westminster; turnover is associated with deprivation and high-need areas. Migration of GPs across health authority borders was rare. Entry and exit rates were also positively related to measures of deprivation and need. Relatively underprovided health authorities lost 23 GPs over the study period as a result of migration; relatively overprovided ones gained three. CONCLUSION: Turnover is driven primarily by exits from general practice and is related to deprivation and high need. Retention appears to be the main problem in ensuring an adequate GP supply in relatively deprived and underprovided health authorities.     

The development of a short instrument to identify common unmet needs in older people in general practice.

BACKGROUND: No structured needs assessment tool exists that is appropriate for older people and also suitable for use in routine consultations in general practice. AIMS: To engage older people in the development of a brief, valid, practical, and acceptable instrument to help identify common unmet needs suitable for use in routine clinical practice in primary care. DESIGN OF STUDY: User involvement in a multi-stages approach to heuristic development. SETTING: General practices, voluntary groups, and community organisations in north and central London. METHOD: Subjects included patients aged 65 years and over in purposively selected practices, voluntary organisations for older people in the same localities, community organisations involving older people, general practitioners and community nurses. Data were collected through mixed methodology interviews using a structured assessment tool (Camberwell Assessment of Need for the Elderly), a postal questionnaire, and focus groups. Synthesis and interpretation of results was done through a consensus conference followed by a Delphi process involving primary care professionals. RESULTS: Five domains of unmet need were identified as priority areas by all three data collection methods, the consensus conference, and the Delphi process: senses (vision and hearing), physical ability (mobility and falls), incontinence, cognition, and emotional distress (depression and anxiety) (SPICE). CONCLUSIONS: Public involvement in the design of clinical tools allowed the development of a brief assessment instrument that could potentially identify common, important, and tractable unmet needs in older people.     

Evaluating a mental health assessment for older people with depressive symptoms in general practice: a randomised controlled trial.

BACKGROUND: There is a lack of evidence on the most effective primary care management of older people with minor depression. AIM: To evaluate a follow-up assessment by the community mental health team (CMHT) for older people with depressive symptoms identified by practice nurses at a health check for people over the age of 75 years. DESIGN OF STUDY: A pragmatic randomised controlled trial. SETTING: A single large general practice in Leicestershire. METHOD: Patients receiving a health check administered by a practice nurse and scoring 5 or more on the 15-item Geriatric Depression Scale (GDS15) were randomised to either follow-up by the CMHT or routine general practitioner (GP) care. The GDS15 score was measured at the subsequent health check 18 months later. RESULTS: Forty-seven patients were randomised to CMHT assessment and 46 to routine GP care. Uptake of the intervention was 72% (n = 34). At the follow-up health check a greater proportion of the control group had improved GDS15 scores (P = 0.08). Following assessment, the CMHT recommended their further involvement in the care of 12 patients and this was authorised by patients' GPs in six cases. CONCLUSIONS: A follow-up mental health assessment by a member of the local CMHT was not effective in improving outcomes for mildly depressed older people. Other than random error possible reasons for this include the length of follow-up and a failure to meet raised expectations among the intervention group. If complex referral procedures do not improve outcomes for this group, then specialist community services should play a more prominent part in the training of practice staff to care for their depressed older patients.     

Inequalities in treated heart disease and mental illness in England and Wales, 1994-1998.

BACKGROUND: Current government policy is directed towards reducing inequalities in health. General practice is increasingly the focus for health care provision in the United Kingdom and it is therefore important to understand the relationship between socioeconomic factors and health at the general practice level. A deprivation measure was used for the area in which the practice is located and two key priority areas were focused upon: mental health and heart disease. AIM: To explore the relationship between area deprivation and the prevalence of treated heart disease and mental illness in England and Wales. DESIGN OF STUDY: Analysis of data from medical records from practices contributing to the General Practice Research Database. SETTING: A total of 211 practices located in England and Wales. METHOD: The data from the practices were used to examine deprivation differentials in treated disease prevalence rates. RESULTS: There are strong deprivation gradients (highest prevalence in the most deprived category) for treated depression, anxiety, schizophrenia, coronary heart disease and non-insulin-treated diabetes. In general the deprivation differentials are wider in the middle of the age range. Women aged 35 to 64 years in the most deprived areas had rates of treated coronary heart disease two to three times those in the least deprived areas. Men aged 25 to 44 years in the most deprived areas had rates of treated depression 50% higher than those in the least deprived areas. CONCLUSIONS: This study has identified wide deprivation differentials in the prevalence of treated mental illness and heart disease. If all of England and Wales experienced the rates of the least deprived fifth of the population then the number of people being treated for depression, anxiety, and coronary heart disease would fall by 10%, 16%, and 11% respectively.     

Links between mental health care professionals and general practices in England and Wales: the impact of GP fundholding.

BACKGROUND: Fundholding general practitioners are able to determine the type of contracts they place with providers of mental health care, and are able to employ some categories of mental health care professionals directly. The impact of this on the care of the mental health of patients in non-fundholding practices is not yet fully known. AIM: A survey was undertaken of 100 fundholding general practices and 100 similarly sized non-fundholding practices in order to investigate the changes in mental health provision made by general practitioners. METHODS: A sample of 100 fundholding general practices in England and Wales was randomly chosen from the list supplied by the Association of Fundholders and matched to a similarly randomly chosen sample of non-fundholding practices. Postal questionnaires were sent to the senior partner and to the practice manager in each practice. RESULTS: The number of mental health care professionals who are either employed by or attached to general practices, or who visit the general practice on a regular basis appears to have increased substantially since 1991. This increase was particularly marked in fundholding practices. The results suggest that general practitioners with specific links to particular mental health care providers were more satisfied with the service provided by the mental health care team, and more likely to increase referrals to that service in the last 2 years, than general practitioners without such links. There was little evidence to suggest that increasing the number of mental health care professionals in primary care had brought about a major reduction in referrals to psychiatrists. CONCLUSION: General practitioners, particularly fundholders, are increasing their links with mental health professionals, and community psychiatric nurses, psychiatrists, psychologists and counsellors are spending more time either based in general practice or visiting regularly. While the shift of resources to primary care, particularly to fundholders, may increase the treatment options available to patients with less severe illnesses, this may have the effect of reducing the services available for the long-term and severely mentally ill.     

The role of the general practitioner in the community care of people with HIV infection and AIDS: a comparative study of high- and low-prevalence areas in England.

BACKGROUND: Policy for the care of people suffering from HIV and AIDS has changed over the past decade. Schemes for shared primary and secondary care have been met with varying success, and patients may be reluctant to become involved. No systematic evaluation comparing the views of primary care providers and users in areas of varying HIV prevalence has been published. AIM: To examine the role of general practice in areas of England with low and high human immunodeficiency virus (HIV) prevalence and to compare barriers to general practice care in each area. METHOD: We used focus groups, semistructured questionnaires and interviews in north London (high HIV prevalence) and Nottingham (low HIV prevalence). RESULTS: Four focus groups took place in London. A total of 411 general practitioners (GPs) in London and 405 in Nottingham replied to postal questionnaires. Overall, 121 primary care staff in 40 London practices and 26 staff in five Nottingham practices were interviewed. In all, 54 people infected with HIV were interviewed in London and 20 in Nottingham. Providers and users regarded the 24-hour availability and the familiar environment of general practice as its key assets. Lack of expertise and time were its disadvantages. Providers were concerned about inadequate communication with specialist services. Although providers were concerned about confidentiality, whether they had liberal and sympathetic attitudes was more important in deciding whether people with HIV used the service. In the low-prevalence area, general practice involvement was the result of individual initiatives, and practices were not integrated into specialist care. In the high-prevalence area, HIV care was more usual in general practice, but there was also little integration with HIV services. CONCLUSIONS: In high-prevalence districts, a strategy to make HIV care routine for all GPs may be appropriate. In low-prevalence areas, a network of selected, strategically located, relatively high-involvement practices may be more effective in meeting the primary care needs of people with HIV infection and acquired immunodeficiency syndrome (AIDS).     

Characteristics of general practices involved in undergraduate medical teaching.

BACKGROUND: The movement of medical education into the community has accelerated the development of a new model of general practice in which core clinical services are complemented by educational and research activities involving the whole primary care team. AIM: To compare quality indicators, workload characteristics, and health authority income of general practices involved in undergraduate medical education in east London with those of other practices in the area and national figures where available. DESIGN OF STUDY: A comprehensive survey of undergraduate and postgraduate clinical placements and practice-based research activity within general practice. SETTING: One-hundred and sixty-one practices based in East London and the City Health Authority (ELCHA). METHOD: Cross-sectional survey comparing routinely-collected information on practice resources, workload, income, and performance between teaching and non-teaching practices. RESULTS: In east London, teaching practices are larger partnerships with smaller list sizes, higher staff costs, and better quality premises than non-teaching practices. Teaching practices demonstrate significantly better performance on quality indicators, such as cervical cytology coverage and prescribing indicators. Patient-related health authority income per whole time equivalent (WTE) general practitioner (GP) is significantly lower among teaching practices. A multiple regression analysis was used to explore the association between teaching status and income. Eighty-eight per cent of the variation in patient-related income could be explained by the combination of list size, list turnover, removals at doctor's request, quality of premises, and immunisation and cytology rates. CONCLUSION: This study demonstrates that practice involvement in undergraduate education in east London is associated with higher scores on a range of organisational and performance quality indicators. The lower patient-related income of teaching practices is associated with smaller list sizes and may only be partially replaced by teaching income. Lower vacancy rates suggest that teaching practices are more attractive to doctors seeking partnerships in east London.     

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.     

Effect of practice and patient population characteristics on the uptake of childhood immunizations.

BACKGROUND. The target-linked payments introduced by the 1990 general practitioners' contact were intended to reflect a close association between payments and performance in general practice. However, a straightforward direct relationship between service uptake in primary care and financial incentives should not be assumed. AIM. This study set out to examine the relationship between the factors which provide a broad profile of practices and general practitioners' performance in terms of primary childhood immunization targets. METHOD. Anonymized data on primary immunization uptake rates in 208 practices in Greater Glasgow Health Board and selected characteristics of the practices and their patient populations were analysed. RESULTS. Seventy five per cent of the practices in the study qualified for a high-target payment in the last quarter of the 1991-92 financial year, but only 53% managed to do so in all four quarters of the year. Tests of differences between means showed that the provision of child health surveillance, the notional' mortality ratio for each practice's patient population and the percentage of patients attracting deprivation payments were significant differentiating factors among the practices grouped according to immunization target achieved at 1 October 1991--high target, low target and neither. There was no evidence that the target achieved was significantly affected by the activity or clinical staffing levels of the practices--number of patients per general practitioner, number of practice nurses or being single handed. A disproportionate number of practices reaching the high target were located in the more affluent areas, whereas a higher than expected proportion of those which either achieved the low target or missed both targets was located in the more deprived areas. Similar results were obtained when the performance of the practices in achieving the high target over four consecutive quarters was considered. CONCLUSION. Practice serving populations living in socially deprived areas and with poorer health were less likely to achieve the high target for childhood immunizations. Evidence of repetition of performance in immunization uptake among the practices leads to concern over increased risk of infectious diseases among children from socially deprived populations who fail to be immunized. This seems to be yet another example of the inverse care law.     

The relationship between social deprivation and the quality of primary care: a national survey using indicators from the UK Quality and Outcomes Framework

BACKGROUND: The existence of health inequalities between least and most socially deprived areas is now well established. AIM: To use Quality and Outcomes Framework (QOF) indicators to explore the characteristics of primary care in deprived communities. DESIGN OF STUDY: Two-year study. SETTING: Primary care in England. METHOD: QOF data were obtained for each practice in England in 2004-2005 and 2005-2006 and linked with census derived social deprivation data (Index of Multiple Deprivation scores 2004), national urbanicity scores and a database of practice characteristics. Data were available for 8480 practices in 2004-2005 and 8264 practices in 2005-2006. Comparisons were made between practices in the least and most deprived quintiles. RESULTS: The difference in mean total QOF score between practices in least and most deprived quintiles was 64.5 points in 2004-2005 (mean score, all practices, 959.9) and 30.4 in 2005-2006 (mean, 1012.6). In 2005-2006, the QOF indicators displaying the largest differences between least and most deprived quintiles were: recall of patients not attending appointments for injectable neuroleptics (79 versus 58%, respectively), practices opening > or =45 hours/week (90 versus 74%), practices conducting > or = 12 significant event audits in previous 3 years (93 versus 81%), proportion of epileptics who were seizure free > or = 12 months (77 versus 65%) and proportion of patients taking lithium with serum lithium within therapeutic range (90 versus 78%). Geographical differences were less in group and training practices. CONCLUSIONS: Overall differences between primary care quality indicators in deprived and prosperous communities were small. However, shortfalls in specific indicators, both clinical and non-clinical, suggest that focused interventions could be applied to improve the quality of primary care in deprived areas.     

Human resource management in general practice: survey of current practice.

BACKGROUND: The organization and management of general practice is changing as a result of government policies designed to expand primary health care services. One aspect of practice management which has been underresearched concerns staffing: the recruitment, retention, management and motivation of practice managers. AIM: A study set out to find out who is routinely involved in making decisions about staffing matters in general practice, to establish the extent to which the human resource management function is formalized and specialized, and to describe the characteristics of the practice managers. METHOD: A postal questionnaire was sent to a stratified random sample of 750 general practices in England and Wales in February 1994 enquiring about the practice (for example, the fundholding status and number of general practitioner partners), how the practice dealt with a range of staffing matters and about the practice manager (for example, employment background and training in human resource management). Practices were classed as small (single-handed and two or three general practitioner partners), medium (four or five partners) or large (six or more partners). RESULTS: Replies were received from 477 practices (64%). Practice managers had limited authority to make decisions alone in the majority of practices although there was a greater likelihood of them taking independent action as the size of practice increased. Formality in handling staffing matters (as measured by the existence and use of written policies and procedures) also increased with practice size. Larger practices were more likely than smaller practices to have additional tiers in their management structure through the creation of posts with the titles assistant practice manager, fund manager and senior receptionist. Most practice managers had been recruited from within general practice but larger practices were more likely than smaller practices to recruit from outwith general practice. Three quarters of practice managers reported having received some type of formal training in staff management. CONCLUSION: This study shows that practice size is a major factor associated with differences in the organization and management of staffing. Any initiatives which increase the scale of primary care functions and services would have to address the issues of communication and coordination that might be associated with such a change.     

A qualitative study of older people''s views of out-of-hours services.

BACKGROUND: Out-of-hours primary care services continues to change with the growth of general practitioner (GP) co-operatives and the more recent development of NHS Direct. While older people are more likely to have increased needs for such services, evidence suggests that they are reluctant users of GP out-of-hours services. AIM: To explore older people's experiences and perceptions of different models of general practice out-of-hours services. DESIGN OF STUDY: Focus group methodology, with qualitative data analysis undertaken using a grounded theory (Framework) approach. SETTING: Thirty people aged between 65 and 81 years old from community groups based in south east London. METHOD: Four focus groups were held, each with between five and 12 participants. Each focus group session lasted 90 minutes and was audiotape-recorded with the permission of the participants. The tapes were transcribed verbatim. RESULTS: Two related themes were identified. First, attitudes to health and healthcare professionals with reference to the use of health services prior to the establishment of the NHS, a stoical attitude towards health, and not wanting to make excessive demands on health services. Second, the experience of out-of-hours care and the perceived barriers to its use, including the use of the telephone and travelling at night. Participants preferred contact with a familiar doctor and were distrustful of telephone advice, particularly from nurses. CONCLUSIONS: Older people appear reluctant to make use of out-of-hours services and are critical of the trend away from out-of-hours care being delivered by a familiar GP. With increasing numbers of older people in the population it is important to consider steps to address their reluctance to use out-of-hours and telephone advice services, particularly those based around less personal models of care.     

Linking survey data with computerised records to predict consulting by older people.

Despite high consultation rates, little is known about predictors of primary care use by older people. A survey of patients aged > or = 65 years from two London practices included details on physical health and functioning, psychological measures, social support, and socioeconomic measures. The response rate was 75% (1704/2276). We obtained consent to link the survey data to subjects' computerised primary care records for 92% (1565/1704) of responders. Individual factors (physical ill health, anxiety, female sex), social factors (frequent telephone contact with friends or family), and practice factors independently predicted consultation in the year post survey. Although physical ill health was the most important, the other factors had independent effects and may be useful in understanding the increase in consulting by older people.     

Provision of health promotion clinics in relation to population need: another example of the inverse care law?

The new contract encourages health promotion in general practice. The aim of this study was to explore the pattern of provision of health promotion clinics across one family health services authority and to relate this to possible indicators of health need in the practice population. Single-handed practices were less likely to be running health promotion clinics. The proportion of practices running clinics increased with increasing numbers of partners. Practices located in wards where the standardized mortality ratio was greater than 100, and practices receiving deprivation payments were less likely to be offering health promotion clinics. This was explained by the presence of most single-handed practitioners in deprived, historically unhealthy wards. If effective, health promotion clinics will have tended to benefit populations in Bedfordshire at lower risk of ill-health. Other shortcomings of the clinic-based health promotion model are discussed.     

Estimated prevalence of people with learning disabilities: template for general practice.

BACKGROUND: In 2001, a white paper set out a commitment to ensure that people with a learning disability receive equal access to health services, with an expectation that general practices would have identified all people with a learning disability registered with the practice by June 2004. AIM: To outline the development of a template to create practice-based registers of people with learning disabilities in general practice. DESIGN OF STUDY: The study was prospective, employing a template to identify patients in general practice with a learning disability. The study used capture-recapture methodology to estimate the prevalence of learning disability in the population. SETTING: General practices in Leeds. METHOD: A template was developed that uses Read code searches of practices' electronic medical records, along with practice knowledge to identify patients who have a learning disability. RESULTS: The tool was piloted in 30 general practices in Leeds and validated against a city-wide database of people with learning disability. There was a wide variation between the practices in terms of how many people were identified, with the average being 0.4% of the practice population. Combined with validation from the city-wide database, this increased to 0.7%. CONCLUSION: The template provides a valuable tool for general practices to begin developing a practice-based register of patients with a learning disability. This is particularly timely in view of the revised General Medical Services contract Quality and Outcomes Framework indicator, stimulating practices to produce a register of patients with learning disability. Use of a common definition for learning disability is needed to improve consistency in identification across practices.     

Deprivation,demography, and the distribution of general practice:: challenging the conventional wisdom of inverse care

It is generally believed that the most deprived populations have the worst access to primary care. Lord Darzi''s review of the NHS responds to this conventional wisdom and makes a number of proposals for improving the supply of GP services in deprived communities. This paper argues that these proposals are based on an incomplete understanding of inverse care which underestimates the degree to which, relative to their healthcare needs, older populations experience low availability of primary care. Many deprived practices appear to have a better match between need and supply than practices serving affluent but ageing populations. However, practices serving the oldest and most deprived populations have the worst availability of all.     

A prospective study of the consulting behaviour of older people with knee pain

BACKGROUND: Knee pain is common among older adults but only a minority consult their doctor about it. AIM: To determine predictors of new episodes of consultation in primary care among older people with knee pain. DESIGN OF STUDY: Population-based prospective cohort study linking baseline survey to primary care medical records. SETTING: Three general practices in North Staffordshire, UK. METHOD: Subjects were 1797 people aged > or =50 years who responded to a general population survey, reported knee pain in the previous 12 months and had no record of a knee disorder consultation in the 18 months prior to the survey. The main outcome measure was a record of a knee disorder consultation in the 18 months following the survey. RESULTS: The incidence of a new episode of general practice care was approximately 10% per year. Apart from chronicity (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.1 to 2.1), measures of pain severity were not strong influences on future consultation. No social support (measured by having no partner) increased likelihood of future consultation (OR = 1.3; 95% CI = 1.0 to 1.8). Among those with chronic and severe pain, main predictors were previous experiences of health care (use of non-GP services OR = 1.8; previous knee injury OR = 1.7). Current depression reduced likelihood of consulting about the knee problem (OR = 0.6; 95% CI = 0.3 to 0.9). CONCLUSIONS: Knee pain is common in the older population but a minority consult their doctor about it. Severity of pain and disability is not a strong influence on consultation. For those more severely affected, depression may act as a barrier to healthcare use.     

Community-based teaching: the challenges.

The amount of undergraduate medical education delivered in general practice is expanding rapidly, both in the United Kingdom and internationally. There are a number of challenges facing general practice as well as medical schools, health authorities and primary care groups, which must be met for this development to be sustainable. These include: impact on service general practice; resources; difficulties with integrating basic sciences with clinical teaching; recruitment, training and maintenance of GP tutors; quality control; impact on academic departments of primary care; and the importance of rigorous evaluation of educational initiatives. Possible solutions are discussed, such as development of university linked practices and the move toward a culture of 'evidence-based education', where all medical education is scrutinized for effectiveness.     

Relationship style between GPs and community mental health teams affects referral rates.

BACKGROUND: Community mental health teams (CMHTs) are the established model for supporting patients with serious mental illness in the community. However, up to 25% of those with psychotic disorders are managed solely by primary care teams. Effective management depends upon locally negotiated referral and shared care arrangements between CMHTs and primary care. AIM: To examine whether the style of working relationship between general practices and CMHTs affects the numbers and types of referrals from general practices to CMHTs, taking into account population and practice factors and provision of other mental health services which may influence referral rates. DESIGN OF STUDY: Cross-sectional study. SETTING: All 161 general practices in East London and the City Health Authority. METHOD: Questionnaire survey to all general practices to identify style of relationship. Collection of routinely available referral data to all statutory mental health services over a two-year period. Main outcome measures were number and types of referrals from general practices to CMHTs. RESULTS: The average annual referral rate to the eleven CMHTs in east London is 10 per 1000 adult population annually. The teams show a sixfold variation in rates of referral from all sources. Where good working relationships (a consultation-liaison style) exist between CMHTs and general practice, there are greater numbers of referrals requiring both long and short-term work by CMHTs. Two-stage multivariate models explained 47% of the referral variation between practices. Where primary care-based psychologists work with practices there are greater numbers of CMHT referrals, but less use of psychiatric services. CONCLUSION: Shifting to a consultation-liaison relationship should increase rates of referral of patients with serious mental illness, including those who can most benefit from the skills of CMHTs. Increasing the provision of primary care-based psychology might improve practice use of mental health services, reducing avoidable outpatient psychiatric referrals.