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PubMed1995

What do we known about fundholding in general practice?

The general practice fundholding scheme was introduced four years ago. So far its impact has not been formally evaluated nationally, but review of published research shows some trends. Fundholding has curbed prescribing costs and given general practitioners greater power to lever improvements in hospital services--for example, reducing waiting times for hospital treatment--but fundholding practices may have received more money than non-fundholding practices. The impact of fundholding on transactions costs, equity, and quality of care (particularly for patients of non-fundholding general practitioners) is unknown. Research into costly reforms such as fundholding needs to be coordinated.

Community Participation↗
PubMed2003

Head lice diagnosed in general practice in the West Midlands between 1993 and 2000: a survey using the General Practice Research Database.

The potential of the General Practice Research Database (GPRD) for communicable disease surveillance was explored using head lice as an example. All diagnoses of head lice and prescriptions for parasiticidal agents from 1993 to 2000 in the West Midlands were analysed. Diagnoses reached a peak of 28.2 per 1,000 patient years at risk and total prescriptions reached a peak of 27.1 per 1,000 patient years at risk in 1997. Malathion and permethrin were prescribed most often. The proportion of further parasiticidal prescriptions issued within 30 days of the initial prescription increased to a peak of 11.5% of prescriptions in 1997. The ratio of the same:different further prescriptions changed during the study period, reaching a high of 5:1 in 2000. These trends are mirrored by the Royal College of General Practitioners (RCGP) Weekly Returns Service and Prescribing Analysis and Cost (PACT) data. Use of GPRD provides additional insights into patient data, particularly on prescribing, that would not be available from other sources.

Adolescent↗
PubMed1996

Negotiating the role of the practice nurse in general practice.

The debate about the role of the practice nurse is not only about practice nursing per se, but raises broader issues about the organization of primary health care. Two related issues emerge as significant: the role of the practice nurse in providing primary health care; and the effective use of the practice nurse resource in the 'new' National Health Service. This paper, by drawing on material from a qualitative study, specifically examines the type of work performed by practice nurses and the factors that influence this. The responses of practice nurses, general practitioners, Family Health Service Authority (FHSA) advisers, community nurse purchasers and managers of community nursing provider units suggest that a consensus on the future development of practice nursing is unlikely. The different stakeholders emphasized different issues, reflecting their own priorities and backgrounds. Practice nurses' accounts of the future, for example, focused on professional issues. General practitioners stressed the importance of role development which met their General Medical Service responsibilities. Purchasing agencies, provider units and FHSAs adopted a wider perspective and were more concerned to develop an effective and integrated primary health care service. The tensions generated by their different interests and perspectives, and the subsequent organizational and policy initiatives that emerge, will provide the context in which the role of practice nurses will be negotiated.

Attitude of Health Personnel↗
PubMed2000

Detection of psychological distress by practice nurses in general practice.

BACKGROUND: The general practitioner (GP) has traditionally been the first port of call for people with psychiatric morbidity but increasingly other members of the primary care team see the patients first, particularly practice nurses. The numbers and roles of practice nurses have expanded greatly over the past decade and it is important that practice nurses are able to recognize patients with psychiatric morbidity. This paper reports a study to determine the abilities of 24 practice nurses to detect psychiatric morbidity in patients attending their clinics. METHODS: Twenty-four practices were randomly selected from 41 practices recruited from South London and Kent. One nurse per practice took part in the study. Patients were asked to complete a 12-item General Health Questionnaire (GHQ-12) while waiting for their appointment with the practice nurse. Following their consultation, the practice nurse rated the patients' level of psychological distress on a five-point rating scale. RESULTS: The response rate of patients was 97% (N= 1710). The GHQ case rate was 36%. The mean detection rate by practice nurses when identifying significant distress was 16% (between nurse variation, 0% to 61%). The mean specificity was 96% (variation 77% to 100%). A second analysis, changing the nurse criterion to recognition of distress increased the mean sensitivity rate to 58% (variation 31% to 84%) but the mean specificity rate decreased to 66% (variation 26% to 95%). CONCLUSIONS: These results demonstrate that practice nurses' caseloads include a high proportion of patients with psychiatric morbidity and that agreement with the GHQ classification of psychiatric morbidity is modest. Therefore, training in detection will be crucial for the nurses.

Adolescent↗
PubMed2002

GP recruitment and retention: a qualitative analysis of doctors' comments about training for and working in general practice.

BACKGROUND AND AIMS: General practice in the UK is experiencing difficulty with medical staff recruitment and retention, with reduced numbers choosing careers in general practice or entering principalships, and increases in less-than-full-time working, career breaks, early retirement and locum employment. Information is scarce about the reasons for these changes and factors that could increase recruitment and retention. The UK Medical Careers Research Group (UKMCRG) regularly surveys cohorts of UK medical graduates to determine their career choices and progression. We also invite written comments from respondents about their careers and the factors that influence them. Most respondents report high levels of job satisfaction. A noteworthy minority, however, make critical comments about general practice. Although their views may not represent those of all general practitioners (GPs), they nonetheless indicate a range of concerns that deserve to be understood. This paper reports on respondents' comments about general practice. ANALYSIS OF DOCTORS' COMMENTS: Training Greater exposure to general practice at undergraduate level could help to promote general practice careers and better inform career decisions. Postgraduate general practice training in hospital-based posts was seen as poor quality, irrelevant and run as if it were of secondary importance to service commitments. In contrast, general practice-based postgraduate training was widely praised for good formal teaching that met educational needs. The quality of vocational training was dependent upon the skills and enthusiasm of individual trainers. Recruitment problems Perceived deterrents to choosing general practice were its portrayal, by some hospital-based teachers, as a second class career compared to hospital medicine, and a perception of low morale amongst current GPs. The choice of a career in general practice was commonly made for lifestyle reasons rather than professional aspirations. Some GPs had encountered difficulties in obtaining posts in general practice suited to their needs, while others perceived discrimination. Newly qualified GPs often sought work as non-principals because they felt too inexperienced for partnership or because their domestic situation prevented them from settling in a particular area. Changes to general practice The 1990 National Health Service (NHS) reforms were largely viewed unfavourably, partly because they had led to a substantial increase in GPs' workloads that was compounded by growing public expectations, and partly because the two-tier system of fund-holding was considered unfair. Fund-holding and, more recently, GP commissioning threatened the GP's role as patient advocate by shifting the responsibility for rationing of health care from government to GPs. Some concerns were also expressed about the introduction of primary care groups (PCGs) and trusts (PCTs). Together, increased workload and the continual process of change had, for some, resulted in work-related stress, low morale, reduced job satisfaction and quality of life. These problems had been partially alleviated by the formation of GP co-operatives. Retention difficulties Loss of GPs' time from the NHS workforce occurs in four ways: reduced working hours, temporary career breaks, leaving the NHS to work elsewhere and early retirement. Child rearing and a desire to pursue interests outside medicine were cited as reasons for seeking shorter working hours or career breaks. A desire to reduce pressure of work was a common reason for seeking shorter working hours, taking career breaks, early retirement or leaving NHS general practice. Other reasons for leaving NHS general practice, temporarily or permanently, were difficulty in finding a GP post suited to individual needs and a desire to work abroad. CONCLUSIONS: A cultural change amongst medical educationalists is needed to promote general practice as a career choice that is equally attractive as hospital practice. The introduction of Pre-Registration House Officer (PRHO) placements in general practice and improved flexibility of GP vocational training schemes, together with plans to improve the quality of Senior House Officer (SHO) training in the future, are welcome developments and should address some of the concerns about poor quality GP training raised by our respondents. The reluctance of newly qualified GPs to enter principalships, and the increasing demand from experienced GPs for less-than-full-time work, indicates a need for a greater variety of contractual arrangements to reflect doctors' desires for more flexible patterns of working in general practice.

Attitude of Health Personnel↗
PubMed2001

Gonorrhoea screening in general practice: perceived barriers and strategies to improve screening rates.

OBJECTIVE: To investigate perceived barriers to gonorrhoea screening in general practice and suggest strategies to overcome them. DESIGN: Questionnaire-based survey. SETTING AND PARTICIPANTS: All 47 general practitioners (GPs) authorised to prescribe subsidised HIV drugs under the Pharmaceutical Benefits Scheme in inner, eastern and northern Sydney. MAIN OUTCOME MEASURES: Agreement on a five-point Likert scale with statements about attitudes and practices in relation to gonorrhoea screening of homosexually active men, and views on how testing rates could be increased. RESULTS: 32 GPs responded (68%). Perceived barriers to gonorrhoea testing included structural measures imposed by the Federal Government to limit pathology testing by GPs (the Medicare "three-test rule") (17 respondents agreed or strongly agreed), pressure from the Health Insurance Commission (HIC) to minimise pathology testing (15), concerns about confidentiality of notification procedures (8), clinical time pressure (8), and concerns about recriminations against HIV patients with gonorrhoea (6). Suggested measures to increase testing were education of gay men to request testing (25), relaxation of the three-test rule (25), easier tests (23), anonymous notification procedures, review of HIC policy on screening, and training about testing (21 each). CONCLUSIONS: Sydney GPs with high HIV caseloads perceived structural barriers to gonorrhoea testing and supported a range of achievable strategies to overcome these. As the sustained epidemic of gonorrhoea in Sydney may be directly promoting HIV transmission, these strategies should be considered urgently.

Adult↗
PubMed1990

Variety and views in general practice.

Ninety general practitioners described their practices and gave their views on their work. The differences between urban and rural general practices were found to be greater than those between single practices, partnerships and group practices. Rural doctors were on call more frequently (50% being on call more than 11 nights per month and 54% at least every third weekend), had lower adult fees, were more likely to have hospital appointments (54%) and expressed more concern about their independence than urban doctors. Most of the general practitioners (94.5%) said that their surgeries usually ran over time (44% up to an hour, 5.5% longer), longer consultations and extra patients being seen as the prime causes. The general practitioners particularly enjoyed their involvement with people and the variety in their work (34% and 22% of comments respectively), but felt overworked and found difficulties with particular people (33% and 20% of comments respectively). In their general comments the general practitioners wanted to see an improved image for family doctors (23%) and more support for doctors (17%). Fifteen percent of the comments affirmed the quality of general practice.

Attitude of Health Personnel↗
PubMed2006

Trends in sexually transmitted infections in general practice 1990-2000: population based study using data from the UK general practice research database.

OBJECTIVE: To describe the contribution of primary care to the diagnosis and management of sexually transmitted infections in the United Kingdom, 1990-2000, in the context of increasing incidence of infections in genitourinary medicine clinics. DESIGN: Population based study. SETTING: UK primary care. PARTICIPANTS: Patients registered in the UK general practice research database. MAIN OUTCOME MEASURES: Incidence of diagnosed sexually transmitted infections in primary care and estimation of the proportion of major such infections diagnosed in primary care. RESULTS: An estimated 23.0% of chlamydia cases in women but only 5.3% in men were diagnosed and treated in primary care during 1998-2000, along with 49.2% cases of non-specific urethritis and urethral discharge in men and 5.7% cases of gonorrhoea in women and 2.9% in men. Rates of diagnosis in primary care rose substantially in the late 1990s. CONCLUSIONS: A substantial and increasing number of sexually transmitted infections are diagnosed and treated in primary care in the United Kingdom, with sex ratios differing from those in genitourinary medicine clinics. Large numbers of men are treated in primary care for presumptive sexually transmitted infections.

Adolescent↗
PubMed2000

Improving management of bereavement in general practice based on a survey of recently bereaved subjects in a single general practice.

BACKGROUND: Previous studies of bereavement in primary care have tended to concentrate on the attitudes of general practitioners (GPs) to bereavement support and little has been documented on the views of patients. AIM: To establish the role, content, and value of a protocol designed to help the newly bereaved by examining the experiences and expectations of a group of bereaved patients within a single general practice, with a view to developing patient care within this area. METHOD: A qualitative approach was adopted using a semi-structured questionnaire, data collection, and analysis consistent with the principles of grounded theory. Patients were approached by letter and those who agreed to take part in the study were interviewed at home. RESULTS: Many of those interviewed expected some form of contact from their GP after bereavement, although the nature of the contact they would have liked varied. The majority would have appreciated a letter of sympathy and none would have objected to it. Over half expressed some form of dissatisfaction either with their GP or with the hospital. Quality of information giving and communication affected bereavement outcomes for some. The role of the GP was examined and patients responded positively to practical suggestions to improve bereavement care. CONCLUSIONS: Bereavement support was seen to be an important part of the GP role by the majority of those interviewed. As a result recommendations have been made for a protocol to support the newly bereaved.

Aged↗
PubMed2006

Why do patients want to have their blood tested? A qualitative study of patient expectations in general practice.

BACKGROUND: General practitioners often take their impression of patients' expectations into account in their decision to have blood tests done. It is commonly recommended to involve patients in decision-making during consultations. The study aimed to obtain detailed information on patients' expectations about blood tests. METHODS: Qualitative study among patients in waiting rooms of general practices. Each patient was presented with a short questionnaire about their preferences in terms of diagnostics. Patients who would like blood tests to be done were interviewed. RESULTS: Fifty-seven (26%) of the 224 respondents wanted blood tests. Twenty-two were interviewed. Patients overestimated the qualities of blood tests. Favourable test results were regarded as proof of good health. Patients regarded blood tests as a useful instrument to screen for serious disorders, and were confirmed in this belief by people in their social environment and by the media. Many patients expected their GP to take an active test ordering approach, though some indicated that they might be convinced if their GP proposed a wait-and-see policy. CONCLUSIONS: GPs' perceptions about patient expectations seem justified: patients appear to have high hopes for testing as a diagnostic tool. They expect diagnostic certainty without mistakes and a proof of good health. The question is whether it would be desirable to remove patients' misconceptions, allowing them to participate in policy decisions on the basis of sound information, or whether it would be better to leave the misconceptions uncontested, in order to retain the 'magic' of additional tests and reassure patients. We expect that clarifying the precise nature of patients' expectations by the GP may be helpful in creating a diagnostic strategy that satisfies both patients and GPs. GPs will have to balance the benefits of reassuring their patients by means of blood tests which may be unnecessary against the benefits of avoiding unnecessary tests. Further research is needed into the effects of different types of patient information and the effects of testing on satisfaction and anxiety.

Adult↗
PubMed1984

Fear of cancer among patients in general practice.

The general practitioners dealing with cancer has other parameters than statistics of incidence and prevalence. In 400 consecutive interviews with patients in general practice when asked if the consultation was brought about because of fear or thoughts of cancer, eight % answered "yes" and 11% "partly". When asked if they thought about or feared cancer, a total of 47% answered "yes" or "sometimes". Many more women than men expressed fear of cancer. The fear did not increase with age in contrast to the increasing incidence of the disease. For every new case of diagnosed cancer there are many patients in whom malignancy has been suspected but not verified. Almost every tenth patient in this study was investigated further due to possible cancer.

Adult↗
PubMed1999

[Do computerized reminders to the patients affect the preventive work in general practice?].

Norwegian general practitioners have the opportunity to perform preventive medicine on many levels. There are uncertainties as to the effect of this activity. A systematic approach is one of the prerequisites for obtaining significant results. We have made a study of the review literature concerning computerised patient-specific reminders used in preventive health care. Electronic literature search was supplemented by expert-guided manual search. We found that a conclusion from the literature is that such computerised reminders have a lasting effect regarding doctors' handling of preventive care issues. The effect of reminders in a general practice setting will be determined by the way they are implemented. In this process it will be necessary to address motivating issues, technical solutions and administrative adjustments.

Decision Making, Computer-Assisted↗
PubMed1986

Management of hypertension in twelve Oxfordshire general practices.

The general practice records of 2371 hypertensive patients on drug therapy in 12 practices were reviewed retrospectively. It was found that the mean systolic blood pressure of the patients had fallen by 29 mmHg and the mean diastolic pressure by 16 mmHg after one year of treatment and that there was a further reduction of 5 mmHg in the systolic pressure and 5 mmHg in the diastolic pressure at the most recent recording of blood pressure. Half of the patients had only a single blood pressure reading recorded before treatment was started and for 56% of the patients there was no record of smoking habit and for 69% no record of weight. Twenty-seven per cent of the patients suffered from mild hypertension, that is blood pressure less than 180/110 mmHg, and 56% were over 65 years of age. These results indicate the need for policies for selection of patients for treatment and for standards of recording. It is suggested that practices should review their results and undertake to treat elderly hypertensive patients and those with mild hypertension only when they can demonstrate that their policies are effective for young hypertensive patients and for those with moderate or severe hypertension.

Adult↗
PubMed1978

Integrated residency training in family medicine and general practice dentistry.

General practice dental training and family practice medical training can be combined into one effective integrated program. This combination benefits the patients in a family practice model unit, enhances family practice resident education, and will ultimately benefit patient care delivery. This paper describes the experience of such an integrated program which is now well established.

Education, Dental↗
PubMed1996

[Skin prick tests with allergens in general practice].

Eleven general practitioners performed skin prick tests for specific pollen allergy (birch, timothy and mugwort) in 109 patients. One to two weeks later all 109 patients were skin prick tested again by one and the same very experienced nurse in a specialised allergy clinic. The results of the allergy-nurse were defined as "the real values". When the two sets of skin prick test were compared, 272 (83%) of all 327 skin pricks were of same size and class compared with the positive histamine-references. Forty-eight skin pricks (14%) were marginally different. Three skin prick tests (1%) were falsely positive and four (1%) were falsely negative. The study shows that general practitioners can after a short time of education and training perform and classify skin prick testing with great performance and at the same level as specialised allergy clinics. Skin prick test is a good supplement to clinical examination in general practice in the diagnosis of specific allergy in rhinoconjunctivitis and asthma bronchiale and in making suitable referrals to specialised allergy clinics.

Adolescent↗