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PubMed1997

[Increased daytime tiredness, nocturnal hypertension and sleep apnea: studies in rural general practice].

Studies in a Rural General Practice: Sleep-Related Breathing Disorders (SRBD) and altered circadian blood pressure profile are related to increased cardiovascular risk. We investigated the prevalence and coincidence of both diseases in male patients from a general practice in a small community of 2500 people. Out of 409 selected patients (using a questionnaire regarding symptoms and findings of SRBD), 185 were monitored in an outpatient setting with an apnoea-screening system Mesam IV. Ambulatory blood pressure monitoring (Spacelabs 90207). Holter-ECG and actigraphy were also measured. Sixty patients had a Respiratory Disturbance Index (RDI) > 10. An indication for further sleep studies was seen in 40 patients; 36.5% of daytime hypertensives were "Non-Dipper", and 47.6% of normotensives were also "Non-Dipper". Excessive daytime sleepiness (EDS) is an important symptom of SRBD, and in this investigation we noticed a large number of patients without this symptom suffering from relevant SRBD. Therefore, absence of EDS alone is not indicative for the use of ambulatory monitoring.

Adult↗

PubMed1978

Evaluation of structured and unstructured training for general practice.

Twenty-four general-practice trainees were assessed at the beginning and end of their training year. They improved significantly in their factual recall and problem-solving ability. Sixteen young principals who had had an unstructured training for general practice were assessed at the same time and were initially of the same standard but their results showed no difference over the same year.

Education, Medical, Graduate↗

PubMed1973

Treatment of depression in general practice.

With the co-operation of the family doctors in five selected urban general practices the general-practitioner treatment of 73 patients suffering from a new episode of depressive illness was evaluated over a period of four months. The purpose was to test the belief that general practitioners are best fitted to manage most psychological ailments, and depression was chosen as the psychiatric illness most commonly seen in general practice. Medication was the principal treatment offered, and this was often inadequate in dosage or the patient defaulted. Drug defaulting was thought to be due partly to failure of supervision and follow-up and to too low a consultation rate. The low consultation rate was also thought to explain why few patients thought there was a therapeutic value in the doctor-patient relationship. The results of the study indicate that patients with depressive illness do not receive the best treatment in general practice. The reasons are several and responsibility must be shared by the medical practitioners, the current system of the general practice, and the patients themselves.

Adolescent↗

PubMed1977

Classifying disease in general practice.

I have developed a system of classifying diseases in general practice based on headings relevant to general practice which are built up in a hierarchy. I believe this is better than abbreviating the International Classification of Disease with the addition of individual symptoms.Ideally, a classification ought to include occupational diseases and psychosocial problems, and it must be accompanied by a terminology defining as precisely as possible the different categories based on criteria relevant to ordinary general practice. It should still follow the main divisions of the International Classification of Disease as far as possible.I believe that general practice will not progress any further unless it is prepared to loosen its traditional allegiance to hospitalorientated disease classifications, which are, for our purpose, inappropriately rigid.

Disease↗

PubMed1998

The patient's view of general practice fundholding: results of a cross-sectional survey.

We report the results of a survey of patients' awareness, attitudes and satisfaction regarding fundholding and related developments in primary care, and compare the responses of patients in fundholding and non-fundholding practices. (Six total fundholding general practices and two non-fundholding general practices in West Berkshire were included.) An anonymous postal questionnaire was sent to 1150 patients with joint pain aged 17-80, of whom 715 (63%) returned completed questionnaires. Few (17%) fundholding respondents had received information from their practice about fundholding or (36%) were aware of new or different services being offered but the majority had heard of fundholding and were able to describe it accurately. Satisfaction with GP services was high in both types of practice, but fundholding patients reported higher levels of satisfaction with getting a referral to a hospital specialist (FH: 81% vs. NFH: 63%), and with the length of time between referral and treatment (FH: 81% vs. NFH: 59%). A majority of patients in both types of practice wanted to be involved in decisions about the services available to them but only a third of patients thought that fundholding would make this easier. Fundholding patients were more likely to report being given enough choice about treatments available to them (51%) than their non-fundholding counterparts (35%). Fundholding patients had not perceived a reduction in quality of care as a result of budgetary pressures and were more satisfied with the process of referral to secondary care than their counterparts in non-fundholding practices. Patients in both types of practice felt that it was important to be involved in decisions about the services available to them, but few thought that this would be more likely as a result of fundholding. Provision of information to patients is a prerequisite for their involvement, but judging by the number of patients receiving any information about fundholding from their practices this aspect of the reforms does not seem to have been implemented.

Journal Article↗

PubMed1995

Investigation of benefits and costs of an ophthalmic outreach clinic in general practice.

BACKGROUND: With the advent of general practitioner fundholding, there has been growth in outreach clinics covering many specialties. The benefits and costs of this model of service provision are unclear. AIM: A pilot study aimed to evaluate an outreach model of ophthalmic care in terms of its impact on general practitioners, their use of secondary ophthalmology services, patients' views, and costs. METHOD: A prospective study, from April 1992 to March 1993, of the introduction of an ophthalmic outreach service in 17 general practices in London was undertaken. An ophthalmic outreach team, comprising an ophthalmic medical practitioner and an ophthalmic nurse, held clinics in the practices once a month. Referral rates to Edgware General Hospital ophthalmology outpatient department over one year from the study practices were compared with those from 17 control practices. General practitioners' assessments of the scheme and its impact on their knowledge and practice of ophthalmology were sought through a postal survey of all partners and interviews with one partner in each practice. Patient surveys were conducted using self-administered structured questionnaires. A costings exercise compared the outreach model with the conventional hospital ophthalmology outpatient clinic. RESULTS: Of 1309 patients seen by the outreach team in the study practices, 480 (37%) were referred to the ophthalmology outpatient department. The annual referral rate to this department from control practices was 9.5 per 10,000 registered patients compared with 3.8 per 10,000 registered patients from study practices. A total of 1187 patients were referred to the outpatient department from control practices. An increase in knowledge of ophthalmology was reported by 18 of 47 general practitioners (38%). Nineteen (40%) of 47 general practitioners took advantage of the opportunity for inservice training with the outreach team; they were more likely to change their routine practice for ophthalmic care or referral criteria for patients with cataracts or diabetes than those who did not attend for inservice training. The outreach scheme was popular with patients, for whom ease of access and familiarity of surroundings were major advantages. The cost per patient seen in the outreach clinics (48.09 pounds) was about three times the cost per patient seen in the outpatient department (15.71 pounds). CONCLUSION: The model of ophthalmic outreach care in this pilot study was popular with patients and general practitioners and appeared to act as an effective filter of demand for care in the hospital setting. However, the educational impact of the scheme was limited. Although the unit costs (per patient) of the outreach scheme compared unfavourably with those of conventional outpatient treatment, potential health gains from this more accessible model of care require further exploration.

Ambulatory Care Facilities↗

PubMed1999

Explaining variation in hospital admission rates between general practices: cross sectional study.

OBJECTIVES: To quantify the extent of the variation in hospital admission rates between general practices, and to investigate whether this variation can be explained by factors relating to the patient, the hospital, and the general practice. DESIGN: Cross sectional analysis of routine data. SETTING: Merton, Sutton, and Wandsworth Health Authority, which includes areas of inner and outer London. SUBJECTS: 209 136 hospital admissions in 1995-6 in patients registered with 120 general practices in the study area. MAIN OUTCOME MEASURES: Hospital admission rates for general practices for overall, emergency, and elective admissions. RESULTS: Crude admission rates for general practices displayed a twofold difference between the 10th and the 90th centile for all, emergency, and elective admissions. This difference was only minimally reduced by standardising for age and sex. Sociodemographic patient factors derived from census data accounted for 42% of the variation in overall admission rates; 45% in emergency admission rates; and 25% in elective admission rates. There was a strong positive correlation between factors related to deprivation and emergency, but not elective, admission rates, raising questions about equity of provision of health care. The percentage of each practice's admissions to different local hospitals added significantly to the explanation of variation, while the general practice characteristics considered added very little. CONCLUSIONS: Hospital admission rates varied greatly between general practices; this was largely explained by differences in patient populations. The lack of significant factors related to general practice is of little help for the direct management of admission rates, although the effect of sociological rather than organisational practice variables should be explored further. Admission rates should routinely be standardised for differences in patient populations and hospitals used.

Cross-Sectional Studies↗

PubMed1979

The manpower debate -- what is the current position in relation to general practice?

With the changing situation in medical manpower, it is important that a close watch be kept on the total number of medical practitioners in the community and their distribution between salaried and self-employed work, between hospital and community practice, between city and country practice, between general and specialist practice and between the general specialties and subspecialties. More accurate manpower data are now being sought by the Medical Boards and what must be emphasized is that the collection of these data has to be regular and ongoing, with surveys being conducted each year at the time of registration, and not just spasmodically as the need arises. The groups involved in planning for medical manpower must be able to work with accurate information. Australia is a long way from defining how many medical practitioners are needed in the community, and the RACGP is certainly a long way from defining the number of general practitioners who are needed. As a result, it is probably inappropriate at present to evaluate the current numbers of general practitioners against any stated level of adequacy.

Australia↗

PubMed2003

A national census of Irish general practice training programme graduates 1990-1996.

We followed the career pathways of all graduates of Irish general practice training schemes between 1990 and 1996 inclusive, with specific reference to their current positions, ten year aspirations, perceived barriers to their ideal career and attitudes to out of hours work. A postal survey using a structured questionnaire was performed. Addresses were identified for 253 of the 266 graduates (95%). A total of two hundred and nine responses were received (84% of those with an identifiable address). 173 (83%) have remained in general practice; 90% in Ireland and 60% in the same health board of their training programme. The preferred career option for 79% was to be a general practice principal; this differed significantly between males (89%) and females (74%) (p=0.016). Being a single-handed general practitioner was the preferred option for 2%; 43% considered this unacceptable. A half would prefer to work in a country town; one third considered a rural location as unacceptable. 'Out of hours' commitment and availability of local posts were the most commonly perceived barriers to career progress (53% and 45% respectively). 26% were not prepared to do any out of hours work; this differed significantly between males (10%) and females (30%) (p<.001). 17% have permanently left a career in general practice. Female general practitioners were not significantly more likely than male general practitioners to have left (19% vs. 14%, p=0.3). The most common reason given for leaving general practice was other career interest (78%). The significant increase in female general practice graduates over the past twenty years is highlighted. The vast majority of these female graduates wished to be a principal in a group practice and were prepared to undertake out of hours work. There is also a mismatch between career aspirations and the present structure of general practice in Ireland. The urgent need for changes in health system organisation to ensure that these intentions can be fulfilled is emphasised.

Career Choice↗

PubMed1995

Allocating census data to general practice populations: implications for study of prescribing variation at practice level.

OBJECTIVES: To assign census data to general practice populations and to test accuracy of different procedures for estimating the proportion of patients aged over 64. DESIGN: Patients' postcodes from patient register of one family health services authority and the directory linking postcodes to census enumeration districts were used to locate patients in their census area of residence. With different levels of census geography and four different allocation procedures, proportion of patients aged over 64 in each area was used to predict proportion of patients aged over 64 in each general practice. Predicted figures were compared with real figures from each practice register to assess accuracy of allocation methods. SETTING: Data from 1991 census and from 73 practices administered by one family health services authority. MAIN OUTCOME MEASURES: Actual and predicted proportions of patients aged over 64 in general practice populations. RESULTS: Correlations between actual and predicted proportions of patients aged over 64 were significant for all four allocation procedures--values of 0.66, 0.7, 0.84, and 0.84 were achieved (P < 0.0005). Predicted ranges of proportions of patients aged over 64, however, were well short of those that actually existed, and significant differences existed between predicted percentages and actual figures for all four methods. CONCLUSION: Although predicted values correlated with actual values, the failure of the allocation procedures to correctly predict values, especially at the extremes, casts doubt on the validity of similar techniques for allocating census variables to general practice populations.

Age Factors↗

PubMed1964