Roles,risks, and responsibilities in maternity care: trainees' beliefs and the effects of practice obstetric training.

OBJECTIVES--To document the content of practice obstetric vocational training, the beliefs of general practitioner trainees about the roles of midwives and general practitioners in maternity care, and the risks of providing such care; and to ascertain if undergoing such training affects their beliefs. DESIGN--Confidential postal questionnaire survey. SUBJECTS--Random one in four sample of all general practitioner trainees in the United Kingdom on vocational training schemes or in training practices in autumn 1990. MAIN OUTCOME MEASURES--Beliefs scored on seven point Likert scales and characteristics of trainer and training practice. RESULTS--Of 1019 trainees sent questionnaires, 765 (75.1% response rate) replied; 638 (83.3%) had done some part of their practice year. Of their trainers, 224 (35.1%) provided full obstetric care. 749 (99%) and 364 (48%) trainees believed that midwives and general practitioners respectively have an important role in normal labour; 681 (91.7%) trainees believed that general practice intrapartum care is a high risk "specialty." Those trainees whose trainers provide full obstetric care were significantly more likely to believe that both midwives and general practitioners have an important role in abnormal labour and to see the provision of intrapartum care as an incentive to join a practice. CONCLUSION--In this series most general practitioner trainees believed that both midwives and general practitioners have important roles in maternity care. Exposure of trainees to the provision of full obstetric care while in their training practice resulted in a more positive attitude towards the provision of such care by general practitioners.     

Hospital admissions for asthma in east London: associations with characteristics of local general practices,prescribing, and population.

OBJECTIVE: To determine the relative importance of appropriate prescribing for asthma in explaining high rates of hospital admission for asthma among east London general practices. DESIGN: Poisson regression analysis describing relation of each general practice''s admission rates for asthma with prescribing for asthma and characteristics of general practitioners, practices, and practice populations. SETTING: East London, a deprived inner city area with high admission rates for asthma. SUBJECTS: All 163 general practices in East London and the City Health Authority (complete data available for 124 practices). MAIN OUTCOME MEASURES: Admission rates for asthma, excluding readmissions, for ages 5-64 years; ratio of asthma prophylaxis to bronchodilator prescribing; selected characteristics of general practitioners, practices, and practice populations. RESULTS: Median admission rate for asthma was 0.9 (range 0-3.6) per 1000 patients per year. Higher admission rates were most strongly associated with small size of practice partnership: admission rates of singlehanded and two partner practices were higher than those of practices with three or more principals by 1.7 times (95% confidence interval 1.4 to 2.0, P < 0.001) and 1.3 times (1.1 to 1.6, P = 0.001) respectively. Practices with higher rates of night visits also had significantly higher admission rates: an increase in night visiting rate by 10 visits per 1000 patients over two years was associated with an increase in admission rates for asthma by 4% (1% to 7%). These associations were independent of asthma prescribing ratios, measures of practice resources, and characteristics of practice populations. CONCLUSIONS: Higher asthma admission rates in east London practices were most strongly associated with smaller partnership size and higher rates of night visiting. Evaluating ways of helping smaller partnerships develop structured proactive care for asthma patients at high risk of admission is a priority.     

Psychological and social problems in HIV infection: interviews with general practitioners in London.

OBJECTIVE--To assess current practice and opinions of general practitioners in London about managing psychological and social problems relating to HIV infection. DESIGN--A stratified random sample of general practitioners, including those with a range of experience of people with HIV infection, were interviewed by medically trained interviewers. SETTING--Doctor''s surgeries. PARTICIPANTS--270 General practitioners working within the area covered by London postcodes. RESULTS--Two thirds of doctors had treated at least one patient with HIV infection and described their work with these patients. General practitioners were counselling and educating many of their patients about AIDS and associated risk behaviours and were aware of the need for careful attention to confidentiality. Doctors with no experience of patients with HIV infection were often older, in singlehanded practice, less inclined to deal with drug abusers or to counsel their patients on risk behaviours, and more in favour of insurance companies'' policies towards people with HIV infection. CONCLUSIONS--General practitioners in London are quickly becoming involved in the care of patients with HIV infection and their relatives and friends. Many are counselling patients and testing for antibodies themselves and regard this as an integral part of their work. A considerable workload in primary care comprised patients who obsessively fear contracting HIV infection.     

Uptake of immunisation in district health authorities in England

The uptakes of immunisation in the district health authorities in England were studied for the years 1983-5. Multiple regression analysis showed that the factors significantly associated with a low uptake of immunisation were mainly related to social conditions, particularly overcrowding of households and population density. Of the service factors, high proportions of elderly and singlehanded general practitioners and high average list sizes were also associated with a low uptake of immunisation in some of the analyses.The results suggest that the measures outlined in the government''s white paper on improving primary health care services are likely to lead to improved uptakes of immunisation. If, however, the uptakes of immunisation are used as a measure of standards of the services provided they should first be adjusted to control for variations in social conditions, and the quality of vaccination data would have to be improved.     

Provision of first contact care out of hours in four urban areas in England.

In a typical two week period in 1984 in three urban areas with general practitioner deputising services roughly 40% of first contact patient encounters out of hours were with hospital accident and emergency departments, and only a quarter were with general practitioner deputising services, although 47%, 64%, and 97% of general practitioners in the areas had permission to use such services. Roughly a third only of the encounters were with the practices themselves, and even fewer occurred overnight (11 pm-7 am). In a fourth urban area where 68% of general practitioners formed an out of hours cooperative rota a third of the encounters were with the accident and emergency department and half (more overnight) were with the rota. The presence of a woman principal in a practice and large partnerships of four principals or more were associated with an increased proportion of encounters with the practice itself. Undue prominence may have been given to the role of deputising services in out of hours care. Paradoxically, the use of general practitioner cooperatives may result in even less personal care being given by the patient''s own practice.     

Home care for patients with suspected myocardial infarction: use made by general practitioners of a hospital team for initial management.

Two hundred and sixty three general practitioners were offered the use of a hospital based service consisting of a medical senior house officer, a nurse attached to a coronary care unit, and a specially equipped ambulance estate car to help with the initial management of patients with suspected myocardial infarction who might be suitable for home care. One hundred and sixty nine general practitioners registered as potential users of this service; during 22 months they called the hospital team to see 271 patients, 235 of whom the team suspected had indeed suffered a myocardial infarction. During the same period, however, these general practitioners also admitted 317 patients with suspected myocardial infarction directly to hospital. Other general practitioners admitted 323 patients and deputising doctors 258. A further 529 patients with suspected infarction were admitted without the intervention of a general practitioner. Of the patients seen by the team, 54 required immediate admission to hospital; 17 of the remaining patients who initially appeared suitable for home care later required admission to hospital. In a large city such as Nottingham the provision of hospital based facilities to help general practitioners with home management is unlikely to make an appreciable impact on the overall pattern of care of patients with suspected myocardial infarction.     

Is histological examination of tissue removed by general practitioners always necessary? Before and after comparison of detection rates of serious skin lesions.

OBJECTIVES: To examine whether histological examination of all tissue removed by general practitioners in minor surgery increases the rate of detection of clinically important skin lesions, and to assess the impact of such a policy on pathologists'' workload. DESIGN: Before and after comparison. SETTING: Stratified random sample of 257 general practitioner partnerships from the catchment areas of 19 English pathology laboratories. SUBJECTS: Tissue removed in minor surgery by general practitioners during the control period (September 1992 to February 1993) and intervention period (September 1993 to February 1994). INTERVENTION: General practitioners referred to their local pathology laboratory all solid tissue removed in all minor surgery, irrespective of their previous policy. MAIN OUTCOME MEASURES: Numbers of specimens referred for histology by general practitioners during intervention and control periods; numbers of primary malignant melanomas, non-melanoma malignancies, premalignant lesions, and benign lesions. RESULTS: 257/330 partnerships participated (response rate 78%). During the intervention period 5723 specimens were sent, compared with 4430 during the control period. The referral rate increased by an estimated 1.34 specimens per 1000 patient years (95% confidence interval 0.93 to 1.76, P < 0.0001). General practitioners sent 204 specimens that were malignant (including 16 malignant melanomas) in the control period and 188 that were malignant (including 15 malignant melanomas) during the intervention period (change in total number of malignancies, -1.0 per 100,000 patient years (-5.9 to 3.8, non-significant). CONCLUSIONS: The intervention was associated with a substantial increase in laboratory workload, all of which was accounted for by increases in non-serious lesions. This observation should be taken into account when considering the merits of a policy requiring histological examination in every case.     

Use of non-orthodox and conventional health care in Great Britain.

OBJECTIVE--To describe the characteristics of patients using non-orthodox health care and their pattern of use of conventional health care with respect to a particular problem. DESIGN--Postal survey of all 2152 practitioners of acupuncture, chiropractic, homeopathy, naturopathy, and osteopathy identified from 11 national professional association registers. Patients attending a representative sample of 101 responding practitioners completed questionnaires covering demographic characteristics, presenting problems, and use of the health service. SETTING--Practices of practitioners of non-orthodox health care in England, Scotland, and Wales. SUBJECTS--Qualified, non-medical practitioners of non-orthodox health care working in Great Britain and 2473 patients who had attended one of the sampled practitioners in an allocated time period between August 1987 and July 1988. RESULTS--An estimated 1909 practitioners were actively practising one of the study treatments in Great Britain in 1987. Of the estimated 70,600 patients seen by this group of practitioners in an average week, most (78%) were attending with a musculoskeletal problem. Two thirds of the patients were women. Only 2% were aged under 16, but 15% were aged 65 or over. One in three patients had not received previous conventional care for their main problem; 18% were receiving concurrent non-orthodox and conventional care. Twenty two per cent of the patients reported having seen their general practitioner for any reason in the two weeks before the surveyed consultation. CONCLUSIONS--Patients of non-orthodox health care, as provided by this group of practitioners, had not turned their backs on conventional health care. Non-orthodox treatment was sought for a limited range of problems and used most frequently as a supplement to orthodox medicine.     

Nurse practitioners in primary care iv. Impact of an interdisciplinary team on attitudes of a rural population.

Attitudes toward the expanded role of nurse practitioners in primary care (family practice nurses) have been determined for persons from a semirural area who chose as their principal souce of care an interdisciplinary family medical centre (FMC) incorporating two nurse practitioners, and those for whom the FMC was not the usual source of care. Data were obtaine using"before-and-after" structured interviews of a random sample of persons living in a southern Ontario township. Slowly evolving, nonsignificant trends of greater acceptance were observed among patiens who had dealth with family practice nurses. The greatest change observed was an increased acceptance of the nnurse by FMC users as the person who would be contacted as a second choice if theirfirst choice, usually a physician, could not be reached in specific worrry-inducing situations. FMC users depended more on nurses to provide information. A conclusion of increased general acceptance of the family practive nurse by FMC users is supported by a 34 per cent higher use of nurses by FMC patients compared to other persons of comparable characteristics living in the same community.     

Influences on hospital admission for asthma in south Asian and white adults: qualitative interview study

ObjectiveTo explore reasons for increased risk of hospital admission among south Asian patients with asthma.DesignQualitative interview study using modified critical incident technique and framework analysis.SettingNewham, east London, a deprived area with a large mixed south Asian population.Participants58 south Asian and white adults with asthma (49 admitted to hospital with asthma, 9 not admitted); 17 general practitioners; 5 accident and emergency doctors; 2 out of hours general practitioners; 1 asthma specialist nurse.ResultsSouth Asian and white patients admitted to hospital coped differently with asthma. South Asians described less confidence in controlling their asthma, were unfamiliar with the concept of preventive medication, and often expressed less confidence in their general practitioner. South Asians managed asthma exacerbations with family advocacy, without systematic changes in prophylaxis, and without systemic corticosteroids. Patients describing difficulty accessing primary care during asthma exacerbations were registered with practices with weak strategies for asthma care and were often south Asian. Patients with easy access described care suggesting partnerships with their general practitioner, had better confidence to control asthma, and were registered with practices with well developed asthma strategies that included policies for avoiding hospital admission.ConclusionsThe different ways of coping with asthma exacerbations and accessing care may partly explain the increased risk of hospital admission in south Asian patients. Interventions that increase confidence to control asthma, confidence in the general practitioner, understanding of preventive treatment, and use of systemic corticosteroids in exacerbations may reduce hospital admissions. Development of more sophisticated asthma strategies by practices with better access and partnerships with patients may also achieve this.

What is already known on this topic

South Asian patients with asthma are at increased risk of hospital admission with asthma compared with white patientsNo consistent differences in severity or prevalence of asthma, prescribed drugs, or asthma education have been described, and interventions to reduce admission rates in Asian patients have met with variable success

What this study adds

Compared with white patients, south Asian patients admitted to hospital with asthma had less confidence to control asthma, were unfamiliar with the concept of preventive medication, and had less confidence in their general practitionersSouth Asian patients managed asthma attacks through family advocacy and without systematic changes in prophylaxis and without systemic corticosteroidsPatients reporting difficulty in accessing primary care during attacks were often south Asian     

Findings of a national survey of the role of general practitioners in the treatment of opiate misuse: views on treatment.

An important component of government policy on services for drug misusers is to encourage general practitioners to take a more active role. There are, however, some indications that general practitioners regard drug misusers as undesirable patients, although no evidence is available. As part of a wider investigation of the role of general practitioners in the treatment of opiate misuse, a questionnaire, which was sent in mid-1985 to a 5% random sample of general practitioners in England and Wales, included a section designed to elicit their views on policy and treatment connected with opiate misuse. The results showed that although most general practitioners consider opiate misuse to be a priority concern for the Health Service, they also generally regard opiate misusers as especially difficult to manage, beyond their competence to treat, and less acceptable as patients than others in need of care. General practitioners who have qualified recently were somewhat less unfavourable in their views. These findings suggest that the effective implementation of government policy will require trying to modify general practitioners'' attitudes and providing support for them.     

Evaluation of a primary care adult mental health service: Year 2

Aims This study aimed to examine the effectiveness of a primary care adult mental health service operating within a stepped care model of service delivery.Methods Supervised by a principal psychologist manager, psychology graduate practitioners provided one-to-one brief cognitive behavioural therapy (CBT) to service users. The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) was used to assess service user treatment outcomes. Satisfaction questionnaires were administered to service users and referring general practitioners (GPs).Results A total of 43 individuals attended for an initial appointment, of whom 19 (44.2%) completed brief CBT treatment. Of the 13 service users who were in the clinical range pre-treatment, 11 (84.6%) achieved clinical and reliably significant improvement. Of the six service users who were in the non-clinical range pre-treatment, three (50%) achieved reliably significant improvement. Both service users and GPs indicated high levels of satisfaction with the service, although service accessibility was highlighted as needing improvement.Conclusion The service was effective in treating mild to moderate mental health problems in primary care. Stricter adherence to a stepped care model through the provision of low-intensity, high-throughput interventions would be desirable for future service provision.     

Effect of medicolegal liability on patterns of general and family practice in Canada.

As part of the Federal/Provincial/Territorial Review on Liability and Compensation Issues in Health Care, in 1988 we surveyed Canadian general practitioners and family physicians to determine the effect of liability concerns on their practices in the previous 5 years. Questionnaires were sent to a random, stratified national sample of 1295 physicians, with a response rate of 64.6%. However, a high proportion of the returned questionnaires were ineligible because the physicians were not in general or family practice, were not involved in direct patient care, or had died or moved; thus, the corrected response rate was 50.8%. The newsletter of the Canadian Medical Protective Association was the source of information on liability most frequently cited (by 88.1% of the physicians) and most influential (to 62.4%). Only 15.5% of the physicians cited personal involvement with medicolegal issues as a source of information; the rate was higher for Ontario physicians and those in urban areas generally. A total of 74.6% of the respondents had altered their style of practice in the previous 5 years, and 56.3% reported changes in the scope of their practice. Concern about litigation was the most important reason for changing style of practice and reducing or eliminating administration of anesthesia, whereas lifestyle and other issues along with liability concerns most influenced decisions to reduce obstetric care and emergency department work. Our findings suggest that physicians'' perceptions of liability issues have had a profound influence on primary care practice in Canada in the past several years.     

Sources of primary health care for women in an urban centre.

Family or general practitioners and obstetrician-gynecologists have the opportunity to provide primary health care to women. Who actually gives this care in a large urban setting was the focus of this study. In the Montreal area 297 women were asked by telephone whether they had an obstetrician-gynecologist and whether they would see another type of doctor for a cold that was not getting better. Overall, 88% of all the women indicated that they would go to a family or general practitioner for such a problem, and of the women who reported receiving some care from an obstetrician-gynecologist 78% also received care from another physician. Of the respondents seeking health care from only one type of doctor, women with English as the mother tongue were significantly more likely to attend an obstetrician-gynecologist, whereas French-speaking women much more often were cared for by family or general practitioners.     

Screening Primary-Care Patients Forgoing Health Care for Economic Reasons

Background

Growing social inequities have made it important for general practitioners to verify if patients can afford treatment and procedures. Incorporating social conditions into clinical decision-making allows general practitioners to address mismatches between patients'' health-care needs and financial resources.

Objectives

Identify a screening question to, indirectly, rule out patients'' social risk of forgoing health care for economic reasons, and estimate prevalence of forgoing health care and the influence of physicians'' attitudes toward deprivation.

Design

Multicenter cross-sectional survey.

Participants

Forty-seven general practitioners working in the French–speaking part of Switzerland enrolled a random sample of patients attending their private practices.

Main Measures

Patients who had forgone health care were defined as those reporting a household member (including themselves) having forgone treatment for economic reasons during the previous 12 months, through a self-administered questionnaire. Patients were also asked about education and income levels, self-perceived social position, and deprivation levels.

Key Results

Overall, 2,026 patients were included in the analysis; 10.7% (CI95% 9.4–12.1) reported a member of their household to have forgone health care during the 12 previous months. The question “Did you have difficulties paying your household bills during the last 12 months” performed better in identifying patients at risk of forgoing health care than a combination of four objective measures of socio-economic status (gender, age, education level, and income) (R² = 0.184 vs. 0.083). This question effectively ruled out that patients had forgone health care, with a negative predictive value of 96%. Furthermore, for physicians who felt powerless in the face of deprivation, we observed an increase in the odds of patients forgoing health care of 1.5 times.

Conclusion

General practitioners should systematically evaluate the socio-economic status of their patients. Asking patients whether they experience any difficulties in paying their bills is an effective means of identifying patients who might forgo health care.     

Contribution of general practitioner hospitals in England and Wales.

A survey of a one-in-seven sample of general practitioner hospitals in England and Wales, performed to determine the contribution they make to overall hospital work load and the attitudes of the general practitioners working in them, showed that 3% of acute hospital beds in England and Wales were in general practitioner hospitals, which provided initial hospital care for up to 20% of the population. Altogether 16% of general practitioners and 22% of consultants were on the staffs, and they coped with more than 13% of all casualties, 6% of operations, and 4% of x-ray examinations. Nearly a million casualties were treated at no cost to the National Health Service. Twenty new district general hospitals would be needed to cope with the work load currently dealt with by general practitioner hospitals. The results of this survey indicate that these smaller hospitals deal efficiently and cheaply with their work load, and that morale is high. General practitioner hospitals could have an important part to play in providing certain types of care, but there are no financial incentives to enable general practitioners to realise this potential fully.     

Measuring outcomes in primary care: a patient generated measure,MYMOP, compared with the SF-36 health survey.

OBJECTIVE--To assess the sensitivity to within person change over time of an outcome measure for practitioners in primary care that is applicable to a wide range of illness. DESIGN--Comparison of a new patient generated instrument, the measure yourself medical outcome profile (MYMOP), with the SF-36 health profile and a five point change score; all scales were completed during the consultation with'' practitioners and repeated after four weeks. 103 patients were followed up for 16 weeks and their results charted; seven practitioners were interviewed. SETTING--Established practice of the four NHS general practitioners and four of the private complementary practitioners working in one medical centre. SUBJECTS--Systematic sample of 218 patients from general practice and all 47 patients of complementary practitioners; patients had had symptoms for more than seven days. OUTCOME MEASURES--Standardised response mean and index of responsiveness; view of practitioners. RESULTS--The index of responsiveness, relating to the minimal clinically important difference, was high for MYMOP: 1.4 for the first symptom, 1.33 for activity, and 0.85 for the profile compared with < 0.45 for SF-36. MYMOP''s validity was supported by significant correlation between the change score and the change in the MYMOP score and the ability of this instrument to detect more improvement in acute than in chronic conditions. Practitioners found that MYMOP was practical and applicable to all patients with symptoms and that its use increased their awareness of patients'' priorities. CONCLUSION--MYMOP shows promise as an outcome measure for primary care and for complementary treatment. It is more sensitive to change than the SF-36 and has the added bonus of improving patient-practitioner communication.     

Sickness certification system in the United Kingdom: qualitative study of views of general practitioners in Scotland

Objectives To explore how general practitioners operate the sickness certification system, their views on the system, and suggestions for change.Design Qualitative focus group study consisting of 11 focus groups with 67 participants.Setting General practitioners in practices in Glasgow, Tayside, and Highland regions, Scotland.Sample Purposive sample of general practitioners, with further theoretical sampling of key informant general practitioners to examine emerging themes.Results General practitioners believed that the sickness certification system failed to address complex, chronic, or doubtful cases. They seemed to develop various operational strategies for its implementation. There appeared to be important deliberate misuse of the system by general practitioners, possibly related to conflicts about roles and incongruities in the system. The doctor-patient relationship was perceived to conflict with the current role of general practitioners in sickness certification. When making decisions about certification, the general practitioners considered a wide variety of factors. They experienced contradictory demands from other system stakeholders and felt blamed for failing to make impossible reconciliations. They clearly identified the difficulties of operating the system when there was no continuity of patient care. Many wished either to relinquish their gatekeeper role or to continue only with major changes.Conclusions Policy makers need to recognise and accommodate the range and complexity of factors that influence the behaviour of general practitioners operating as gatekeepers to the sickness certification system, before making changes. Such changes are otherwise unlikely to result in improvement. Models other than the primary care gatekeeper model should be considered.     

Community care service for diabetics in the Poole area.

Because of an increasing work load at the hospital diabetic clinic in Poole general practitioners were asked to help in a community care service for diabetics. In this, general practitioners typically care for non-ketotic patients with maturity onset diabetes who are well controlled on diet or diet and oral hypoglycaemic agents, while the clinic concentrates on more difficult cases and screens patients for long-term complications. The hospital laboratory''s work load has been eased because patients may attend for two-hour interval blood sugar estimations when they like; most patients appreciate this flexibility and prefer being looked after by their own doctor. The service has not increased the general practitioners'' work load unduly, but it has heightened their awareness of diabetes in the community, thus allowing the diabetic consultant to deal with the problems for which he has been trained. The service has thus provided improved care for all diabetics in the Poole area.     

Geriatrisch spreekuur door een specialist ouderengeneeskunde in de huisartspraktijk

An innovative project is presented, in which general practitioners, an elderly care physician and specialized nurses work together. The primary aim of the project was early detecting of frail community dwelling elderly and to give them adequate treatment and support, to enable them to stay in their own home situation as long as possible. The detection of frail elderly was performed by mean of the Easycare instrument. Results collected from October 2007 - July 2009 are presented in this article. The findings show that particularly elderly with symptoms of dementia have been detected. The main actions were provision of integrated psychogeriatric care according to a tailormade integral care plan and starting or extending home care. Elderly with somatic problems were seen mostly in one time consultations. The satisfaction about the care provided in the project was high, both for participating patients and professionals. In the pilot a tendency was also found towards fewer referrals to hospital (specialists) and towards a reduction of the number of acute admissions to the nursing home.