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.     

Family doctors and innovation in general practice

Family doctors have been presented with changes in government policies and incentives in a recent white paper on primary care. Little work has been done, however, to find out how general practitioners respond to such measures. The response of general practitioners to professional and economic incentives was examined in relation to the location of the practice and the characteristics of the practitioners in seven different areas of England. The areas represented urban, rural, affluent, and deprived communities. The overall response rate was 74%, but the response varied among the areas, being poorest (64%) in an inner city area. Practices were subdivided as innovative, traditional, or intermediate, according to whether they employed a nurse and participated in the cost rent scheme and the vocational training scheme. Innovative practices were defined as fulfilling two of these criteria and traditional practices as fulfilling none; the remainder were classed as intermediate. The results showed that these three types of practice had distinct strategies that were related to financial constraints and the local population. Innovative practices had more partners and were often located in rural or affluent suburban areas; traditional practices had fewer partners and were more common in urban and working class areas. Innovative practices seemed to be in the best position to increase their services, and hence their incomes, in response to the recent proposals in the white paper. Practices in areas of developmental difficulty (predominantly urban but not necessarily inner city areas) had been less able to respond to existing incentives and had a smaller margin available for developing their services.In view of the effect of local constraints of economics and population on the strategy of practices, concentrating resources for primary care in local budgets for working class and urban areas may be preferable to extending the system of charging fees for services provided by family doctors.     

Family doctors: their choice of practice strategy.

The economic decisions taken by family doctors in one family practitioner area in the north of England were examined. There was evidence of a differential response to professional and economic incentives by a group of "high investing" practices. On five indicators of improvement in practice 32% of the practices accounted for 71% of the positive scores. Nearly all the high investing practices were in affluent areas; they were on average larger and had younger partners than the other practices. The high investing practices also faced more financial problems. There was evidence that older doctors with long lists of patients had a different strategy of income maximization. Innovation in primary care is not determined by attitude alone but also by objective factors such as age, location, and size of the practice.     

Improving uptake of breast screening in multiethnic populations: a randomised controlled trial using practice reception staff to contact non-attenders.

OBJECTIVES: To determine whether a two hour training programme for general practice reception staff could improve uptake in patients who had failed to attend for breast screening, and whether women from different ethnic groups benefited equally. DESIGN: Controlled trial, randomised by general practice. SETTING: Inner London borough of Newham. SUBJECTS: 2064 women aged 50-64 years who had failed to attend for breast screening. Women came from 26 of 37 eligible practices, 31% were white, 17% were Indian, 10% Pakistani, 14% black, 6% Bangladeshi, 1% Chinese, 4% were from other ethnic groups, and in 16% the ethnic group was not reported. MAIN OUTCOME MEASURES: Attendance for breast screening in relation to ethnic group in women who had not taken up their original invitation. RESULTS: Attendance in the intervention group was significantly better than in the control group (9% v 4%). The response was best in Indian women--it was 19% in the intervention group and 5% in the control group. CONCLUSIONS: This simple, low cost intervention improved breast screening rates modestly. Improvement was greatest in Indian women--probably because many practice staff shared their cultural and linguistic background. This intervention could be effective as part of a multifaceted strategy to improve uptake in areas with low rates.     

Use of thermometers in general practice.

OBJECTIVE--To identify the attitudes of general practitioners towards the use of thermometers in general practice. DESIGN--Postal questionnaire survey. SETTING--All general practitioners in the catchment area of Frimley Park Hospital, Surrey. SUBJECTS--145 general practitioners. MAIN OUTCOME MEASURES--Answers to questions covering a variety of aspects concerning the use of thermometers in general practice. RESULTS--116 (80%) doctors replied. Seven doctors did not have any method of taking a patient''s temperature; up to 12 more doctors did not use their thermometers and 56 doctors used them infrequently, less than once a fortnight. Mercury glass thermometers were most commonly used (80 doctors; 69%), but only 8% of doctors used them correctly. Six doctors failed to clean their thermometers between patients. The study failed to identify the roles of axillary and rectal temperature readings. CONCLUSION--There is a wide variation in attitudes towards the use of thermometers in general practice.     

A career structure for general practice.

Training for general practitioners usually provides little experience in research, business management, or dealing with chronic disease. It is these areas that could provide scope for further training after becoming a general practitioner principal and provided career goals. Formally recognised research practices, perhaps with one partner coordinating research but all participating, and district research facilitators could increase both the quality and the quantity of research in general practice. Recognising the different skills of doctors in the partnership and referring patients to the most appropriate partner will improve care for patients as well as provide career development. Further training could be aimed at filling gaps in the practice''s pool of skills. Good management skills are becoming more important as practice teams get bigger and fundholding spreads. Some doctors may wish to become full time or part time managers and the idea of accredited courses for management has been raised.     

Recruiting new principals in general practice.

New principals in general practice who were appointed from 1981 to 1983 by two family practitioner committees, one in an inner city and one in a combination of an inner city and suburban area, were surveyed to find out if they were making improvements to primary medical care in their new practices. Most were not. The highly trained, motivated, young doctors on the whole had joined group practices and practices in health centres, where facilities tended to be good. Older doctors, who may not be as concerned with change, had joined smaller practices, in which it was difficult to make changes owing to, for example, the type of premises and costs.     

Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in east London.

OBJECTIVE--To determine whether locally developed guidelines on asthma and diabetes disseminated through practice based education improve quality of care in non-training, inner city general practices. DESIGN--Randomised controlled trial with each practice receiving one set of guidelines but providing data on the management of both conditions. SUBJECTS--24 inner city, non-training general practices. SETTING--East London. MAIN OUTCOME MEASURES--Recording of key variables in patient records (asthma: peak flow rate, review of inhaler technique, review of asthma symptoms, prophylaxis, occupation, and smoking habit; diabetes: blood glucose concentration, glycaemic control, funduscopy, feet examination, weight, and smoking habit); size of practice disease registers; prescribing in asthma; and use of structured consultation "prompts." RESULTS--In practices receiving diabetes guidelines, significant improvements in recording were seen for all seven diabetes variables. Both groups of practices showed improved recording of review of inhaler technique, smoking habit, and review of asthma symptoms. In practices receiving asthma guidelines, further improvement was seen only in recording of review of inhaler technique and quality of prescribing in asthma. Sizes of disease registers were unchanged. The use of structured prompts was associated with improved recording of four of seven variables on diabetes and all six variables on asthma. CONCLUSIONS--Local guidelines disseminated via practice based education improve the management of diabetes and possibly of asthma in inner city, non-training practices. The use of simple prompts may enhance this improvement.     

Patients' assessment of out of hours care in general practice

A sample of 177 patients drawn from 13 north London practices were interviewed shortly after they had sought help from their practice outside normal surgery hours. Patients were asked to describe the process and outcome of their out of hours call, to comment on specific aspects of the consultation, and to access their overall satisfaction with the encounter.Parents seeking consultations for children were least satisfied with the consultation; those aged over 60 responded most positively. Visits from general practitioners were more acceptable than visits from deputising doctors for patients aged under 60, but for patients aged over 60 visits from general practitioners and deputising doctors were equally acceptable.Monitoring of patients'' views of out of hours consultations is feasible, and the findings of this study suggest that practices should regularly review the organisation of their out of hours care and discuss strategies for minimising conflict in out of hours calls—particularly those concerning children.     

Identifying predictors of high quality care in English general practice: observational study

ObjectivesTo assess variation in the quality of care in general practice and identify factors associated with high quality care.Design Observational study.Setting Stratified random sample of 60 general practices in six areas of England.Results Quality of clinical care varied substantially, and access to care, continuity of care, and interpersonal care varied moderately. Scores for asthma, diabetes, and angina were 67%, 21%, and 17% higher in practices with 10 minute booking intervals for consultations compared with practices with five minute booking intervals. Diabetes care was better in larger practices and in practices where staff reported better team climate. Access to care was better in small practices. Preventive care was worse in practices located in socioeconomically deprived areas. Scores for satisfaction, continuity of care, and access to care were higher in practices where staff reported better team climate.Conclusions Longer consultation times are essential for providing high quality clinical care. Good teamworking is a key part of providing high quality care across a range of areas and may need specific support if quality of care is to be improved. Additional support is needed to provide preventive care to deprived populations. No single type of practice has a monopoly on high quality care: different types of practice may have different strengths.

What is already known on this topic

Quality of care varies in virtually all aspects of medicine that have been studiedMost studies look at quality of care from a single perspective or for a single condition

What this study adds

Quality of care varies for both clinical care and assessments by patients of access and interpersonal carePractices with longer booking intervals provide better management of chronic disease; preventive care is less good in practices in deprived areasNo single type of practice has a monopoly on high quality care—small practices provide better access but poorer diabetes careGood team climate reported by staff is associated with a range of aspects of high quality care     

Questioning behaviour in general practice: a pragmatic study.

OBJECTIVE: To study the extent to which general practitioners'' questioning behaviour in routine practice is likely to encourage the adoption of evidence based medicine. DESIGN: Self recording of questions by doctors during consultations immediately followed by semistructured interview. SETTING: Urban Australian general practice. SUBJECTS: Random sample of 27 general practitioners followed over a half day of consultations. MAIN OUTCOME MEASURES: Rate of recording of clinical questions about patients'' care which doctors would like answered; frequency with which doctors found answers to their questions. RESULTS: Doctors asked a total of 85 clinical questions, at a rate of 2.4 for every 10 patients seen. They found satisfactory answers to 67 (79%) of these questions. Doctors who worked in small practices (of one or two doctors) had a significantly lower rate of questioning than did those in larger practices (1.6 questions per 10 patients v 3.0 patients, P = 0.049). No other factors were significantly related to rate of questioning. CONCLUSIONS: These results do not support the view that doctors routinely generate a large number of unanswered clinical questions. It may be necessary to promote questioning behaviour in routine practice if evidence based medicine and other forms of self directed learning are to be successfully introduced.     

Lithium treatment: prescribing and monitoring habits in hospital and general practice.

OBJECTIVES--To define current clinical practice of lithium prescribing and monitoring and to compare hospital based practice with general practice. DESIGN--Prospective study of doctors'' practice. SETTING--Psychiatric hospital day and outpatient facilities and general practices in Edinburgh and Midlothian district (population 600,000). SUBJECTS--458 patients taking lithium who had been stabilised and who remained as outpatients during the year of study. 219 were treated by their general practitioner and 190 by the hospital; 49 had shared care or care transferred during the study. MAIN OUTCOME MEASURES--Daily dose, duration of treatment, psychiatric diagnosis, mean annual serum lithium concentration, frequency of occurrence of and response to raised serum concentrations. RESULTS--Compared with hospital doctors general practitioners were more likely to prescribe lithium three or more times daily (43/219 (general practice) v 10/190 (hospital); chi 2 = 18.6, p = 0.001) and to estimate serum concentrations less frequently (4.5 v 5.3 measurements/year; t = 3.04, p = 0.003), and their patients were more likely to experience raised lithium concentrations (39/219 v 17/190; chi 2 = 6.8, p = 0.01). One third of doctors made no response to raised lithium concentrations in the next six weeks. CONCLUSIONS--General practitioners and hospital doctors care for similar types of patients and the stringency of lithium surveillance varies greatly among doctors. Certain aspects of practice give cause for concern and could be improved by following more uniform guidelines.     

General practice orthopaedic outpatient referrals in North Staffordshire.

A study was made of 813 orthopaedic referrals by 134 general practitioners in North Staffordshire. The referral rates showed no relation to practice list size or the doctors'' previous orthopaedic experience. The published waiting times did not accurately reflect clinic vacancies, and no effective priority rating of letters by consultants was shown. Less than 1% of patients had an appointment within four weeks. One quarter of the patients failed to attend and, of those who did, 27% received physiotherapy or a "simple" appliance, or both, while 16% received treatment already available from their general practitioner. Patients from high referring doctors showed the same pattern of distribution in body area affected and treatment outcome as those from low referring doctors, but had a significantly longer time to wait for their appointment. A survey of non-attenders showed that 56% of the patients failed to attend because the condition had resolved.     

General practitioners' continuing medical education within and outside their practice.

To study continuing medical education 96 out of 101 general practitioners chosen at random from the list held by a family practitioner committee were interviewed. The results provided little evidence of regular attendance at local postgraduate centre meetings, though practice based educational meetings were common. Thirty one of the general practitioners worked in practices that held one or more practice based educational meetings each month at which the doctors provided the main educational content. Performance review was undertaken in the practices of 51 of the general practitioners, and 80 of the doctors recognised its value. The general practitioners considered that the most valuable educational activities occurred within the practice, the most valued being contact with partners. They asked for increased contact with hospital doctors. The development of general practitioners'' continuing medical education should be based on the content of the individual general practitioner''s day to day work and entail contact with his or her professional colleagues.     

Survey of general practice audit in Leeds.

OBJECTIVE--To determine general practitioners'' attitudes to medical audit and to establish what initiatives are already being undertaken; to define future ideas for audit and perceived difficulties in implementing audit in primary care. DESIGN--Analysis of responses to a self administered postal questionnaire. SETTING--Urban conurbation with a population of about 750,000. PARTICIPANTS--386 general practitioners on the general medical list of Leeds Family Practitioner Committee. MAIN OUTCOME MEASURES--Extent of recording of practice activity data and outcome measures and clinical data, use of data, and audit performed; ideas for audit and perceived difficulties. RESULTS--317 doctors responded to the questionnaire (individual response rate 82%) from 121 practices (practice response rate 88%). In all, 206 doctors thought that audit could improve the quality of care; 292 collected practice activity data, though 143 of them did not use it. A total of 111 doctors recorded some outcome measures, though half of them did not use them. Varying proportions of doctors had registers, for various diseases (136 had at least one register), disease management policies (60 doctors), and prescribing policies. In all, 184 doctors met monthly with other members of the primary health care team. CONCLUSIONS--Much poorly focused data collection is taking place. Some doctors have experience in setting up basic information systems and practice policies, and some audit is being performed. The family health services authorities need to take seriously the perceived difficulties of time, organisation, and resources concerned with audit.     

HIV and measures to control infection in general practice.

OBJECTIVE--To assess the impact of HIV on procedures to control infection in general practices. DESIGN--A postal questionnaire survey. SETTING--General practices throughout Britain. SUBJECTS--5359 General practitioners, 3429 (63.9%) of whom returned the questionnaire. MAIN OUTCOME MEASURE--Response to questionnaire on knowledge about HIV and policies for controlling infection. RESULTS--Most doctors (2018) had started to wear gloves when taking blood. Almost half (1510) had not resheathed needles previously but a further 776 had adopted this policy because of HIV. Over half of the doctors did not know or were unsure about the risk of infection from needlestick injuries, and 1759 had no practice policy for controlling infection. CONCLUSIONS--Many doctors are uncertain about measures to control infection in general practice. More information and advice are needed to help doctors develop policies to protect patients and staff.     

Buccaling under the pressure: influence of secondary care establishments on the prescribing of glyceryl trinitrate buccal tablets in primary care.

OBJECTIVE: To determine which characteristics were the best predictors of high rates of prescribing of glyceryl trinitrate buccal tablets. DESIGN: Practice and patient characteristics from 197 practices were examined, and a multiple regression analysis was performed to examine which variables were important in predicting this prescribing. SETTING: Former family health services authority (197 practices). MAIN OUTCOME MEASURE: Volume of prescribing of glyceryl trinitrate buccal tablets. RESULTS: Four variables contributed significantly to a multiple regression model: the catchment area of the secondary care establishment; the number of partners in a practice; the level of practice deprivation; and whether the practice served an urban or a rural area. The model suggests that the most important variable was the catchment area of the secondary care establishment in which the practice was located. CONCLUSION: Although only the prescribing of short acting glyceryl trinitrate buccal tablets was studied, an impact of this size on primary care prescribing may have extensive implications for all drug expenditure in primary care.     

Comparison of out of hours care provided by patients' own general practitioners and commercial deputising services: a randomised controlled trial. II: The outcome of care.

OBJECTIVE: To compare the outcome of out of hours care given by general practitioners from patients'' own practices and by commercial deputising services. DESIGN: Randomised controlled trial. SETTING: Four urban areas in Manchester, Salford, Stockport, and Leicester. SUBJECTS: 2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals in general practice) who responded to the requests. MAIN OUTCOME MEASURES: Health status outcome, patient satisfaction, and subsequent health service use. RESULTS: Patients seen by deputising doctors were less satisfied with the care they received. The mean overall satisfaction score for practice doctors was 70.7 (95% confidence interval 68.1 to 73.2) and for deputising doctors 61.8 (59.9 to 63.7). The greatest difference in satisfaction was with the delay in visiting. There were no differences in the change in health or overall health status measured 24 to 120 hours after the out of hours call or subsequent use of the health service in the two groups. CONCLUSIONS: Patients are more satisfied with the out of hours care provided by practice doctors than that provided by deputising doctors. Organisation of doctors into large groups may produce lower levels of patient satisfaction, especially when associated with increased delays in the time taken to visit. There seem to be no appreciable differences in health outcome between the two types of service.