Self referral to an accident and emergency department for another opinion.

OBJECTIVE--To determine whether patients referring themselves to an accident and emergency department for another opinion after consulting their general practitioner present with serious illness, show any risk factors for being admitted, or are more likely to be patients of particular practitioners. DESIGN--Six month prospective survey. SETTING--District general hospital''s accident and emergency department, receiving 42,000 new patients a year. PATIENTS--180 Patients identified as attending for another opinion having already consulted a general practitioner. INTERVENTIONS--Classified as admission, referral to specialist clinic, follow up in accident and emergency department, or referral back to general practitioner. END POINT--Admission, with an analysis of admitted patients. MEASUREMENTS AND MAIN RESULTS--General outcome, diagnostic category, age, time of attendance, time since seen by general practitioner, and name of general practitioner were recorded. Forty seven patients were admitted, 99 were discharged back to the general practitioner (62 without a letter), and two died. Patients were most likely to be admitted if they attended within 24 hours after seeing a general practitioner, were aged under 5, or presented with respiratory or gastrointestinal complaints. Some general practitioners were overrepresented. CONCLUSIONS--Important disorders present in this way, and therefore these patients should be seen by a doctor. Information about these attendances could be useful to general practitioners in reviewing their performance.     

A general practitioner in an ophthalmology accident and emergency department.

After a short period of intensive training, a general practitioner successfully replaced a senior house officer (SHO) in the accident and emergency department of an eye hospital on one morning a week for a year. An unbiased observer compared the performance of the general practitioner after one year with that of a full-time SHO who had had 17 months'' experience; their performances were about equal. Although a sessional general practitioner costs about 28% more than an SHO, the real cost is much less because undue length of service as an SHO or change to another specialty (because of the SHO surplus) delays achievement of a permanent grade. Continuity is a great advantage of the general practitioner. Replacement of some SHOs by general practitioners would reduce the surplus of SHOs with poor promotion prospects. The commonest diagnoses were Meibomian cysts (18%), corneal foreign bodies (20%), corneal abrasions (12%), and conjunctivitis (8%).     

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.     

Self referral to accident and emergency department: patients' perceptions.

A study was conducted (a) to assess the number of patients registered with a south London general practice who over 11 weeks referred themselves to an accident and emergency department, (b) to identify the characteristics of those patients, and (c) to determine their perceptions of the services and resources available within their general practices and of the role of accident and emergency departments. Two hundred and thirty four patients referred themselves to a casualty department during the study period, of whom 217 (93%) were interviewed by means of a semistructured questionnaire. Of the 217 patients interviewed, only 15 had tried to contact their general practitioner before attending the casualty department. Eighty nine patients considered that their problem was urgent and required immediate attention and many that they would need an x ray examination. A substantial minority of patients thought that their doctor would not be available. It is concluded that patients'' perceptions of their problems and of access to their doctors are the main determinants of self referral to a casualty department. These findings have important implications for patient education.     

Census of single homeless people in Sheffield.

OBJECTIVE--To determine the number of single homeless people in Sheffield and to examine their demography and social and medical details. DESIGN--Census carried out between 8 am and 8 pm on one day. Participants completed a questionnaire designed to provide data relating to employment history, contact with welfare and health services, social state, prison history, medical history, and health state. SETTING--Sites in Sheffield identified by local workers as being places of residence of homeless people. SUBJECTS--340 single homeless people. MAIN OUTCOME MEASURES--Self reported history of alcohol or drug misuse, existence of a chronic medical condition, and use of general practitioner and hospital services. RESULTS--The mean age of the population was 42.5 years and a quarter of the population were aged less than 30; there were 48 women. Significant differences were noted between men and women with respect to self reported psychiatric illness (77/266 men v 27/42 women), self reported alcoholism (83/273 v 4/44), prison history (152/255 v 8/41), and registration with a general practitioner (73/275 v 38/46). Various chronic medical conditions were reported, and the perceived health state of the population was low; 129 claimed to have been admitted to a psychiatric hospital. 220 people were registered with a general practitioner, and 179 claimed to see their doctor. Sixty five had attended or been admitted to a general hospital in the month preceding the study, 45 for accident and emergency services. CONCLUSIONS--The homeless in this population were younger than those found in previous studies. The prevalence of psychiatric illness was high in the population, and the overall health state was poor. Most subjects obtained health services from general practitioners.     

Facilitating care of patients with HIV infection by hospital and primary care teams.

To complement the role of primary care teams working with patients with HIV disease and AIDS within greater London and to ease the load on the special hospital units a home support team was developed. It comprises six specialist nurses, a general practitioner trained medical officer, and a receptionist and is funded from regional and district sources and charities. A nurse is available for out of hours and emergency weekend calls, with support from the patient''s general practitioner or the attached medical officer. During the first 18 months 249 patients were seen; the mean duration of care was five months. Nearly a third (18/50, 30%) of patients who were terminally ill died at home. The team''s activities included practical nursing care, emotional support for carers and patients, and advice and guidance to primary care teams. Problems in providing care in patients'' homes included issues relating to confidentiality and 24 hour cover. With the increasing incidence of HIV infection the home support team may be a useful model for care of large numbers of patients with symptomatic HIV disease, especially in large urban areas.     

Cost effectiveness of treating primary care patients in accident and emergency: a comparison between general practitioners,senior house officers,and registrars.

OBJECTIVES--To compare outcome and costs of general practitioners, senior house officers, and registrars treating patients who attended accident and emergency department with problems assessed at triage as being of primary care type. DESIGN--Prospective intervention study which was later costed. SETTING--Inner city accident and emergency department in south east London. SUBJECTS--4641 patients presenting with primary care problems: 1702 were seen by general practitioners, 2382 by senior house officers, and 557 by registrars. MAIN OUTCOME MEASURES--Satisfaction and outcome assessed in subsample of 565 patients 7-10 days after hospital attendance and aggregate costs of hospital care provided. RESULTS--Most patients expressed high levels of satisfaction with clinical assessment (430/562 (77%)), treatment (418/557 (75%)), and consulting doctor''s manner (434/492 (88%)). Patients'' reported outcome and use of general practice in 7-10 days after attendance were similar: 206/241 (85%), 224/263 (85%), and 52/59 (88%) of those seen by general practitioners, senior house officers, and registrars respectively were fully recovered or improving (chi2 = 0.35, P = 0.840), while 48/240 (20%), 48/268 (18%), and 12/57 (21%) respectively consulted a general practitioner or practice nurse (chi2 = 0.51, P = 0.774). Excluding costs of admissions, the average costs per case were 19.30 pounds, 17.97 pounds, and 11.70 pounds for senior house officers, registrars, and general practitioners respectively. With cost of admissions included, these costs were 58.25 pounds, 44.68 pounds, and 32.30 pounds respectively. CONCLUSION--Management of patients with primary care needs in accident and emergency department by general practitioners reduced costs with no apparent detrimental effect on outcome. These results support new role for general practitioners.     

Can telemedicine be used to improve communication between primary and secondary care?

OBJECTIVE: To test feasibility and acceptability of teleconferencing routine outpatient consultations. DESIGN: Exploratory trial of teleconferenced outpatient referrals of general practitioners. SETTING: An inner city teaching hospital and surrounding general practices. SUBJECTS: Six general practices linked to hospital outpatient clinics. MAIN OUTCOME MEASURES: Levels of participants'' satisfaction measured with self administered questionnaires. RESULTS: 54 teleconsultations were performed in 10 different specialties. Few serious technical problems were encountered, and high levels of satisfaction with the consultations were reported by patients, hospital specialists, and general practitioners. CONCLUSIONS: Teleconferenced consultations for routine outpatient referrals with joint participation of general practitioner were feasible. These may have an important potential benefit for improving communication between primary and secondary care.     

Can primary prevention or selective screening for melanoma be more precisely targeted through general practice? A prospective study to validate a self administered risk score.

OBJECTIVES: To establish whether a questionnaire incorporating MacKie''s risk factor flow chart can identify patients at high risk for melanoma so that they can be targeted for primary and secondary prevention. To validate the risk score derived from the questionnaire and test the feasibility of self completion by comparing patients'' self reported skin characteristics with a skin examination performed by an experienced general practitioner. DESIGN: Prospective questionnaire survey followed by a comparative study. SETTING: 16 randomly selected group practices in a health district in Cheshire, United Kingdom. SUBJECTS: Questionnaire survey--3105 consecutive patients aged 16 years and over attending for a primary care consultation; comparative study--a self selected subsample of 388 of the 3,105 patients. MAIN OUTCOME MEASURES: MacKie risk group for melanoma. Comparison of high risk skin characteristics reported by patients and those noted during a skin examination by a doctor (kappa statistic). RESULTS: 4.3% of patients (87% women) were in the highest risk group and 4.4% (79% men) were in the second highest risk group, as defined by the MacKie score. Agreement between patients'' self appraisal of skin characteristics and clinical skin examinations was reflected in kappa values of 0.67 for freckles, 0.60 for moles, and 0.43 for atypical naevi. CONCLUSION: This questionnaire helped to identify a group at high risk for melanoma. Furthermore, good agreement was found when the patient''s risk scores were compared with results of the clinical skin examination. This risk score is potentially useful in targeting primary and secondary prevention of melanoma through general practice.     

Factors Affecting Admission to a Coronary Care Unit

Of 103 patients with suspected myocardial infarction admitted to an intensive care unit in a general hospital half were admitted within four and a half hours of the onset of symptoms. In general, patients who attended the casualty department were under intensive care sooner than patients who sought attention from their general practitioner before admission. Patients who were seen by a locum from the emergency treatment service at night or weekends were more likely to remain at home until seen the next day by their own general practitioner, compared with patients seen by their own general practitioner initially.     

Unemployment and patterns of consultation with the general practitioner.

The relation between unemployment and consultations with the general practitioner was investigated among 13,275 economically active men aged 18-64 by using the British general household surveys. Men who were unemployed but seeking work consulted with doctors significantly more (odds ratio 1.83; 95% confidence interval 1.61 to 2.09) than those in employment, the highest consultation rate being among those who had been out of work for five years or more (odds ratio 2.12; 95% confidence interval 1.12 to 3.78). The high consultation rates persisted even after adjustment for self reported longstanding illness (odds ratio 1.53; 95% confidence interval 1.34 to 1.76). These findings suggest that in areas with high unemployment general practitioner workload is likely to be high.     

Nurse practitioners in accident and emergency departments: what do they do?

OBJECTIVE--To determine the distribution and scope of nurse practitioner schemes in accident and emergency departments in England and Wales; to describe the caseloads of doctors and nurse practitioners on two representative days; and to estimate the number of patients managed by nurse practitioners in the year to 31 March 1991. DESIGN--A postal survey of accident and emergency departments and a content analysis of case notes of new patients attending a representative sample of accident and emergency departments on two days. SETTING--All accident and emergency departments in England and Wales. PARTICIPANTS--Survey: 560 nurses in charge of accident and emergency departments. Census: case notes of 5814 patients in 37 accident and emergency departments. MAIN OUTCOME MEASURES--Survey: number of accident and emergency departments with nurse practitioner schemes. Census: demographic and clinical characteristics of new patients attending and whether nurse practitioner or doctor made diagnoses and ordered investigations, treatments, referrals, discharges. RESULTS--513 replies (92%) from 465 surveyed functioning accident and emergency departments and 48 departments recently closed. 27 (6%) departments used designated nurse practitioners and 159 (34%) "unofficial" nurse practitioners. Only 530 (9%) of the 5814 patients in the census were managed entirely or mainly by nurse practitioners, with higher proportions in ophthalmic departments (nearly 30%) and minor casualty departments (over 40%) than in major departments (3%). Most patients managed by nurse practitioners (86%) had minor trauma. In the year ending 31 March 1991 an estimated 390,000 (95% confidence interval 260,000 to 520,000) patients out of a total of 12.5 million (3.1%, 2.1% to 4.1%) were clinically managed by a nurse practitioner. CONCLUSIONS--Designated nurse practitioner schemes are rare. The volume and range of nurse practitioner work in major general accident and emergency departments is small compared with those in specialised and minor accident and emergency departments.     

Self screening for risk of melanoma: validity of self mole counting by patients in a single general practice.

OBJECTIVE--To validate self screening by patients of high mole counts, assess the within family association of sun protection behaviour and mole counts, and estimate prevalence of risk factors for melanoma. SETTING AND SUBJECTS--Systematic sample of families from a single affluent general practice population in Wessex. DESIGN--Subjects completed a questionnaire about risk factors for melanoma and counted their moles. Subsequently a mole count was done by a general practitioner trained at dermatology clinics. MAIN OUTCOME MEASURES--Validation of self counts by observer''s count. Within family association of sun protection behaviour and mole counts; self reported risk factors. RESULTS--199/237 subjects (84%) returned the questionnaire; 212/237 (89%) were examined. High counts by patients on the front of the trunk (> 7 moles of > or = 2 mm) were reasonably sensitive (79%), predictive (75%), and specific (97%) of the observer''s mole counts (kappa = 0.74), unlike arm or total body counts. Sun protection behaviour correlated between individuals and other family members (Spearman''s coefficient r = 0.50, P < 0.01). In the past three months 15/114 adults (13.2%, 95% confidence interval 7.0% to 19.4%) reported any change in a mole and 6/114 (5.3%, 2.0% to 11.1%) "major" changes; 6/109 adults (5.5%, 2.1% to 11.6%) had both high mole counts and freckling. CONCLUSIONS--Asking patients to count trunk moles could be a feasible way of identifying patients at high risk of melanoma. Concentrating on reported major changes in moles should avoid considerable workload in general practice. The generalisability of these findings and the adverse effects, net benefit in earlier diagnosis and prevention, and workload implications of such self screening need further research.     

An instrument for assessment of videotapes of general practitioners' performance.

OBJECTIVES--To identify those important characteristics of doctors'' and patients'' behaviour that distinguish between "good" and "bad" consultations when viewed on videotape; to use these characteristics to develop a reliable instrument for assessing general practitioners'' performance in their own consultations. DESIGN--Questionnaires completed by patients, general practitioner trainers, and general practitioner trainees. Reliability of draft instrument tested by general practitioner trainers. SETTING--All vocational training schemes for general practice in the Northern region of England. SUBJECTS--First stage: 76 patients in seven groups, 108 general practice trainers in 12 groups, and 122 general practice trainees in 10 groups. Second stage: 85 general practice trainers in 12 groups. MAIN OUTCOME MEASURES--Trainers'' ratings of importance; alpha coefficients of draft instrument by trainee, group, and consultation. RESULTS--6890 characteristics of good and bad consultations were consolidated into a draft assessment instrument consisting of 46 pairs of definitions separated by six point bipolar scales. Nine statement pairs given low importance ratings by trainers were eliminated, reducing the instrument to 37 statement pairs. To test reliability, general practitioner trainers used the instrument to assess three consultations. With the exception of one group of trainers, all alpha coefficients exceeded the acceptable level of 0.80. CONCLUSION--The instrument produced is reliable for assessing general practitioners'' performance in their own consultations.     

Evaluation of extended training for general practice in Northern Ireland: qualitative study

Objective To evaluate participants'' perceptions of the impact on them of an additional six months'' training beyond the standard 12 month general practice vocational training scheme.Design Qualitative study using focus groups.Setting General practice vocational training in Northern Ireland.Participants 13 general practitioner registrars, six of whom participated in the additional six months'' training, and four trainers involved in the additional six months'' training.Main outcome measures: Participants'' views about their experiences in 18 month and 12 month courses.Results Participants reported that the 12 month course was generally positive but was too pressurised and focused on examinations, and also that it had a negative impact on self care. The nature of the learning and assessment was reported to have left participants feeling averse to further continuing education and lacking in confidence. In contrast, the extended six month component was reported to have restimulated learning by focusing more on patient care and promoting self directed learning. It developed confidence, promoted teamwork, and gave experience of two practice contexts, and was reported as valuable by both ex-registrars and trainers. However, both the 12 and 18 month courses left participants feeling underprepared for practice management and self care.Conclusions 12 months'' training in general practice does not provide doctors with the necessary competencies and confidence to enter independent practice. The extended period was reported to promote greater professional development, critical evaluation skills, and orientation to lifelong learning but does not fill all the gaps.     

Avoidable referrals? Analysis of 170 consecutive referrals to secondary care.

OBJECTIVE--To determine appropriateness of referrals from primary care to secondary care. DESIGN--Retrospective evaluation of appropriateness of referrals from a single-handed general practice: evaluations carried out independently by referring doctor and by second general practitioner who worked in same area and had access to similar secondary care services. SUBJECTS--168 referrals made between 1 October 1990 and 31 March 1991 and followed up for up to 12 months by matching with available information on outcome of episode of care. MAIN OUTCOME MEASURES--Appropriateness of referral and reasons for inappropriate referrals. RESULTS--110 referrals were agreed to be appropriate and 58 were considered avoidable. The reason for 32 of the inappropriate referrals was lack of resources: 10 were due to lack of information (mainly failure of hospitals to pass on information to general practitioner), nine were due to a deficient primary health care team; five were due to insufficient use of home care nurses, three were due to absence of direct access to day hospital, and five were due to lack of access to general practitioner beds or other facilities. Most of the remaining 26 avoidable referrals were because available resources had not been fully used, because recognised management plans had not been followed, or because of lack of skills to perform certain procedures. CONCLUSIONS--Many theoretically avoidable referrals were due to managers'' and politicians'' decisions about allocation of resources, but some inappropriate referrals could be avoided by assessment of general practitioners'' needs for further knowledge and skills.