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.     

Ultrasonic vocalization by female mice in the presence of a conspecific carrying food cues

In female mice, Mus domesticus, reunion with a same-sex conspecific is associated with intense ultrasonic vocalization. We examined whether the palatability of a familiar food eaten by a demonstrator mouse and the motivational state of the conspecific observer could modulate the number of ultrasonic calls uttered during female-female interaction in NMRI mice. A pilot study indicated that these calls were uttered almost exclusively by the observer member of the pair. Observers were either food deprived or not deprived and demonstrators were offered either no food, a palatable diet or an unpalatable diet. We monitored both the number of ultrasounds (range 65-75 kHz) uttered and a series of behavioural parameters during the first 3 min of social interaction after 24 h of separation. Observers investigated the nose area of demonstrators fed on the unpalatable diet more than the same area of demonstrators not given food. No differences were found in demonstrators' behaviour. Ultrasonic calls were given immediately after female-female reunion and were affected by both the motivational state of the observer and the salience of the information carried by the conspecific. These results suggest that the motivational state of the observer affects ultrasonic calling towards a demonstrator conspecific. Nondeprived animals produced more calls towards demonstrators fed on palatable food, whereas food-deprived subjects vocalized more to fed conspecifics, independently of the palatability of the food eaten by the demonstrator. We suggest that ultrasonic vocalization in female mice can facilitate proximity with a conspecific and the number of these calls is modulated by the salience of the information carried by the companion. Copyright 2000 The Association for the Study of Animal Behaviour.     

Area variations in the process of care in urban general practice.

One hundred and eighty three practitioners collected data on 110 000 consultations. Case mix and pattern of care are compared for doctors practising in different urban areas. Inner city areas are compared with outer areas and the most deprived with the most affluent. Case mix varies slightly between areas, but there are no systematic differences in the pattern of care, which is equally variable in different areas. The stereotype of inner city general practice is not confirmed.     

基于缓冲带的贵港市城市景观格局梯度分析

运用景观格局指数与城市建成区缓冲带划分相结合的方法,分析了广西贵港市近20a来城市建成区整体景观与主要城市景观类型（公共设施用地、工业用地、居住用地及农田）的圈层梯度变化特征.分析结果表明：贵港市城市建成区可以看作是居住用地与公共设施用地的镶嵌景观,但这种镶嵌景观随着城市化的发展,存在日趋不明显的特征;整个景观层面的指数20a来在31个梯度带内,表现出相似的变化趋势,斑块面积指数显示出贵港市城市建成区存在两个较为明显的商业金融中心;各梯度带内景观的平均面积增大,景观的形状日臻规则,景观多样性随景观类型及均匀度的增加显著上升.2004年主要城市景观类型在缓冲区中间各带能够很好的反映出格局的变化特征,其中工业用地和农田用地的斑块数和斑块密度随缓冲区梯度表现出较为一致的变化特征,而公共设施用地和居住用地的梯度变化趋势相似.各个梯度带中工业用地形状最为复杂,所占比重最低,平均斑块面积最大;公共设施和居住用地形状较为简单,在各带中所占比重较高,平均斑块面积较小;农田景观在各带中所占比例变化不大,近似连续分布,对城市生态环境的调节起到一定作用.     

Comparison of two scores for allocating resources to doctors in deprived areas.

Current proposals in the general practitioner contract include additional payments to doctors working among deprived populations. The underprivileged area score will be used to identify local authority wards with the greatest levels of deprivation, thus acting as the basis for distributing considerable resources. Two methods of identifying deprived populations--the underprivileged area score and the material deprivation score--were compared to determine whether they result in similar allocation of resources to regions. Financial allocations to regions based on figures derived from the contract differed considerably if the material deprivation score was used instead of the underprivileged area score: Northern and Mersey regions gained over 50% of their allocation whereas East Anglia, Oxford, and South West Thames regions lost more than 30% of theirs. Such differences have considerable implications for doctors working among deprived populations as up to 60m pounds each year might be distributed by these payments.     

Women doctors in urban general practice: the doctors.

A large study of general practitioners in Manchester showed that women doctors were younger than men doctors, and few were single handed or worked in deprived inner city areas. They had closely similar patterns of care to their male colleagues, and although they worked slightly fewer hours in surgery, they had almost identical consultation times per patient. Women general practitioners were less active in politics and education than men.     

Out of hours service: the Danish solution examined.

In Denmark the provision of out of hours care by general practitioners came under increasing pressure in the 1980s because of growing demand for services by the public and increasing complaints from rural doctors about their heavy workload and disproportionately low remuneration in comparison with urban doctors. As a result, the out of hours service was reformed at the start of 1992: locally negotiated rota systems were replaced with county based services. Each county now has a coordination centre, where all patients'' calls are received by a team of doctors. The doctors may give a telephone consultation, advise the patient to attend one of the emergency clinics strategically placed about the county, or arrange for a home visit. Doctors on home visiting duty are located at bases throughout the county and keep in touch with the coordination centre with mobile telephones. Graded fees mean that doctors are encouraged to give telephone consultations rather than arrange for clinic consultations or home visits. The reforms have reduced doctors'' out of hours workload and the number of home visits made and have proved acceptable to patients, doctors, and administrators.     

A gradient analysis based on the buffer zones of urban landscape pattern of the constructed area in Guigang City, Guangxi, China

Over the last century urbanization on the landscape has increased and intensified. Urban development has a great impact on the environment at the local, regional and even global levels. As a driving force in global change, the need to understand the dynamics of urban pattern and its change in an accurate and efficient manner is ever more pressing. Based on aerial color infrared photography in 1985 and QuickBird satellite imagery in 2004 and according to the standard for plan and construction of city land use, the landscape of Guigang City was divided into 11 types. In the landscape classification maps, 31 buffer zones, each being 200 m wide, were divided. With the aid of GIS software ArcView 3.2 and landscape pattern analysis software FRAGSTATS 3.3, the landscape spatial patterns of each buffer zone were analyzed at the landscape level and class level. The landscape indices, such as patch size, patch fractal dimension, diversity index and evenness index, were calculated. The results indicated the following: The total area of the residential land and the communal land in 2004 covered 46.3% of the entire constructed area of Guigang City and the sum of the patch number of the two patch types occupied about 39.7% of the total patch number, while the percentages were respectively 48.2% and 45.4% in 1985. This showed that the mosaic landscape with the residential land and communal facilities land became increasingly unclear following urban development and landscape diversity. Based on the gradient analysis with the landscape-level index and the class-level index, there were two business and finance centers in the constructed area. One was located in the urban center with a range of 0.8 km; the other was from the 10^th to the 16^th zone. In each buffer zone, the mean patch size was larger and the landscape shape was more regular in 2004 than in 1985. Furthermore, the Shannon diversity index of each buffer zone rose in 2004 with patch richness and evenness increasing. The landscape index computed for the main landscape types (communal facilities land, industrial estate land, residential land and farmland) in the middle of the buffer zones clearly indicated the changes taking place in urbanization. The patch size and the patch number of industrial estate land and farmland also pointed to these changes, while communal facilities land and residential land assumed another similar tendency towards changes. In each gradient zone, industrial estate land had the most complex shape, the lowest area percentage of each zone and the biggest mean patch size, whereas communal facilities land and residential land were opposite to industrial estate land. Farmland had a steady percentage along the buffer zone and its continuous distribution had an important impact on the urban eco-environment. The question of how to relate the pattern of changing characteristics along the buffer zone to the urban ecological process and urban ecological planning remains to be studied further in the future.     

The Liverpool urban obstetric flying squad: changing patterns of practice 1965-84.

Obstetric flying squads operate from most maternity units in the United Kingdom. The 20 years from 1965 to 1984 saw 860 calls being made to the obstetric flying squad in the Liverpool urban area, with striking changes occurring in both the number of calls made and the reasons for making the calls. Management of the problems encountered has now become almost exclusively conservative, with such procedures as blood transfusion and general anaesthesia being virtually eliminated from practice.     

Avian species richness and numbers in the built environment: can new housing developments be good for birds?

Bird species richness (S) and numbers (N) were studied in the breeding season in housing developments of different ages in a small English town and compared with village sites, urban green corridors and adjacent arable farmland. S and N were highest in village and green corridor sites. S in urban plots ranged from 13 to 18 species, similar to farmland, but N was much lower in farmland. Marked differences in the number of individual species between plots were recorded. S and N were independent of age of development and area of gardens within plots but both were correlated with the area of greenspace. Greenspace alone and combined with gardens was correlated with the numbers of several individual species. The results are discussed in relation to proposed new large-scale housing developments in England.     

Housing Market Activity is Associated with Disparities in Urban and Metropolitan Vegetation

In urban areas, the consistent and positive association between vegetation density and household income has been explained historically by either the capitalization of larger lawns and lower housing densities or landscaping and lifestyle districts that convey prestige. Yet cities with shrinking populations and rising land burdens often exhibit high vegetation density in declining neighborhoods. Because the observed associations do not directly address the causal connection between measures of social privilege and vegetation in urban landscapes, it is difficult to understand the forces that maintain them. Here, we compare patterns of household income with new measures derived from housing market data and other parcel-level sources—sale prices, tax foreclosures, new housing construction, demolitions, and the balance of construction and demolition. Our aim is to evaluate whether these spatially, temporally and semantically finer measures of neighborhood social conditions are better predictors of the distribution of urban vegetation. Furthermore, we examine how these relationships differ at two scales: within the City of Detroit and across the Detroit metropolitan area. We demonstrate, first, that linear relationships between income or home values and urban vegetation, though evident at broad metropolitan scales, do not explain recent variations in vegetation density within the City of Detroit. Second, we find that the real estate and demolition records demonstrate a stronger relationship with changes in vegetation density than corresponding changes in US Census measures like income, which suggests they hold at least as much interest for understanding how the relationships between biophysical changes and neighborhood change processes come about.     

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.     

城市小区环境生物剂气溶胶的扩散模拟研究

目的:研究城市小区中生物剂气溶胶的扩散模拟和污染区域的划分,为反生物恐怖危害评估及应急响应提供决策依据。方法:以典型生物剂炭疽为例,利用计算流体力学中的离散相模型对小区环境中生物剂气溶胶的扩散规律进行研究;对扩散后生物剂气溶胶的数目分布进行量化分析,结合吸入式炭疽的剂量-反应模型进行污染区域的划分。结果:通过计算机模拟,得到了生物剂气溶胶在小区环境中的扩散规律及数目分布,并依据人员感染炭疽概率的不同划分出小区内的污染区域。结论:利用离散相模型和剂量-反应模型,可以对城市小区中生物剂气溶胶的扩散规律进行模拟并划分污染区域,为反生物恐怖危害评估及应急响应提供决策依据。     

Organisation of telephone services and patients' access to doctors by telephone in general practice.

OBJECTIVES--To assess how accessible general practitioners are to patients by telephone and to examine the relations between organisation, number of lines, and number of patient-doctor calls. DESIGN--Postal survey of a random sample of general practitioners stratified by rural and urban practice areas, with differential sampling fractions. SETTING--General practices in England and Wales. SUBJECTS--2000 general practitioners, of whom 1459 (74%) responded. MAIN OUTCOME MEASURES--Number of calls received by general practitioner a day, time reserved for patients'' calls, and communication of availability of telephone contact. RESULTS--1421 general practitioners said that they accepted non-emergency calls from patients during the day and 285 reported reserving specific times of the day for this purpose. 848 estimated that they received four or fewer patient calls a day. The number of calls was significantly related to reserving time for calls (p less than 0.001), informing patients that the doctor was accessible by telephone (p less than 0.00001), and the number of periods when calls were accepted (p less than 0.00001). On average there were 3659 patients per incoming line; the number of patients per incoming line rose significantly as practice size increased (p less than 0.00001). CONCLUSIONS--The apparent willingness of general practitioners to accept calls was not reflected in the number of calls received. Reserving time, increasing periods of availability, and publicising telephone access increased the number of doctor-patient telephone contacts. Line congestion may be a problem, and impartial advice and guidance on telephone organisation and line requirements would be helpful.     

General practitioner attendance at emergencies notified to ambulance control.

For two years doctors from a small village went to the scene of emergency calls received by ambulance control. On 80% of the occasions when the doctor was called at the same time as the ambulance was dispatched the doctor arrived before the ambulance. There were 24 incidents, 16 of which were road traffic accidents. In two cases the doctor established a clear airway in an unconscious patient before the ambulance arrived. Two patients were trapped in their vehicles and were given parenteral analgesics. Four patients required intravenous fluids. The call out system provided first aid for patients before the ambulance arrived and medical assistance to the emergency services at serious accidents. Patients who did not require hospital attention could be examined and treated at the scene, making the ambulance available for other duties and reducing the number of patients taken to the hospital accident and emergency department.     

B.M.A. Deputizing Service in Sheffield, 1970

Seventy-four per cent. of Sheffield general practitioners and 78% of those in Nottingham used a deputizing service in 1970. In each city the deputizing service was used by about 80% of single-handed general practitioners, 90% of doctors in two-doctor practices, and 60% of those in partnerships of three or more.The Sheffield deputizing service handled 15,988 new calls in the year, an average of 106 per subscribing doctor, and in addition made 339 revisits. The median number of calls handled for single-handed doctors was 98, for those in two-doctor practices 95, and for those in partnerships of three or more 75. The growth of group practice has not eliminated the demand for deputizing services.Sixty-six per cent. of consultations were with deputies who were primarily hospital doctors, 20% with a full-time deputy, 11% with deputies who were primarily general practitioners, and 3% with the switchboard staff, who were also trained nurses. The deputies had been qualified, on average, for eight years. Seventy-two per cent. of patients attended were seen within one hour of receipt of the call.Calls handled by the deputizing service represented approximately 1% of all the subscribers'' consultations, 5% of their home visits, and half their calls between midnight and 07.00 hours. At this level of activity the concept of “personal doctoring” was not threatened.     

Catchment areas in general practice and their relation to size and quality of practice and deprivation: a descriptive study in one London borough.

OBJECTIVE: To relate the sizes of general practice catchment areas in one London borough to list size, deprivation payments, medical staffing, and locally and nationally recognised measures of quality. DESIGN: Study of general practice catchment area maps. SETTING: London borough of Lambeth. SUBJECTS: 60 out of the 71 general practices in Lambeth. MAIN OUTCOME MEASURES: Practice catchment area size with corrections for numbers of doctors and patients. RESULTS: Catchment area size varied greatly between practices, showing an almost 150-fold difference between the largest and smallest practices. This size differential was even more marked when the size of the catchment area was corrected for the number of general practitioners in the practice, where a 300-fold difference was found. Substantial differences existed between practices in each of the four locally assigned quality bands. The weakest practices had catchment areas three times as large as those of the strongest practices. When corrected for medical staffing, the difference was eight times as great. A calculated measure of patient dispersion showed that the practice population of the strongest practices was four times as densely clustered as that of the weakest practices, whose patients were more widely geographically dispersed. CONCLUSIONS: Large variations exist in the size of catchment areas of inner city practices even when corrected for numbers of doctors and patients. These differences are associated with variations in quality of care.     

社区卫生服务机构基本药物合理用药评价的研究

目的：了解并评价社区卫生服务机构基本药物合理使用情况,为基层基本药物合理用药提供参考意见。方法：对社区卫生服务机构进行抽样调查,通过对处方进行抽样和对医生进行抽样问卷调查,根据医疗机构合理用药评价指标对处方基本药物使用情况进行评价,并分析可能导致不合理用药的相关因素。结果：单张处方平均使用药品数为：城区（4．9±1．2）个,农村（213±0．7）个;每100张处方抗生素使用比例：城区78．9％,农村57．3％,其中两联使用比例分别为20．1％和32．4％;人均药费：城区为（36．9±5．2）元,农村为（21．3±4．7）元;参加合理用药培训的医生所开处方药品合理使用的比率是98．0％,而未参加过培训的医生合理用药的比率是77．1％,经卡方检验,差异有统计学意义,P〈0．05。结论：社区卫生服务机构存在一定的基本药物使用不合理现象,对医生加强基本药物合理使用的培训可以提高基本药物合理使用率。     

The comparative breeding biology of magpies Pica pica in an urban and a rural habitat (Aves: Corvidae)

The breeding biology of magpies in an adjacent urban and rural area in the same year was compared. Breeding commenced earlier in the urban habitat. This was attributed to the earlier availability of invertebrate food in the urban habitat as a result of higher urban ambient temperature. Hatching success and the amount of nest predation were lower in the urban area than in the rural area. Low levels of nest predation in urban areas were due to reduced human predation and probably to the relatively low numbers of many natural predators. Differences in the nest tree species utilized also influenced the probability of human predation. Despite these differences in the causes of egg and chick mortality, the number of young reared to 14 days of age per nest was similar in both habitats.