Paediatric home nursing scheme in Gateshead.

A scheme to provide specialised nursing care for sick children in their own homes was begun in Gateshead in 1974. Selected district nurses were retrained in the paediatric unit on which the scheme was based and nursed at home 22 children referred to them by general practitioners as the alternative to hospital admission and 39 discharged to their care by the hospital. Most of the children were aged 3 years or less and came from working-class homes. Most of the mothers who were asked were in favour of the scheme.     

Opinions of general practitioners in Nottinghamshire about provision of intrapartum care.

OBJECTIVE--To examine the beliefs of general practitioners concerning intrapartum care. DESIGN--Postal questionnaire survey. SUBJECTS--All general practitioners with patients in Nottinghamshire Family Health Services Authority in September 1993. MAIN OUTCOME MEASURES--General practitioners'' current involvement in maternity care, and beliefs on intrapartum care. RESULTS--Of 694 general practitioners sent questionnaires, 550 (79.2%) replied. 529 of these were on the obstetric list; 437 had not attended a delivery in the past 12 months; 36 had attended two or more; 358 general practitioners did not wish to provide more intrapartum care; 349 did not feel competent to do so. Reasons for not wanting to provide intrapartum care included current workload (453), disruption to personal life (407), and the fear of litigation (377). General practitioners who already booked women for home delivery were more likely to wish to do more deliveries (62/42 v 61/316, chi 2 = 85.3; P < 0.0001) and to have more positive attitudes towards increasing women''s choice in maternity care (90/22 v 195/151, chi 2 = 227; P < 0.0001). CONCLUSIONS--The involvement of general practitioners in intrapartum care in Nottinghamshire is low, and most general practitioners are unwilling to increase their role. However, general practitioners who already book for home delivery are keen to do more.     

General practitioners and management of infection with HIV

General practitioners will have an increasingly important role in the management of patients with the acquired immune deficiency syndrome (AIDS) and infections with human immunodeficiency virus (HIV) as the numbers of cases increase. Altogether 280 general practitioners working in Oxfordshire were sent a postal questionnaire inquiring about their education, knowledge, current practice, and attitudes in relation to managing infections with HIV. Of the 235 (84%) general practitioners who replied, nine out of 10 were giving advice about infection with HIV to their patients. One in two were testing patients for such infection, and one in four were caring for infected patients. Nevertheless, uncertainty remained about the risks of transmission of infection with HIV and general practitioners'' knowledge of educational activities for their patients could be improved.The introduction of a facilitator to work with general practitioners in managing patients with AIDS or infection with HIV is planned, especially to help general practitioners develop the skills needed for prevention.     

Planned and unplanned deliveries at home: implications of a changing ratio.

The observation that perinatal mortality among babies delivered at home has tended to increase beyond that among babies delivered in consultant obstetric units has caused alarm and prompted recommendations that delivery at home should be further phased out. With data derived from the Cardiff Births Survey the possibility was investigated that this trend might reflect a changing ratio of planned to unplanned domiciliary births. At the beginning of the 1970s deliveries at home that were planned to be so outnumbered those that were not by nearly five to one. By 1979 unplanned deliveries at home outnumbered planned deliveries. The characteristics of the mothers, the health care they received, and the outcome of delivery differed strikingly between planned and unplanned deliveries at home. It is concluded, firstly, that every year the maternity services must try to meet the various needs of about 2000 women in England and Wales who give birth at home without planning to do so; and, secondly, that the heterogeneity of births at home and in hospital will continue to obstruct the search for unbiased estimates of the risks attributable to delivery in specialist obstetric units, general practitioner units, and at home.     

Fair shares in health care? Ethnic and socioeconomic influences on recording of preventive care in selected inner London general practices. Healthy Eastenders Project.

OBJECTIVE--To describe the association of ethnic and socioeconomic status with recording of preventive care information by selected general practitioners. DESIGN--Random selection of people aged 20-64 registered with 43 general practitioners. Ethnic and social characteristics of stratified samples were determined at interview in the subject''s home. Recording of preventive information was ascertained from general practitioners'' medical records. SETTING--Inner London borough of Tower Hamlets. SUBJECTS--505 ut of 739 people confirmed as residents at their home address (190 white, 86 black, 112 Bangladeshi, 105 Chinese or Vietnamese, 12 other). MAIN OUTCOME MEASURES--Socioeconomic characteristics, consultation with general practitioner, and recorded preventive activities for ethnic groups. RESULTS--Minority ethnic groups were considerably more disadvantaged than white people and five times more likely to be overcrowded (31% v 6%), three times less likely to own their own home(11% v 37%), twice as likely to be in social classes IV and V (54% v 28%) and less likely to be employed (34% v 63%). There were no significant differences between white, black, Bangladeshi, and Chinese or Vietnamese subjects in recording smoking, blood pressure, alcohol consumption, weight, and height in the general practitioners'' medical records. White women were more likely to have a record of mammography (46% v 20%; P=0.03) and of cervical smears than women in minority ethnic groups. CONCLUSION--Despite major socioeconomic inequity, equitable recording of preventive activity for the major causes of death for white, black and Bangladeshi populations is possible. Chinese and Vietnamese people had lower levels of recording and consultation. Mammography and, to a lesser extent, cervical cytology are inequitably recorded and require additional support at practice level.     

Attendance of general practitioners at child protection case conferences.

OBJECTIVE--To investigate general practitioners'' attendance at and views on child protection conferences and their confidence in dealing with sexual abuse in children. DESIGN--Anonymous postal questionnaire sent to all general practitioners in Tower Hamlets and review of consecutive case conferences held by social services for three months in 1989. SETTING--Tower Hamlets health district. SUBJECTS--91 general practitioners, 56 of whom (62%) responded. MAIN OUTCOME MEASURES--Number of conferences attended, reasons for non-attendance, and reported confidence in dealing with sexual abuse. RESULTS--General practitioners estimated that 202 child protection conferences had been held in 1989 on their patients and that they had attended 85 of these. Information from social services for three months suggested that general practitioners had attended only nine of the 114 conferences reviewed. Timing of the conference was the most important reason for non-attendance. All respondents wanted access to the minutes of these conferences irrespective of their own attendance. Most general practitioners were very or moderately confident of their ability to detect child sexual abuse and non-accidental injury and to communicate with the family. CONCLUSION--More effort should be made to ensure that general practitioners are notified of case conferences and that the timing and location of conferences is compatible with their other commitments.     

Evalution of Home Nurse Attachment in Bristol

By the end of June 1969 home nurses in Bristol were attached to 18 general practices caring for about 137,000 patients, or about one-third of the city''s population. Attachment was associated with an increase by about one-third in the number of patients referred by general practitioners for home nursing. Additional benefits derived from attachment during the nine months from January to September 1969 were 2,047 items of service performed by nurses in general practitioners'' surgeries, 65 home visits to patients who were not receiving domiciliary nursing care, improved communications between general practitioners and nurses, and opportunities for both doctors and nurses to widen their fields of work. The travelling expenses paid to Bristol''s nurses increased by 9·5%.It is suggested that the benefits to patients, doctors, and nurses of attachment far outweigh the costs and that there is scope for extending the role of the attached nurse in the surgery and in home visiting.     

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.     

Higher professional training in general practice: provision of master's degree courses in the United Kingdom in 1993.

Review of a 1993 survey of the 29 United Kingdom departments of general practice (or equivalent) identified seven master''s degree courses available for general practitioners. Up to another 11 are planned within the next five years. Around 50 general practitioners undertake all such courses at any one time. Possible reasons for this low uptake include cost, lack of flexibility of courses, and the prospect of writing a thesis. Appropriate master''s courses are essential to the future development of general practice, and this paper postulates the characteristics of an "ideal" course.     

Urinary Tract Infection/Vaginitis Protocol: Use in a Walk-in Clinic

A process, outcome and salary-cost analysis was made of the use of a urinary tract infection/vaginitis protocol. Three nurse practitioners, in a university-based, walk-in clinic, cared for 128 women presenting with complaints of dysuria or vaginal discharge, or both. There were no significant differences among the nurse practitioners in data collection, diagnostic accuracy or patient outcome. The diagnoses were correct in 92 percent, incorrect in 6 percent and indeterminate in 2 percent of the patients. Incorrect diagnoses were due to presumption of urinary tract infection in patients with the urethral syndrome or vaginitis. Of the patients, 78 percent were actually sent home without seeing a physician. Concordance with the nurse practitioners'' physical examination was 100 percent in those patients examined by a physician. In 82 percent of the patients there was alleviation of symptoms. Patient satisfaction with this method of care was extraordinary, with 98 percent of the patients giving favorable reports. True physician extension was achieved with a reduction in physician time per patient from 20 minutes to 6 minutes. In contrast to previously reported data, only a modest reduction in salary cost savings (10 percent) could be shown. The author concludes that nurse practitioners working in an acute care clinic or emergency department can see the patients defined in the study and provide high-quality care at a reasonable cost.     

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.     

Home visiting by general practitioners in England and Wales.

OBJECTIVE--To use data from the fourth national survey of morbidity in general practice to investigate the association between home visiting rates and patients'' characteristics. DESIGN--Survey of diagnostic data on all home visits by general practitioners. SETTING--60 general practices in England and Wales. SUBJECTS--502 493 patients visited at home between September 1991 and August 1992. MAIN OUTCOME MEASURES--Home visiting rates per 1000 patient years and home visiting ratios standardised for age and sex. RESULTS--10.1% (139 801/1 378 510) of contacts with general practitioners took place in patients'' homes. The average annual home visiting rate was 299/1000 patient years. Rates showed a J shaped relation with age and were lowest in people aged 16-24 years (103/1000) and highest in people aged > or = 85 years (3009/1000). 1.3% of patients were visited five or more times and received 39% of visits. Age and sex standardised home visiting ratios increased from 69 (95% confidence interval 68 to 70) in social class I to 129 (128 to 130) in social class V. The commonest diagnostic group was diseases of the respiratory system. In older age groups, diseases of the circulatory system was also a common diagnostic group. Standardised home visiting ratios for the 60 practices in the study varied nearly eightfold, from 28 to 218 (interquartile range 67 to 126). CONCLUSIONS--Home visits remain an important component of general practitioners'' workload. As well as the strong associations between home visiting rates and patient characteristics, there were also large differences between practices in home visiting rates. A small number of patients received a disproportionately high number of home visits. Further investigation of patients with high home visiting rates may help to explain the large differences in workload between general practices and help in allocation of resources to practices.     

Babies with spina bifida treated without surgery: parents' views on home versus hospital care.

From 1971 to 1981, 98 babies born with meningomyelocoele at the North Staffordshire Hospital Centre''s district maternity hospital, were thought not suitable for surgery. Sixty three survived for more than one week. Over the period the hospital''s policy changed: initially all such babies were kept in hospital, but later parents were given the choice of taking their baby home for palliative and terminal care. In an attempt to determine parents'' views on the care of their baby the parents of 44 of the babies who survived to one week were traced in 1985-6, five to 14 years later; 80 of them were asked how they felt about the lives and deaths of their babies. Eighteen babies had been taken home, and they had lived longer than the 26 who had been cared for in hospital. Parents whose baby had remained in hospital were sadder than those who had taken their baby home when they looked back at their experiences, and they also considered that their baby''s life had been of poor quality. Most of those who had taken their baby home had a more positive view of their child''s life. The figures suggest that the bereavement process after a baby''s death is longer than has been thought, but despite residual sadness just over half of the parents interviewed thought that something positive had come out of their experience.     

Diagnosis of urogenital Chlamydia trachomatis infection in women based on mailed samples obtained at home: multipractice comparative study.

OBJECTIVE: To compare urine and vaginal flush samples collected by women at home with endocervical and urethral swabs obtained by general practitioners for their efficacy in the diagnosis of urogenital Chlamydia trachomatis infection. DESIGN: Multipractice comparative study. SETTING: 33 general practices and a central department of clinical microbiology in Aarhus County, Denmark. SUBJECTS: 222 women aged 18-25 years who for any reason had a gynaecological examination. INTERVENTIONS: Endocervical and urethral swabs were obtained by the women''s general practitioners. The same women when at home then collected a first void urine sample, a midstream urine sample, and a vaginal flush sample (using a vaginal pipette) and mailed them to the laboratory. MAIN OUTCOME MEASURES: C trachomatis defected by the polymerase chain reaction and the ligase chain reaction. Eight tests for C trachomatis were performed for every woman. When two of the eight yielded positive results the patient was considered infected. RESULTS: The overall prevalence of C trachomatis infection was 11.2% (23/205 women). Test sensitivities in samples obtained by general practitioners, samples obtained at home subjected to polymerase chain reaction, and samples obtained at home subjected to ligase chain reaction were 91%, 96%, and 100% respectively. The corresponding specificities were 100%, 92.9%, and 99.5%. CONCLUSIONS: The diagnostic efficacy of samples obtained by women at home and mailed to the laboratory was as good as for samples obtained by a general practitioner when using the ligase chain reaction. This may have important implications for the practicability of screening for this common, often asymptomatic, and treatable infection.     

House Calls in Utah

To learn the criteria Utah physicians use in making or not making house calls and their specialty, age and frequency of calls, a random sample of half of Utah''s physicians in family practice, general practice and general medicine was surveyed. Of 225 respondents, 70% reported making house calls at an average rate of 2.6 per month. More family practitioners made house calls than did internists; older physicians made more house calls than their younger counterparts. An estimated 82% of the calls were for patients aged 65 years and older. The most frequently stated reasons for making house calls were that patients were homebound and to assess the family or home situation. Reasons given for not making house calls were inefficient use of time and lack of equipment or necessary facilities.     

The validity of general practitioners' self assessment of knowledge: cross sectional study.

OBJECTIVE: To determine whether general practitioners can make accurate self assessments of their knowledge in specific areas. DESIGN: 67 general practitioners completed a self assessment of their level of knowledge over a variety of topics using a nine point semantic differential scale. An objective assessment of their knowledge was then made by administering true-false tests on two of the topics: thyroid disorders and non-insulin dependent diabetes. The study was repeated with another group of 60 general practitioners, using sexually transmitted diseases as the topic. SETTING: General practices in New Zealand. SUBJECTS: Random sample of 67 general practitioners in Auckland. MAIN OUTCOME MEASURE: Test scores for self assessment and for actual knowledge. RESULTS: Correlations between self assessments and test scores were poor for all three topics studied (r = 0.19 for thyroid disorders, 0.21 for non-insulin dependent diabetes, 0.19 for sexually transmitted diseases). CONCLUSIONS: As general practitioners cannot accurately assess their own level of knowledge on a given topic, professional development programmes that rely on the doctors'' self perceptions to assess their needs are likely to be seriously flawed.     

Use by general practitioners of obstetric beds in a consultant unit: a further report.

Of 1,700 women booked for delivery by general practitioner obstetricians in a consultant unit, 1,399 had uncomplicated deliveries and the co-operation between practitioner and consultant was an obvious advantage for the 257 who were transferred completely to consultant care during pregnancy, labour, or puerperium. The scheme, which started in 1964, has enabled general practitioners to continue to give complete obstetric care to their patients. The number of participating practitioners has, however, declined from 80 to 16 indicating that many preferred to concentrate on antenatal work.     

Contribution of general practitioner hospitals in Scotland.

The results of a survey of 64 Scottish general practitioner hospitals showed that in 1980 these hospitals contained 3.3% of available staffed beds in Scotland; 13.6% of the resident population had access for initial hospital care, and 14.5% of Scottish general practitioners were on their staffs. During the year of the survey they discharged 1.8% of all non-surgical patients, treated almost 100 000 patients for accidents and emergencies and 140 000 outpatients, and 4.4% of all deliveries in Scotland were carried out in the hospitals surveyed. Most communities which are served by general practitioner hospitals in Scotland are rural and on average are more than 30 miles from their nearest district general hospital. The contribution that these small hospitals make to the overall hospital workload has not previously been estimated. It has been shown nationally to be small but not inconsiderable . In terms of the contribution to the health care of the communities they serve it cannot and should not be underestimated.     

Problems of care in a private nursing home.

To assess problems of care in a private nursing home an observational study was carried out over two months, during which a research nurse worked as a member of the staff in a home caring for 25 patients aged 62-90. During the second month a consultant physician visited the home weekly to hold case conferences and assess each patient''s functional ability and drug regimen. Various problems in medical, nursing, and bureaucratic matters were identified--for example, staff failed to understand the appropriate response to various medical symptoms; no clear policy existed for managing pressure sores; and one patient''s anticoagulant state could not be assessed when industrial action meant that transport to take him to hospital was not available--and several changes in drug treatments were recommended. The problems that were identified were mainly due to poor communication between the home and general practitioners and hospitals and to the lack of guidance policy on common issues that arise in long term care. Such a policy could be produced by health authority staff, general practitioners, and representatives of nursing homes.