Information systems for general practitioners for quality assessment: I. Responses of the doctors.

A questionnaire was sent to all general practitioner principals in Leicestershire and Lincolnshire (n = 669) to determine (a) the extent to which they would participate in quality assessment activities based on objective evidence of performance and (b) the personal and professional characteristics of interested doctors. The overall response rate to the questionnaire was 76% (508 replies). The highest response rates were recorded by trainers (100%), principals in training practices (94%), and younger doctors (80-86%), the lowest by overseas graduates (59%) and older doctors (65%). Distinctive patterns of interest and participation in three types of audit activities were clearly evident. Overall, 61% (310) of respondents wished to be provided with profiles of practice activity from their family practitioner committees, 36% (183) volunteered to participate in a prescribing study, and 34% (172) expressed interest in carrying out an audit in depth. Proportionately, the most enthusiastic and active groups were trainers 88%, 70%, 62%), principals in training practices (74%, 49%, 47%), and members or fellows of the Royal College of General Practitioners (71%, 50%, 45%). Also active were younger doctors, vocationally trained doctors, and principals in large group practices. These figures suggest that roughly 15 000 general practitioners in the United Kingdom would be prepared to participate in performance review activities using information provided by external agencies, 10 000 would if they had to generate some of the information, and 7500 would if they had to produce all the information themselves.     

Responses by general practitioners in Avon to proposals for general practice in the white paper Working for Patients.

OBJECTIVE--To determine the views of Avon''s general practitioners about the general practice proposals within the government''s white paper Working for Patients. DESIGN--Postal questionnaire survey. SETTING--A county in south west England. SUBJECTS--All general practitioner principals (n = 537) under contract with Avon Family Practitioner Committee. MEASUREMENTS AND MAIN RESULTS--492 doctors (92%) responded to the survey. More than three quarters of the respondents were opposed to the government''s proposals on budgets for specific surgical procedures, prescribing, and diagnostic tests; and between 63% and 93% felt negative about advantages that might accrue from the proposals. Over three quarters of general practitioners were in favour of family practitioner committees monitoring work load, prescribing, and referrals. General practitioners in large, potentially budget holding practices held similar views to doctors in smaller practices. CONCLUSIONS--Avon''s general practitioners substantially reject most of the government''s proposals about general practice in the white paper Working for Patients.     

Nationwide study of decisions concerning the end of life in general practice in The Netherlands.

OBJECTIVE--To gain insight into decisions made in general practice about the end of life. DESIGN--Study I: interviews with 405 physicians. Study II: analysis of death certificates with data obtained on 5197 cases in which decisions about the end of life may have been made. Study III: prospective study with doctors from study I: questionnaires used to collect information about 2257 deaths. The information was representative for all deaths in the Netherlands. RESULTS--Over two fifths of all patients in the Netherlands die at home. General practitioners took fewer decisions about the end of life than hospital doctors and doctors in nursing homes (34%, 40%, and 56% of all dying patients, respectively). Specifically, decisions to withhold or withdraw treatment to prolong life were taken less often. Euthanasia or assisted suicide, however, was performed in 3.2% of all deaths in general practice compared with 1.4% in hospital practice. In over half of the cases concerning pain relief or non-treatment general practitioners did not discuss the decision with the patient, mostly because of incapacity of the patient, but in 20% of cases for "paternalistic" reasons. Older general practitioners discussed such decisions less often with their patients. Colleagues were consulted more often if the general practitioner worked in group practice. CONCLUSION--Differences in work situation between general practitioners and hospital doctors and differences between the group of general practitioners contribute to differences in the number and type of decisions about the end of life as well as in the decision making process.     

Deputising services: the portsmouth experience.

An analysis of the deputising service in the city of Portsmouth showed that the workload of doctors was not excessive and there was no evidence that the number of calls was higher than in areas where no deputising service exists. Sixty seven per cent of patients were seen within one hour of requesting a call and 93% within two hours. Seven per cent of patients were admitted to hospital and 88% of these were seen within one hour of requesting medical care. Drugs were prescribed at 65% of all contacts between doctor and patient which compares favourably with prescribing rates for consultations in general practice. A notable feature of the Portsmouth scheme is that all subscribers who use the deputising service have to agree to participate as a deputy, with 90% of deputies being practising general practitioners or eligible to be principals in general practice. This has probably conserved costs and hospital resources.     

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.     

Computerisation of primary care in Wales.

OBJECTIVE--To obtain information about the computerisation of general practice in Wales, and to enable more effective planning of educational provision for doctors and other primary health care workers. DESIGN--Postal questionnaire sent to all general practices in Wales. SUBJECTS--553 general practices, of which 401 (73% replied). RESULTS--The level of computerisation varied from 11 (85%) of practices in Powys Family Health Services Authority to 22 (40%) in Mid Glamorgan. Less than half of practices had a computer in only two authorities. The commonest uses of the computer were for patient registration (208 practices), repeat prescribing (180), call and recall of patients (165), and partial clinical records (122). The main suppliers were VAMP (78 practices), AAH Meditel (46), and AMC (23). 102 of 226 practices with a computer had a terminal on each doctor''s desk. Just 33 practices had full patient notes on computer and 51 had modems for electronic communication. CONCLUSION--Mechanisms to encourage greater and more sophisticated use of computers and information technology need to be explored.     

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.     

General practitioners' attitudes to professional reaccreditation.

OBJECTIVE--To determine the views of general practitioners about professional reaccreditation. DESIGN--Postal questionnaire. SUBJECTS--All 278 general practitioner principals working in Cleveland. MAIN OUTCOME MEASURES--General practitioner characteristics; attitudes to reaccreditation; and views on the development, conduct, content, and format of reaccreditation. RESULTS--210 out of 278 (76%) general practitioners responded to the questionnaire. 128 (61%) agreed that general practitioners should undergo reaccreditation. 149 (72%) thought the General Medical Services Committee and local medical committees were appropriate bodies to lead its development. 120 respondents suggested that reaccreditation should be carried out by assessors appointed by the doctor''s own local medical committee. The most favoured interval between reaccreditation episodes was 10 or more years. 152 doctors thought that doctors who failed reaccreditation should be advised on education and reassessed soon afterwards. Clinical knowledge (82%), clinical skill (82%), prescribing practices (67%), standards of medical record keeping (60%), and consultation behaviour (58%) were the most popular subjects for scrutiny. 138 (67%) respondents felt that reaccreditation should be part of continuing medical education. CONCLUSION--Most general practitioners support professional reaccreditation. They believe the process should be led by the profession, be educational, and take account of a range of professional activities.     

Effect of computer use in the consultation on the delivery of care.

The effects of the use of a computer on the delivery of care in consultations in general practice were examined. In this trial a computer system provided for the review and update of patients'' medical histories, notes on doctor-patient contacts, and information on repeat prescribing. Thirty consultations in which the computer system was used and 30 consultations in which no computer was used were matched individually for the doctor consulted, the sex and age of the patient, and the presenting problem(s). Six independent general practitioners blind rated each consultation for the standard of care attained. A minor negative effect of computer use on the doctors'' clinical performance was found. We suggest, however, that this small effect would disappear if a computer system was used routinely.     

Effect of doctors' ethnicity and country of qualification on prescribing patterns in single handed general practices: linkage of information collected by questionnaire and from routine data.

OBJECTIVES: To test whether Asian general practitioners who qualified in the Indian subcontinent prescribe items more often, more expensive items, and fewer generic drugs than their British trained Asian and non-Asian counterparts. DESIGN: Linkage study using data collected by questionnaire and from routine sources. SETTING: General practices in England. SUBJECTS: 155 single handed general practitioners: 42 Asian doctors qualified in United Kingdom (group 1), 58 white doctors qualified in United Kingdom (group 2), and 55 Asian doctors qualified in Indian subcontinent (group 3). MAIN OUTCOME MEASURES: Prescribing cost (cost per ASTRO-PU), prescribing frequency (number of items per ASTRO-PU), and generic prescribing (percentage of drugs prescribed that are generic). RESULTS: Doctors in group 1 were significantly younger than those in the other groups and had a higher proportion of patients who were from deprived wards. There was no difference between the groups in the proportion of female doctors and total list size. After adjustment for confounding factors, there were no significant differences between the three groups for prescribing cost (16.58 (95% confidence interval 6.39 to 26.77) for group 1, 17.31 (6.92 to 27.69) for group 2, 17.80 (7.22 to 28.38) for group 3, P = 0.55); prescribing frequency (6.58 (4.60 to 8.40), 6.45 (4.70 to 8.30), 7.89 (6.16 to 9.64), P = 0.34); and generic prescribing (44.44 (38.95 to 49.93), 47.41 (42.12 to 52.70), 44.04 (38.75 to 49.33), P = 0.37). CONCLUSIONS: Asian doctors qualified from the Indian subcontinent did not differ from British trained doctors in their prescribing practice. This study refutes the common belief that Asian doctors are high volume and high cost prescribers.     

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.     

Hospital training for general practice: views of trainees in the North Western region.

Vocational trainees in the North Western region who were in their general practice year completed a questionnaire concerning the hospital component of their training. Replies were received from 125 trainees, providing information about 451 hospital posts. In a total of 372 posts (85%) less than two hours of formal teaching a week was provided. Trainees stated that they received no informal teaching in nearly one third of posts. The orientation of teaching towards general practice was reported as greatest in the posts that were not part of a vocational training scheme. Study leave was applied for by doctors in only 163 (37%) posts, usually to prepare for or to sit an examination. There seem to be serious educational deficiencies in hospital posts that are used to train both general practitioners and other specialists. Improvements in both the quantity and quality of in service teaching are therefore needed urgently.