Patients' accounts of being removed from their general practitioner's list: qualitative study

Objective To explore patients'' accounts of being removed from a general practitioner''s list.Design Qualitative analysis of semistructured interviews.Setting Patients'' homes in Leicestershire.Participants 28 patients who had recently been removed from a general practitioner''s list.Results The removed patients gave an account of themselves as having genuine illnesses needing medical care. In putting their case that their removal was unjustified, patients were concerned to show that they were “good” patients who complied with the rules that they understood to govern the doctor-patient relationship: they tried to cope with their illness and follow medical advice, used general practice services “appropriately,” were uncomplaining, and were polite with doctors. Removed patients also used their accounts to characterise the removing general practitioner as one who broke the lay rules of the doctor-patient relationship. These “bad” general practitioners were rude, impersonal, uncaring, and clinically incompetent and lied to patients. Patients felt very threatened by being removed from their general practitioner''s list; they experienced removal as an attack on their right to be an NHS patient, as deeply distressing, and as stigmatising.Conclusions Removal is an overwhelmingly negative and distressing experience for patients. Many of the problems encountered by removed patients may be remediable through general practices having an explicit policy on removal and procedures in place to help with “difficult” patients.     

Domiciliary immunisation for preschool child defaulters.

A selective domiciliary immunisation service has been introduced for preschool children living in the Central Manchester Health District. The service is provided for the children of parents who have given written consent for immunisation but have subsequently failed to bring their children to the clinic or their general practitioner''s surgery to start or complete the basic course of immunisation against diphtheria, tetanus, whooping cough, poliomyelitis, and measles. This failure has occurred despite at least two written invitations for each injection and several reminders from the health visitor. Many additional children have been protected by this scheme.     

A Male Sterilization Clinic

In the Cardiff Family Planning Association Clinic 330 men have been sterilized during the past 20 months. Selection for operation was made after a detailed discussion between husband, wife, and a Family Planning Association doctor, and with the general practitioner''s agreement. The outpatient operation was performed under local anaesthetic by a surgeon. It was regarded as being successful or complete when two semen analyses showed azoospermia at an interval of one month.     

The American General Practitioner in Hospital

In the U.S.A. and Canada full access of general practitioners to hospital beds and facilities is regarded as an essential privilege of their work. All hospital constitutions require a review of the credentials of staff applicants and continuing evaluation of their performance. Staff appointment carries administrative as well as clinical responsibilities and hospital work occupies a considerable proportion of the general practitioner''s day. The disciplinary machinery for safeguarding standards is strict by comparison with British hospital practice.This system produces an obvious excellence of clinical standards, postgraduate education, and communication between specialist and general practitioner and is attractive to the more able young British graduate. A pilot experiment of hospital staffing on North American lines in one of our new district general hospitals would be a worthwhile proposition.     

Hypothermia in the elderly: scope for prevention.

Concern is growing about the number of elderly people dying of hypothermia. A register was compiled of patients over 75 on a general practitioner''s list who were identified from their medical records as being at risk of hypothermia, having two or more established risk factors. Twenty four patients from this register were visited early in winter by a doctor to discuss how hypothermia could be prevented. They were then revisited during very cold weather to see whether they had made any changes. Several improvements to heating arrangements were noted, but the median temperature in the bedrooms of houses with no central heating was 10 degrees C below the World Health Organisation''s recommended temperature. In addition, eight patients were not visited daily. Even with media publicity and visits from carers and a doctor, 17 of the 24 elderly people studied continued to live in an environment in which they were at risk of developing hypothermia.     

Interim discharge summaries: how are they best delivered to general practitioners?

All patients discharged from a medical ward during four months were randomly assigned to one of two groups. In one group the patients were given their interim discharge summary for delivery to their general practitioner by hand; in the other group the summary was posted by the hospital. Of the 289 summaries sent by either method, 279 (97%) arrived at the general practitioner''s surgery. A mean (median) time of two (one) days elapsed before arrival when summaries were delivered by hand and a mean (median) of four and a half (four) days when they were posted; at least 55% of summaries delivered by hand arrived within one day of the day of discharge compared with 8% of those posted. If all interim discharge summaries were given to patients to deliver communication between hospitals and general practitioners would be accelerated and considerable savings might be made.     

Diagnosing cancer in general practice: from suspicion to certainty.

Three hundred and eighty two patients who were suspected of having cancer by general practitioners were followed up for up to two years until the suspicion was either confirmed or rejected; 7014 patients who were not suspected of having a malignancy served as the control group. Less than every tenth suspicion proved correct. The general practitioner''s assessment of the strength of suspicion of cancer was the best predictor of outcome in the suspected patients. The incidence of cancer among the unsuspected patients did not differ from the total incidence of cancer in the study area. The patient''s fear of cancer was an important predictor of a malignancy. A higher proportion of patients who consulted for non-symptomatic reasons than for symptomatic reasons was reported to have a malignancy. No single symptom had a strong predictive value for cancer. The predictive value of a palpable lump or tumour was 2.5%.     

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.     

Referral to medical outpatients department at teaching hospitals in Birmingham and Amsterdam.

A method of comparing the referral of patients by general practitioners to medical outpatients departments at teaching hospitals in Amsterdam and Birmingham was devised. This was applied to 89 referral letters to medical specialists at the Free University Medical School Policlinic in Amsterdam and to 88 referral letters to clinics at Birmingham University Medical School, UK. The standards of referral were lower in the Netherlands than in Britain, and this may be related to differences in the health care systems, in the culture, or in the organisation of general practice. The delay between the general practitioner''s referral and the consultation to the outpatient department was four times greater in Britain than in the Netherlands.     

Factors Affecting Work Load in General Practice—II

The second part of a survey studying factors that affect a general practitioner''s work load considers the effects of age, sex, social class and time on list. Women, the old, and the young created the most work for the doctor and his paramedical team. Patients in the lower social classes also generated more work, even though a larger proportion of the higher social classes used the resources of the general practice—and more fully. Newly-registered patients generated slightly more work than the more permanent residents. Not only the size of a doctor''s list, therefore, but also the demographic features of the community should be taken into account in determining the size and structure of the general-practice team needed for an area.     

Night workload in one health district.

The night work (11 pm-7 am) in primary care in one health district (population 195 212 with 93 general practitioners) was studied over a three month period, starting 1 January 1983. The workload proved to be small (15% of all "out of hours" work for general practitioners). An average of three night visits was done a night in the whole health district, and 26 general practitioners were available for these. On average, over seven doctors were available each night for each patient who required a visit in primary care in the health district. It is concluded that there is only sufficient work for (at maximum) two doctors, and a system is proposed to make more efficient use of the general practitioner''s time.     

Psychiatry in General Practice

Psychiatrists should include the family doctor in their plans for future psychiatric services. The general practitioner now treats most of the patients who seek help for psychiatric disorder and he could not give up his psychiatric practice even if he wanted to. Furthermore, there are not now nor will there ever be enough psychiatrists to take over all patients with mental ills. Most emotionally disturbed patients can be better handled by their family physicians than by a specialist.To provide the best care for emotionally disturbed people the communication between family doctors and psychiatrists must be improved. The specialist must acknowledge the importance of the general practitioner''s role in psychiatric diagnosis and treatment and give him more help. Medical schools must provide better undergraduate and postgraduate psychiatric training for the students who will become family doctors. Health plans and other prepayment agencies should properly compensate the general practitioner for giving psychiatric treatment. The specialist in psychiatry should consult more readily with the general practitioner and help him carry out some of the therapy. General hospitals should permit family doctors to admit mental patients to psychiatric wards in a general hospital and to carry out psychiatric treatment with the help of the specialist in psychiatry.     

Old people not known to the general practitioner: low risk group.

The elderly patients in a large general practice aged 75 and over who lived at home (n = 877) were divided into two groups according to the general practitioner''s knowledge of their risk status and were designated "risk status known" (n = 679) and "risk status not known" (n = 198). Forty-three high risk patients in the risk status known group had a functional disability score and experience of mortality that was not dissimilar to those of elderly people in institutions. The medical and social characteristics of a random sample (n = 150) of the risk status known group, after excluding the high risk patients, were compared with the risk status not known group using a Barber Wallis questionnaire. A response rate of 90% was achieved from both groups and a cumulative risk score was calculated by totalling unfavourable replies to the questions. The risk status not known group, which comprised 14% of the patients who lived at home after correcting for the number who had died and moved, had appreciably less contact with the general practitioners, had an appreciably lower cumulative risk score, were confined at home less because of ill health, were less concerned about their health, and were less in need of nursing attention. The findings of this study suggest that the elderly patients who are not known to their general practitioners are in relatively good health when compared with the patients that the general practitioner knows well.     

Open access gastroscopy: too much to swallow?

OBJECTIVES--To ascertain the proportion of endoscopic examinations with normal findings in patients referred for gastroscopy through hospital medical staff or directly by their general practitioner and to assess the likely effect of targeting endoscopy in older patients. DESIGN--Retrospective audit of the gastroscopy practice of one consultant from 1986 to 1988 from information recorded on a standard form completed at the time of the examination, which contained details of patients, their endoscopic findings, and mode of referral (open access or clinic). SETTING--One district general hospital. PATIENTS--1545 Consecutive patients from primary catchment area attending for their first gastroscopy; 454 were referred through the outpatient clinic or by hospital colleagues (clinic group) and 1091 were accepted for endoscopy solely on their general practitioner''s clinical diagnosis (open access group). RESULTS--Similar numbers (about 40%) of examinations with normal findings were performed in each group, although in patients aged over 40 the proportion with normal findings was significantly higher in the clinic group (p less than 0.03). Endoscopic evidence of gastro-oesophageal reflux disease, peptic ulceration, and gastroduodenal inflammation was equally common in each group; upper gastrointestinal malignancy, however, was significantly more common in patients referred through hospital doctors (5%, 23/454 v 2%, 22/1091 respectively; p less than 0.005) (although many of these patients had already been extensively investigated). IMPLICATIONS--Open access gastroscopy does not increase the number of unnecessary examinations and should become more widely available. Targeting this service to patients aged over 40 would reduce the number of requests but increase the diagnostic yield.     

Rectal examination in general practice.

OBJECTIVE--To investigate factors influencing a general practitioner''s decision to do a rectal examination in patients with anorectal or urinary symptoms. DESIGN--Postal questionnaire survey. SETTING--General practices in inner London and Devon. SUBJECTS--859 General practitioners, 609 (71%) of whom returned the questionnaire. MAIN OUTCOME MEASURES--Number of rectal examinations done each month; the indication score, derived from answers to a question asking whether the respondent would do a rectal examination for various symptoms; and the confidence score, which indicated the respondent''s confidence in the diagnosis made on rectal examination. RESULTS--279 General practitioners did five or fewer rectal examinations each month and 96 did more than 10 each month. Factors significantly associated with doing fewer rectal examinations were a small partnership and being a female general practitioner, and the expectation that the examination would be repeated. Lack of time in the surgery, and a waiting time of less than two weeks for an urgent outpatient appointment were also important. General practitioners were deterred from doing rectal examinations by reluctance of the patient (278), the expectation that the examination would be repeated (141), and lack of time (123) or a chaperone (39). Confidence in diagnosis was significantly associated with doing more rectal examinations, the perception of having been well taught to do a rectal examination at medical school, and being a male general practitioner. CONCLUSIONS--Factors other than clinical judgment influence the frequency of rectal examination in general practice. Rectal examination may become commoner with the trend towards larger group practices and if diagnostic confidence is increased and greater emphasis put on rectal examination in undergraduate and postgraduate teaching.     

Quality of obstetric care provided for Asian immigrants in Leicestershire.

Between 1976 and 1981 some 939 perinatal deaths occurred to women living in Leicestershire, of which 128 (14%) were to Asian women. The qualifications of the general practitioners, the gestation at which women start antenatal care, and perinatal death were used as structural, process, and outcome measures for evaluating the services provided to Asian immigrants within this population. Perinatal deaths were divided into four groups: congenital malformation, macerated stillbirth, asphyxia in labour, and immaturity. Asian mothers had one and a half times the risk of perinatal mortality when social class, parity, height, legitimacy, and the general practitioner''s qualifications were taken into account. Asian and non-Asian mothers with general practitioners who were not on the obstetric list had more than twice the risk of a perinatal death when a similar adjustment was made. Recommendations include priority allocation of community midwives to practitioners not on the obstetric list, the establishment of postgraduate courses for such doctors, and the continued evaluation of the effect of such proposals on perinatal mortality.     

Psychiatric Illness in General Practice: A Detailed Study Using a New Method of Case Identification

A self-administered questionary (the General Health Questionnaire) aimed at detecting current psychiatric disturbance was given to 553 consecutive attenders to a general practitioner''s surgery. A sample of 200 of these patients was given an independent assessment of their mental state by a psychiatrist using a standardized psychiatric interview. Over 90% of the patients were correctly classified as “well” or “ill” by the questionary, and the correlation between questionary score and the clinical assessment of severity of disturbance was found to be +0·80.The “conspicuous psychiatric morbidity” of a suburban general practice assessed by a general practitioner who was himself a psychiatrist and validated against independent psychiatric assessment was found to be 20%. “Hidden psychiatric morbidity” was found to account for one-third of all disturbed patients. These patients were similar to patients with “conspicuous illnesses” in terms both of degree of disturbance and the course of their illnesses at six-month follow-up, but were distinguished by their attitude to their illness and by usually presenting a physical symptom to the general practitioner.When 87 patients who had been assessed as psychiatric cases at the index consultation were called back for follow-up six months later, two-thirds of them were functioning in the normal range. Frequency of attendance at the surgery in the six months following index consultation was found to have only a modest relationship to severity of psychiatric disturbance.It is argued that minor affective illnesses and physical complaints often accompany each other and usually have a good prognosis.     

PROBLEMS OF HOMOSEXUALITY

Moral, religious and legal attitudes in attempts to control sexual behavior have interfered with a clear view of the medical and psychological aspects of homosexuality. This phenomenon is probably much less destructive of social aspects of our society and culture than is generally believed, since it is actually more widespread than is generally acknowledged.Homosexuality probably has hormonal and undoubtedly social and psychological factors, the latter of which are the only ones which can be worked with successfully in our present state of knowledge. A general practitioner''s task is to aid those who wish and need help with this problem in finding psychiatric treatment in the same way that persons with any other emotional disturbance are referred. This should be carried out without bias just as with any other emotional disturbance.     

The unmet need for interpreting provision in UK primary care

Background

With increasing globalisation, the challenges of providing accessible and safe healthcare to all are great. Studies show that there are substantial numbers of people who are not fluent in English to a level where they can make best use of health services. We examined how health professionals manage language barriers in a consultation.

Methods and Findings

This was a cross-sectional study in 41 UK general practices . Health professionals completed a proforma for a randomly allocated consultation session.Seventy-seven (63%) practitioners responded, from 41(59%) practices. From 1008 consultations, 555 involved patients who did not have English as a first language; 710 took place in English; 222 were in other languages, the practitioner either communicating with the patient in their own language/using an alternative language. Seven consultations were in a mixture of English/patient''s own language. Patients'' first languages numbered 37 (apart from English), in contrast to health practitioners, who declared at least a basic level of proficiency in 22 languages other than English. The practitioner''s reported proficiency in the language used was at a basic level in 24 consultations, whereas in 21, they reported having no proficiency at all. In 57 consultations, a relative/friend interpreted and in 6, a bilingual member of staff/community worker was used. Only in 6 cases was a professional interpreter booked. The main limitation was that only one random session was selected and assessment of patient/professional fluency in English was subjective.

Conclusions

It would appear that professional interpreters are under-used in relation to the need for them, with bilingual staff/family and friends being used commonly. In many cases where the patient spoke little/no English, the practitioner consulted in the patient''s language but this approach was also used where reported practitioner proficiency was low. Further research in different setting is needed to substantiate these findings.