General practitioner participation in intranatal care in the northern region in 1983.

In 1983 a quarter of general practitioners in the Northern region of England cared for obstetric deliveries and half of these for a minimum of 10 deliveries a year. Most expected their intranatal work to remain at the same level or increase in the next 10 years. Most participating general practitioners did their own forceps deliveries and initiated inductions. Most out of hours deliveries were attended by the mother''s own general practitioner or a partner. A quarter of all respondents had cared for planned and unplanned home births. Few were happy about attending them, but most would provide planned home care if urged to do so.     

Contribution of general practitioner hospitals in England and Wales.

A survey of a one-in-seven sample of general practitioner hospitals in England and Wales, performed to determine the contribution they make to overall hospital work load and the attitudes of the general practitioners working in them, showed that 3% of acute hospital beds in England and Wales were in general practitioner hospitals, which provided initial hospital care for up to 20% of the population. Altogether 16% of general practitioners and 22% of consultants were on the staffs, and they coped with more than 13% of all casualties, 6% of operations, and 4% of x-ray examinations. Nearly a million casualties were treated at no cost to the National Health Service. Twenty new district general hospitals would be needed to cope with the work load currently dealt with by general practitioner hospitals. The results of this survey indicate that these smaller hospitals deal efficiently and cheaply with their work load, and that morale is high. General practitioner hospitals could have an important part to play in providing certain types of care, but there are no financial incentives to enable general practitioners to realise this potential fully.     

General practitioner obstetrics in Bradford.

The standard of obstetrics care by general practitioners in Bradford was assessed by reviewing the case records of all women who in 1988 were booked for delivery under their general practitioner but subsequently required transfer to consultant care. A total of 5885 women were delivered in Bradford during 1988. Of 1289 booked under their general practitioner, 637 required transfer to consultant care. In 259 cases transfer occurred during labour; only 37 of these women were visited by their general practitioner. Many of the problems that precipitated transfer were predictable and some were considered preventable: 263 of the women transferred were considered unsuitable for booking by general practitioners. The perinatal mortality among women booked under their general practitioner was 10.1/1000 and the stillbirth rate 7.8/1000. These figures are high and suggest a need for tighter controls over the qualifications and experience of doctors participating in a fully integrated system of obstetric care.     

Laboratory and radiological investigations in general practice. I-Type requested and rate of use.

The use that 30 general practitioners in four group practices made of open access laboratory and radiological facilities was studied for one year. We were particularly interested in whether general practitioners hoped to exclude rather than confirm abnormality when requesting investigations. All but two of the general practitioners studied used investigations to exclude abnormality to a greater extent than to confirm it. The rate at which the practices investigated patients and the number of investigations requested were appreciably different and were different for individual general practitioners, part time general practitioners requesting more investigations than trainees and full time general practitioners. Haematological investigations accounted for over 30% of requests for investigations in all but one practice, biochemical investigations being requested as often as bacteriological investigations in two of the four practices. The ratio of expected to unexpected results varied among general practitioners; no general practitioner had more unexpected results and the range of ratios was similar for full time and part time general practitioners and for trainees. The proportion of patients with abnormalities uncovered by each practice increased disproportionately as the use of investigations increased, supporting a higher rather than lower rate of investigation among general practitioners. Compared with the results of other studies the use of the radiological facilities available was low. X ray examinations of the skeleton were requested more than chest and contrast media examinations by three of the four practices. Most x ray examinations were used to exclude rather than confirm abnormality by all the practices, with over 85% of results confirming the general practitioner''s initial diagnosis.     

Sources of primary health care for women in an urban centre.

Family or general practitioners and obstetrician-gynecologists have the opportunity to provide primary health care to women. Who actually gives this care in a large urban setting was the focus of this study. In the Montreal area 297 women were asked by telephone whether they had an obstetrician-gynecologist and whether they would see another type of doctor for a cold that was not getting better. Overall, 88% of all the women indicated that they would go to a family or general practitioner for such a problem, and of the women who reported receiving some care from an obstetrician-gynecologist 78% also received care from another physician. Of the respondents seeking health care from only one type of doctor, women with English as the mother tongue were significantly more likely to attend an obstetrician-gynecologist, whereas French-speaking women much more often were cared for by family or general practitioners.     

Roles,risks, and responsibilities in maternity care: trainees' beliefs and the effects of practice obstetric training.

OBJECTIVES--To document the content of practice obstetric vocational training, the beliefs of general practitioner trainees about the roles of midwives and general practitioners in maternity care, and the risks of providing such care; and to ascertain if undergoing such training affects their beliefs. DESIGN--Confidential postal questionnaire survey. SUBJECTS--Random one in four sample of all general practitioner trainees in the United Kingdom on vocational training schemes or in training practices in autumn 1990. MAIN OUTCOME MEASURES--Beliefs scored on seven point Likert scales and characteristics of trainer and training practice. RESULTS--Of 1019 trainees sent questionnaires, 765 (75.1% response rate) replied; 638 (83.3%) had done some part of their practice year. Of their trainers, 224 (35.1%) provided full obstetric care. 749 (99%) and 364 (48%) trainees believed that midwives and general practitioners respectively have an important role in normal labour; 681 (91.7%) trainees believed that general practice intrapartum care is a high risk "specialty." Those trainees whose trainers provide full obstetric care were significantly more likely to believe that both midwives and general practitioners have an important role in abnormal labour and to see the provision of intrapartum care as an incentive to join a practice. CONCLUSION--In this series most general practitioner trainees believed that both midwives and general practitioners have important roles in maternity care. Exposure of trainees to the provision of full obstetric care while in their training practice resulted in a more positive attitude towards the provision of such care by general practitioners.     

General practitioners' management of acute myocardial infarction and cardiac arrest: relevance to thrombolytic treatment.

A questionnaire was sent to 61 general practitioners who had participated 18 months previously in a study of their experience of cardiopulmonary resuscitation and defibrillation in acute myocardial infarction. Fifty (82%) replies were received. Only 16 of the 50 respondents thought that every general practitioner should have a defibrillator, but 46 thought that every group practice should have one. Most practitioners felt the need for more tuition and practice in advanced life support, but 15 did not have the practice defibrillator with them when on call. Only nine doctors normally had an electrocardiograph with them when on call, most relying on clinical acumen to make an operational diagnosis; there appeared to be reluctance to use any drugs other than opiates and atropine in the management of acute myocardial infarction. This study highlights the difficulty of maintaining readiness to deal effectively with myocardial infarction in the community and the problems of relying on the electrocardiogram in deciding who should be given thrombolytic treatment.     

One thousand heart attacks in Grampian: the place of cardiopulmonary resuscitation in general practice.

The outcome of 1011 heart attacks in patients under the care of general practitioners who practised cardiopulmonary resuscitation and were equipped with defibrillators is reported. The 28 day mortality was 36% (367 patients), and 59% of deaths occurred outside hospital. The general practitioner was the first medical contact in 92% of heart attacks and was equipped with a defibrillator in 80% of such calls. Fifty six patients had a cardiac arrest in the presence of a general practitioner, and resuscitation was attempted in 47 cases, representing 5% of all calls for heart attacks. Twenty one (45%) resuscitated patients reached hospital alive, and 13 (28%) survived to leave hospital. The opportunities for cardiopulmonary resuscitation in general practice occur sufficiently often to warrant training and equipping general practitioners for advanced life support. The results of resuscitation by general practitioners working alone compare favourably with those of mobile coronary care units based in hospitals.     

Future Role of the General Practitioner in the Hospital Service

A special subcommittee of the General Practitioner Liaison Committee of the Birmingham Regional Hospital Board used five attitude surveys of groups of general practitioners and a comprehensive study of other publications to determine the future role of the general practitioner in the hospital service.From these and other studies they concluded that, although not all general practitioners wished to participate in hospital work, there was an urgent need to provide suitable facilities and a proper career structure early after qualification for those who did, and that there should be hospital inpatient accommodation in which general practitioners can treat their own patients, preferably in association with consultant beds rather than in separate general-practitioner units.     

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.     

How can good general practitioner care be achieved?

It has been shown that to provide a high standard of care general practitioners probably need to book consultations at intervals of at least 10 minutes. In this study the maximum list size for which a general practitioner might be expected to provide a high standard of care was determined from calculations of the time spent consulting, based on various consultation rates and list sizes and assuming that consultations were 10 minutes long. If good quality care is to be provided and is to include the range of services suggested in the government''s recent green paper average list sizes should probably be no more than 1750, and lower in areas of high demand and high need. In addition to this, minimum standards could be determined for such measures as facilities available in surgeries, practice records, and accessibility of doctors to ensure that basic services were offered by all general practitioners.     

Perinatal mortality rates in isolated general practitioner maternity units.

OBJECTIVE--To determine the perinatal mortality rate among normally formed, singleton babies with birth weights greater than or equal to 2500 g in Bath health district based on the intended place of delivery at the time of onset of labour or at the time of diagnosis of intrauterine death. DESIGN--The numbers of live births and stillbirths were collected monthly returns from the maternity units concerned. Deaths of infants aged less than or equal to 1 week were collected in the same returns. The intended place of delivery was confirmed at the monthly perinatal mortality meeting, during which maternal and fetal factors were discussed. SETTING--A rural health district of 400,000 population where one third of all deliveries occurred in seven isolated general practitioner maternity units, 8% in the integrated general practitioner unit, and the remainder in the consultant unit. SUBJECTS--All babies of women whose deliveries were booked in the district before the onset of labour or the diagnosis of intrauterine death, excluding twins, babies with lethal congenital malformations, and those less than 2500 g. MAIN OUTCOME MEASURES--Outcome of all deliveries and parity of mothers. RESULTS--14,415 Deliveries were analysed. The perinatal mortality rate was 2.8/1000 births in the consultant unit (7950 deliveries), 4.8 in the isolated general practitioner units (5237 deliveries), and zero in the integrated general practitioner unit (1228 deliveries). Perinatal deaths attributable to asphyxia were more common in the isolated general practitioner units (1.5 per 1000) than the consultant unit (0.6 per 1000). The perinatal mortality rate among babies born to nulliparous women was 3.2/1000 births in the consultant unit and 5.7 in the isolated general practitioner units; for those born to multigravid women it was 2.4 and 4.2 respectively. CONCLUSIONS--The outcome of delivery was not influenced by parity. Both antenatal and intrapartum care were responsible for the higher perinatal mortality rate in the isolated general practitioner units. The integrated unit, which shared midwifery staff with the consultant unit, seemed to work well. Analysis by intended place of delivery at the time of onset of labour or diagnosis of intrauterine death suggested that the care given in isolated units needs to be improved, perhaps by better training of general practitioners and consultant supervision of antenatal care.     

Use of non-orthodox and conventional health care in Great Britain.

OBJECTIVE--To describe the characteristics of patients using non-orthodox health care and their pattern of use of conventional health care with respect to a particular problem. DESIGN--Postal survey of all 2152 practitioners of acupuncture, chiropractic, homeopathy, naturopathy, and osteopathy identified from 11 national professional association registers. Patients attending a representative sample of 101 responding practitioners completed questionnaires covering demographic characteristics, presenting problems, and use of the health service. SETTING--Practices of practitioners of non-orthodox health care in England, Scotland, and Wales. SUBJECTS--Qualified, non-medical practitioners of non-orthodox health care working in Great Britain and 2473 patients who had attended one of the sampled practitioners in an allocated time period between August 1987 and July 1988. RESULTS--An estimated 1909 practitioners were actively practising one of the study treatments in Great Britain in 1987. Of the estimated 70,600 patients seen by this group of practitioners in an average week, most (78%) were attending with a musculoskeletal problem. Two thirds of the patients were women. Only 2% were aged under 16, but 15% were aged 65 or over. One in three patients had not received previous conventional care for their main problem; 18% were receiving concurrent non-orthodox and conventional care. Twenty two per cent of the patients reported having seen their general practitioner for any reason in the two weeks before the surveyed consultation. CONCLUSIONS--Patients of non-orthodox health care, as provided by this group of practitioners, had not turned their backs on conventional health care. Non-orthodox treatment was sought for a limited range of problems and used most frequently as a supplement to orthodox medicine.     

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.     

Long-term digoxin treatment in general practice.

A questionnaire was sent to several general practitioners and specialists in an attempt to obtain a consensus on standards of care for patients receiving long-term digoxin treatment. The consultants'' suggested standards were slightly more stringent than those of the general practitioners. The records of 42 patients taking digoxin under the care of two general practitioners were studied to see how far their actual care matched up to the suggested standards. The models of management proposed by these patients'' doctors were only slightly different from those suggested by other practitioners, but measured against these models the patients'' care was in some cases inadequate. Nevertheless, there was little relationship between the recorded levels of care and the health of the patient, and it may have been the standard of recording rather than the care that was inadequate. Measuring plasma digoxin levels in these patients proved to be of little value. Medical audit is thus a useful tool in helping the general practitioner to review his work and improve his knowledge, but it may not be a practical or true way of measuring the quality of care.     

Should obstetricians see women with normal pregnancies? A multicentre randomised controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians.

OBJECTIVE--To compare routine antenatal care provided by general practitioners and midwives with obstetrician led shared care. DESIGN--Multicentre randomised controlled trial. SETTING--51 general practices linked to nine Scottish maternity hospitals. SUBJECTS--1765 women at low risk of antenatal complications. INTERVENTION--Routine antenatal care by general practitioners and midwives according to a care plan and protocols for managing complications. MAIN OUTCOME MEASURES--Comparisons of health service use, indicators of quality of care, and women''s satisfaction. RESULTS--Continuity of care was improved for the general practitioner and midwife group as the number of carers was less (median 5 carers v 7 for shared care group, P<0.0001) and the number of routine visits reduced (10.9 v 11.7, P<0.0001). Fewer women in the general practitioner and midwife group had antenatal admissions (27% (222/834) v 32% (266/840), P<0.05), non-attendances (7% (57) v 11% (89), P<0.01) and daycare (12% (102) v 7% (139), P<0.05) but more were referred (49% (406) v 36% (305), P<0.0001). Rates of antenatal diagnoses did not differ except that fewer women in the general practitioner and midwife group had hypertensive disorders (pregnancy induced hypertension, 5% (37) v 8% (70), P<0.01) and fewer had labour induced (18% (149) v 24% (201), P<0.01). Few failures to comply with the care protocol occurred, but more Rhesus negative women in the general practitioner and midwife group did not have an appropriate antibody check (2.5% (20) v 0.4% (3), P<0.0001). Both groups expressed high satisfaction with care (68% (453/663) v 65% (430/656), P=0.5) and acceptability of allocated style of care (93% (618) v 94% (624), P=0.6). Access to hospital support before labour was similar (45% (302) v 48% (312) visited labour rooms before giving birth, P=0.6). CONCLUSION--Routine specialist visits for women initially at low risk of pregnancy complications offer little or no clinical or consumer benefit.     

Alternatives to hospital care: what are they and who should decide?

OBJECTIVE--To examine potential for alternatives to care in hospitals for acute admissions, and to compare the decisions about these alternatives made by clinicians with different backgrounds. DESIGN--Standardised tool was used to identify patients who could potentially be treated in an alternative form of care. Information about such patients was assessed by three panels of clinicians: general practitioners without experience of general practitioner beds, general practitioners with experience of general practitioner beds, and consultants. SETTING--One hospital for acute admissions in a rural area of the South and West region of England. SUBJECTS--Of 620 patients admitted to specialties of general medicine and care of the elderly, details of 112 were assessed by panels. MAIN OUTCOME MEASURES--Proportion of hospitalised patients who could have received alternative care and identification of most appropriate alternative form of care. RESULTS--Both general practitioner panels estimated that between 51 and 89 of the hospitalised patients could have received alternative care (equivalent to 8-14% of all admissions). Consultants estimated that between 25 and 55 patients could have had alternative care (5.5-9% of all admissions). General practitioner bed and urgent outpatient appointment were the main alternatives chosen by all three panels. CONCLUSION--About 10% of admissions to general hospital might be suitable for alternative forms of care. Doctors with different backgrounds made similar overall assessments of most appropriate forms of care.     

Survey of general practitioners' attitudes to AIDS in the North West Thames and East Anglian regions

As the numbers of people suffering from human immunodeficiency virus infection and the acquired immune deficiency syndrome (AIDS) increase, so will the contribution to care required from general practice. A postal questionnaire survey was therefore carried out among general practitioners in the North West Thames and East Anglian regions to determine their attitudes to AIDS and the issues it raises for them. One hundred and thirty seven questionnaires were returned (response rate 57%) and four factors underlying the doctors'' attitudes identified; these concerned disease control, general practitioner care, patient support, and perception of seriousness. There were wide divergencies of attitude among the general practitioners, younger doctors being more in line with specialist thinking on AIDS than older colleagues, and evidence of important gaps between policies advocated by AIDS specialists and bodies of opinion in general practice.Attitudes to AIDS in general practice may partly be a function of personal experience; further study is required.     

AIDS and the general practitioner: views of patients with HIV infection and AIDS.

An unselected series of outpatients infected with the human immunodeficiency virus (HIV) who attended two London hospitals were interviewed to assess their relationship with their general practitioner. Although most of the 192 patients were registered with a general practitioner, the doctors of only one half knew of the diagnosis. Patients feared a negative reaction from their general practitioner or were concerned about confidentiality. Although those who had told their doctor had received favourable reactions, few general practitioners attempted to counsel or educate their patients. The patients who previously had been open about their homosexuality were not more likely to have told their general practitioner of their HIV infection. Although most did not think that general practitioners were well informed about AIDS, half of the patients wished that general practitioners could take a bigger part in their care.