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.     

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.     

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.     

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.     

GPs in principle but not in practice: a study of vocationally trained doctors not currently working as principals.

OBJECTIVES--To identify doctors who are vocationally trained but not currently practising as principals in general practice; their reasons for not practising as principals; and whether the prospect of a re-entry course would appear to this group. DESIGN--Postal questionnaire survey based on semistructured interviews. SUBJECTS--Doctors who had been vocationally trained but were not currently practising as principals: 351 possible subjects identified by a process of "networking." SETTING--Trent Regional Health Authority. RESULTS--166 of the doctors who replied fitted the criteria (100 women; 66 men). The out of hours commitment was ranked as the most important factor for not practising as a principal--95 women and 50 men rated it important--followed by difficulty in combining work with family commitments--84 women, 31 men. 82 respondents (49%) said they would be interested in a re-entry course if one were available. CONCLUSIONS--There is a pool of vocationally trained doctors in Trent region who are not practising as principals in general practice. More flexible working patterns and the availability of a re-entry course could make the post of principal in general practice a more attractive proposition to these doctors.     

General practitioner training in paediatrics in the Trent region.

A total of 259 postal questionnaires were sent to all final year vocational trainees and new principals in general practice in the Trent region to find out how much training in paediatrics they had had. Questionnaires were returned by 105 trainees and 139 principals (244; 94%). Overall 72% (175) had taken up a hospital post in paediatrics during training, but among the 138 doctors who were on or had completed a three year vocational training scheme the proportion was slightly higher (82%; 115) (p = 0.01). Among the 175 who had had a post in paediatrics 108 (62%) had been given teaching sessions every week, and for half of these doctors the sessions lasted over one hour a week. Seventy five (54%) of the 139 principals reported that in their training in a general practice they had received no teaching about child health and a fifth said that they had not attended a clinic for children; 47 (34%) had received no training on procedures for dealing with cases of child abuse. The doctors who had held posts as senior house officers in paediatrics were more likely to report that they had adequate skills in paediatrics than those who had not, but overall only 62 (44%) reported that they could run a preschool child health surveillance programme. Extra paediatric posts in hospital are needed, but in the mean time improvements can be made to the teaching content in hospital and in the general practice attachment and postgraduate training in paediatrics provided for all general practitioners.     

Medical audit in general practice. I: Effects on doctors' clinical behaviour for common childhood conditions. North of England Study of Standards and Performance in General Practice.

OBJECTIVE--To estimate the effects of medical audit, particularly setting clinical standards, on general practitioners'' clinical behaviour. DESIGN--Before and after study strengthened by a replicated Latin square. SETTING--62 training general practices in the north of England. SUBJECTS--92 general practitioner trainers, 84 (91%) of whom completed the study; random sample of 3500 children consulting one of these trainers for any of five conditions--acute cough, acute vomiting, bedwetting, itchy rash, and recurrent wheezy chest--stratified by doctor consulted, condition, and age. INTERVENTIONS--Clinical standard set by each of 10 small groups of general practitioner trainers for one randomly selected childhood condition. Each group also experienced a different type of medical audit, randomly selected, for each of the four other study conditions (receiving a clinical standard set by another trainer group, tabulated data comparing clinical performance with that of all other groups, tabulated data from only their own group, and nothing ("control" condition)). MAIN MEASURES--Content of initial consultation divided into: history, examination, investigation, diagnosis, and management (abstracted from medical records and "enhancement forms" completed by doctors). RESULTS--There was increased prescribing of bronchodilators for acute cough, oral rehydration fluids for acute vomiting, antibiotics for itchy rash, and bronchodilators and oral steroids for recurrent wheezy chest and reduced prescribing of antibiotics for acute cough and recurrent wheezy chest and tricyclic antidepressants for bedwetting. Fewer children were "discharged." Each change was consistent with the standard and either limited to doctors who set a standard for that condition or significantly greater for them than all other doctors. CONCLUSION--Setting clinical standards improved prescribing and follow up.     

Family doctors: their choice of practice strategy.

The economic decisions taken by family doctors in one family practitioner area in the north of England were examined. There was evidence of a differential response to professional and economic incentives by a group of "high investing" practices. On five indicators of improvement in practice 32% of the practices accounted for 71% of the positive scores. Nearly all the high investing practices were in affluent areas; they were on average larger and had younger partners than the other practices. The high investing practices also faced more financial problems. There was evidence that older doctors with long lists of patients had a different strategy of income maximization. Innovation in primary care is not determined by attitude alone but also by objective factors such as age, location, and size of the practice.     

NHSnet in Scottish primary care: lessons for the future

ObjectiveTo evaluate the primary care communications initiative, which introduced NHSnet to primary care in Scotland.DesignSemi-structured telephone interviews, postal questionnaire.SettingAll 15 Scottish health boards, random sample of 1 in 3 of all Scottish general practices.ParticipantsInformation management and technology managers of health boards, 355 practice managers in the general practices.Results99% of Scottish general practices agreed to participate in initiative. Health boards varied significantly in project management styles (from minimal to total control), the nature of the networks they established (intranets or direct connections), costs to practices (from nothing to £125 per general practitioner per year), and training provided (from none to an extensive programme). In 56% of practices someone accessed NHSnet at least once a week. Practices varied considerably in amount of internet training received and staff groups targeted and in the intention to provide desktop access to NHSnet through a practice network.ConclusionThe initiative has successfully introduced a network that links Scottish general practices, health boards, and hospital trusts. However local variation in this “national” initiative may affect its use in primary care. Health authorities and general practices in England and Wales may wish to note these findings in order to avoid unhelpful variation.     

The Doctor-Patient Relationship: A Survey of Attitudes and Practices of Doctors in Singapore

This article reports the results of a survey, by mailed questionnaire, of the attitudes, values and practices of doctors in Singapore with respect to the doctor-patient relationship. Questionnaires were sent to a random sample of 475 doctors (261 general practitioners and 214 medical specialists), out of which 249 (52.4%) valid responses were completed and returned. The survey is the first of its kind in Singapore. Questions were framed around issues of medical paternalism, consent and patient autonomy. As the doctors were exposed to Western ethical concepts in their training, we were not surprised to find that they would mostly allow patients some say in decision-making and keep patients reasonably informed. In respecting patient autonomy, they would usually seek to influence patient choice by persuasion. However, the residual 'Asian-ness' of doctors in Singapore gives rise to some inconsistencies between values and practices. Many doctors still believe that a number of their patients are incapable of rational choice. There is some lack of openness in telling patients the whole truth. When patients choose to refuse treatment, many doctors are prepared to involve family members in making a consensus decision.
Doctors were also asked how they made ethical judgements in the face of dilemmas, and how they would like disputes with patients to be resolved. By and large, the doctors prefer to make their own judgements rather than to rely on rules. They also wish to keep the law courts out of disputes with patients, preferring less public ways of settling disputes.     

Medical audit in general practice. II: Effects on health of patients with common childhood conditions. North of England Study of Standards and Performance in General Practice.

OBJECTIVE--To estimate the effects of medical audit, particularly setting clinical standards, on patients'' health. DESIGN--Before and after study strengthened by a replicated Latin square. SETTING--62 training general practices in the north of England. PATIENTS--Random sample of 9000 children with any of five conditions--acute cough, acute vomiting, bedwetting, itchy rash, and recurrent wheezy chest--stratified by doctor consulted, condition, and age. INTERVENTIONS--Clinical standard set by each of 10 small groups comprising 84 general practitioner trainers for one randomly selected childhood condition. Each group also experienced a different type of medical audit, randomly selected, for each of the four other study conditions (receiving a clinical standard set by another trainer group, tabulated data comparing clinical performance with that of all other groups, tabulated data from only their own group, and nothing ("control" condition)). MAIN OUTCOME MEASURES--Condition specific, functional, psychological, and educational outcomes; together with parent satisfaction (recorded by home interviews and postal questionnaires). RESULTS--Children consulting trainers for recurrent wheezy chest after those doctors had set a standard for that condition improved both in drug compliance (79% (n = 33) before standard setting v 93% (30) after) and mean number of days of breathlessness (3.8 (SE 1.0) before v 1.7 (0.6) after) and wheeziness (4.7 (0.9) before v 1.8 (0.6) after), compared with those consulting doctors who had not (compliance 74% (144) before v 72% (146) after; breathlessness 2.4 (0.4) before v 2.3 (0.3) after; wheeziness 3.0 (0.4) before v 2.7 (0.4) after). There were no other significant effects of standard setting or audit on patients'' health. CONCLUSION--Setting clinical standards improved drug compliance and respiratory function in children with recurrent wheezy chest.     

Building morale through personal development.

Once general practitioners have established themselves as principals it may seem there is little else to work for. Lack of stimulation may lead to demoralisation, and it is essential that they have other ways to continue to develop their careers. Meeting other doctors to discuss cases and problems and postgraduate education often help but many doctors want to take on extra roles. The options available include undergraduate teacher, tutor for postgraduate education, and participation in medical audit advisory groups, local medical committees, or royal college faculties. Some general practitioners work part time to allow them to fit in these activities. It may also be possible to obtain extended study leave or a sabbatical to broaden experience. Others even more practice to provide new challenges.     

Computers in the surgery. The patient's view.

A postal survey sent to 350 patients from two rural practices confirmed that an appreciable minority of patients (17%) were opposed to doctors using computers. The questionnaire distributed had been carefully designed to identify their opposition more specifically. Most of the general concern was accounted for by the 91 patients (31%) who feared that confidentiality of information would be reduced. The sensitive nature of medical information alerts patients to the possibility of diminished security of records and obliges practices considering acquiring a computer to ensure that these fears are not realised. Smaller proportions of patients were found to oppose computers on other grounds--namely, impersonality, economy, and general anxiety.     

Vocational training for general practice in inner London. Is there a dearth? And if so what's to be done?

OBJECTIVE--To identify the nature and extent of any vocational training deficit within the London initiative zone and investigate the reasons. DESIGN--Collation of statistics and postal questionnaire surveys. SETTING--Thames regions inside and outside the London initiative zone. SUBJECTS--General practice registrars, trainers, principals from non-training practices, and vocational training course organisers. MAIN OUTCOME MEASURES--Trends in numbers of general practice registrars, proportions of trainers, views on current vocational training in inner London. RESULTS--Numbers of general practice registrars fell significantly between 1988 and 1993 within the London initiative zone and in England overall. The number of registrars within the zone fell by more than in the rest of the Thames regions, where the decline was not statistically significant. A lower proportion of principals were approved as trainers within the zone than in the rest of the Thames regions and England overall. In their responses to the survey (88% of inner London registrars responded and 81% of outer Thames registrars) registrars suggested that improving remuneration and personal safety would make training in London more attractive. Trainers and non-trainers (response rates 89% and 66% respectively) also suggested increasing remuneration for trainers together with more protected time for training. CONCLUSIONS--Less vocational training takes place within the London initiative zone than in the rest of the Thames regions and England overall, although there are discrepancies in official statistics. As well as specific recommendations for improving recruitment to vocational training in inner London, measures to tackle inner city deprivation should also remain high on the political agenda.     

Self referral to accident and emergency department: patients' perceptions.

A study was conducted (a) to assess the number of patients registered with a south London general practice who over 11 weeks referred themselves to an accident and emergency department, (b) to identify the characteristics of those patients, and (c) to determine their perceptions of the services and resources available within their general practices and of the role of accident and emergency departments. Two hundred and thirty four patients referred themselves to a casualty department during the study period, of whom 217 (93%) were interviewed by means of a semistructured questionnaire. Of the 217 patients interviewed, only 15 had tried to contact their general practitioner before attending the casualty department. Eighty nine patients considered that their problem was urgent and required immediate attention and many that they would need an x ray examination. A substantial minority of patients thought that their doctor would not be available. It is concluded that patients'' perceptions of their problems and of access to their doctors are the main determinants of self referral to a casualty department. These findings have important implications for patient education.     

General practitioners' views about the statutory annual practice report.

OBJECTIVE--To ascertain the views of primary care professionals about the current purpose, uses, potential, and workload implications of the statutory general practice annual report. DESIGN--Postal questionnaire survey. SETTING--General practices in the Northern region. SUBJECTS--All practices in the region that were singlehanded, fundholding, non-fundholding and with more than five partners, and a one in three random sample of all non-fundholding practices (n = 318). RESULTS--263 practices responded (83%). The report took a median of 12 hours to produce (95% confidence interval 11 to 15 hours; interquartile range 7-35). The main perceived purpose of the report was to monitor practice activity (165 respondents; 63% (95% confidence interval 57% to 69%)), but 44 respondents (17%; 13% to 22%) produced it only because it was contractually required. Practices included statutory and non-statutory data in these reports and would have liked comparative practice activity information (155 respondents; 59%) and "good ideas" (165 respondents; 63%) fed back to them. Respondents would have liked the annual report used to improve practice development planning (122 respondents; 46% (40% to 52%)), to facilitate audit (115 respondents; 44% (38% to 50%)), and to influence resource allocation (104 respondents; 40% (34% to 46%)). One hundred and eighteen practices (45%; 39% to 51%) would produce an annual report even if not contractually required. Data collected were perceived to be already available elsewhere. CONCLUSIONS--Primary care professionals have concerns about the current annual report. They would prefer to collect relevant, standardised data which could lead to better audit, planning, and resource allocation.     

General practice partnerships: till death us do part?

OBJECTIVES--To investigate applications for general practice partnership vacancies by established general practitioner principals, the reasons for changing partnerships, and the disincentives to these moves. DESIGN--Confidential postal questionnaire. SUBJECTS--Applicants to 367 general practices in the United Kingdom advertising for a new full time partner. MAIN OUTCOME MEASURES--The proportion of job applications containing at least one application from established principals, proportion of principals appointed as new partners, incentives and disincentives to changing partnership. RESULTS--Of 325 replies (89% response rate) received, 292 were suitable for further analysis. 210/241 (87%) of all applications contained some applications from at least one established principal. 12% of all applications were made by principals. 41/296 (14%) of the newly appointed partners had previously been an established principal. The main reasons for leaving the previous partnership were a desire to move locality or not getting on with previous partners. The disincentives to changing partnerships were largely financial, including the cost of the move and loss of income. CONCLUSIONS--It is possible for established principals in general practice to overcome the disincentives and to change partnerships. There did not seem to be any overall prejudice against appointing principals, in contrast to previously published views.     

HIV and measures to control infection in general practice.

OBJECTIVE--To assess the impact of HIV on procedures to control infection in general practices. DESIGN--A postal questionnaire survey. SETTING--General practices throughout Britain. SUBJECTS--5359 General practitioners, 3429 (63.9%) of whom returned the questionnaire. MAIN OUTCOME MEASURE--Response to questionnaire on knowledge about HIV and policies for controlling infection. RESULTS--Most doctors (2018) had started to wear gloves when taking blood. Almost half (1510) had not resheathed needles previously but a further 776 had adopted this policy because of HIV. Over half of the doctors did not know or were unsure about the risk of infection from needlestick injuries, and 1759 had no practice policy for controlling infection. CONCLUSIONS--Many doctors are uncertain about measures to control infection in general practice. More information and advice are needed to help doctors develop policies to protect patients and staff.