Findings of a national survey of the role of general practitioners in the treatment of opiate misuse: dealing with the opiate misuser.

Because there has been a substantial increase in the scale of drug misuse general practitioners have become increasingly concerned in responding to this problem. Little is known, however, about how general practitioners manage drug misusers. The findings from a national survey carried out in mid-1985 of a 5% random sample of general practitioners in England and Wales show the extent to which various actions were undertaken by general practitioners who reported on the consultation with the opiate misuser whom they last attended. In more than half of the cases the opiate misuser had been under the care of the general practitioners for this problem for at least six months. The findings indicate that most general practitioners refer these patients to specialist drug dependence clinics or to general psychiatric services but rarely to other agencies. Opiate drugs had been prescribed in nearly a third of cases. The rate of notification to the Home Office conforms with that in other studies and indicates a high degree of undernotification. More detailed study of general practitioners'' activities in managing drug misusers is needed.     

Findings of a national survey of the role of general practitioners in the treatment of opiate misuse: views on treatment.

An important component of government policy on services for drug misusers is to encourage general practitioners to take a more active role. There are, however, some indications that general practitioners regard drug misusers as undesirable patients, although no evidence is available. As part of a wider investigation of the role of general practitioners in the treatment of opiate misuse, a questionnaire, which was sent in mid-1985 to a 5% random sample of general practitioners in England and Wales, included a section designed to elicit their views on policy and treatment connected with opiate misuse. The results showed that although most general practitioners consider opiate misuse to be a priority concern for the Health Service, they also generally regard opiate misusers as especially difficult to manage, beyond their competence to treat, and less acceptable as patients than others in need of care. General practitioners who have qualified recently were somewhat less unfavourable in their views. These findings suggest that the effective implementation of government policy will require trying to modify general practitioners'' attitudes and providing support for them.     

Role of community pharmacies in prevention of AIDS among injecting drug misusers: findings of a survey in England and Wales.

OBJECTIVE--To determine the current and potential roles of community pharmacists in the prevention of AIDS among misusers of injected drugs. DESIGN--Cross sectional postal survey of a one in four random sample of registered pharmacies in England and Wales. SETTING--Project conducted in the addiction research unit of the Institute of Psychiatry, London. SUBJECTS--2469 Community pharmacies in the 15 regional health authorities in England and Wales. MAIN OUTCOME MEASURES--Willingness of pharmacists to sell injecting equipment to known or suspected misusers of drugs; pharmacists'' attitudes to syringe exchange schemes, keeping a "sharps" box for use by misusers of drugs, and offering face to face advice and leaflets; and opinions of community pharmacists on their role in AIDS prevention and drug misuse. RESULTS--1946 Questionnaires were returned, representing a response rate of 79%. This fell short of the target of one in four pharmacies in each family practitioner committee area in England and Wales, and total numbers of respondents were therefore weighted in inverse proportion to the response rate in each area. The findings disclosed a substantial demand for injecting equipment by drug misusers. After weighting of numbers of respondents an estimated 676 of 2434 pharmacies were currently selling injecting equipment and 65 of 2415 (3%) were participating in local syringe exchange schemes; only 94 of 2410 pharmacies (4%) had a sharps box for used equipment. There was a high degree of concern among pharmacists about particular consequences of drug misusers visiting their premises, along with a widespread acceptance that the community pharmacist had an important part to play. CONCLUSIONS--Promoting the participation of community pharmacists in the prevention of AIDS among misusers of injected drugs is a viable policy, but several problems would need to be overcome before it was implemented.     

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.     

List sizes and use of time in general practice.

The claim that list sizes in general practice should continue to fall towards a national average of 1700 patients rests heavily on the assumption that the extra time available to doctors would be used mainly for longer consultations, resulting in better standards of care. Evidence suggests, however, that the time is more likely to be used to increase rates of consultation in surgeries and home visits and to reduce the length of the working week. A national, random sample of 2104 principals in general practice in England and Wales were questioned about their allocation and use of time. The response rate was 67%, and no large biases in response were detected. The smaller their personal list size the less time general practitioners spent on all aspects of their work and the higher their rates of consultation and home visiting. The effects of further reductions in list sizes would be haphazard, being differentially distributed across the range of list sizes. Longer consultations would probably result, but most of the extra time would probably be used in higher rates of consultation in surgeries and home visits and some would be taken as free time.     

Comparison of Respiratory Disease Prevalence among Voluntary Monitoring Systems for Pig Health and Welfare in the UK

Surveillance of animal diseases provides information essential for the protection of animal health and ultimately public health. The voluntary pig health schemes, implemented in the United Kingdom, are integrated systems which capture information on different macroscopic disease conditions detected in slaughtered pigs. Many of these conditions have been associated with a reduction in performance traits and consequent increases in production costs. The schemes are the Wholesome Pigs Scotland in Scotland, the BPEX Pig Health Scheme in England and Wales and the Pig Regen Ltd. health and welfare checks done in Northern Ireland. This report set out to compare the prevalence of four respiratory conditions (enzootic pneumonia-like lesions, pleurisy, pleuropneumonia lesions and abscesses in the lung) assessed by these three Pig Health Schemes. The seasonal variations and year trends associated with the conditions in each scheme are presented. The paper also highlights the differences in prevalence for each condition across these schemes and areas where further research is needed. A general increase in the prevalence of enzootic pneumonia like lesions was observed in Scotland, England and Wales since 2009, while a general decrease was observed in Northern Ireland over the years of the scheme. Pleurisy prevalence has increased since 2010 in all three schemes, whilst pleuropneumonia has been decreasing. Prevalence of abscesses in the lung has decreased in England, Wales and Northern Ireland but has increased in Scotland. This analysis highlights the value of surveillance schemes based on abattoir pathology monitoring of four respiratory lesions. The outputs at scheme level have significant value as indicators of endemic and emerging disease, and for producers and herd veterinarians in planning and evaluating herd health control programs when comparing individual farm results with national averages.     

General practitioner obstetrics in the Northern region in 1983.

In late 1983 a four page questionnaire on general practitioner obstetrics was sent to a 50% random sample of general practitioners in the Northern region of England; 84% responded. Half of them said that they had access to general practitioner facilities for delivery, and half of these used them. A quarter of all respondents had provided intranatal care previously but had given it up, most of them during the late 1970s. Younger general practitioners were more highly qualified in obstetrics than older ones but did not do more intranatal work. Isolated general practitioner maternity units were much more likely to be used than those that were alongside consultant units or integrated with them. Ninety per cent of respondents provided antenatal care, 77% of these at special clinics and 88% with midwives in attendance. Teamwork, however, was not well developed. Increasing general practitioner participation in obstetric care seems feasible but depends heavily on more appropriate training and intranatal facilities being provided for general practitioners in association with specialist units.     

Organisation of telephone services and patients' access to doctors by telephone in general practice.

OBJECTIVES--To assess how accessible general practitioners are to patients by telephone and to examine the relations between organisation, number of lines, and number of patient-doctor calls. DESIGN--Postal survey of a random sample of general practitioners stratified by rural and urban practice areas, with differential sampling fractions. SETTING--General practices in England and Wales. SUBJECTS--2000 general practitioners, of whom 1459 (74%) responded. MAIN OUTCOME MEASURES--Number of calls received by general practitioner a day, time reserved for patients'' calls, and communication of availability of telephone contact. RESULTS--1421 general practitioners said that they accepted non-emergency calls from patients during the day and 285 reported reserving specific times of the day for this purpose. 848 estimated that they received four or fewer patient calls a day. The number of calls was significantly related to reserving time for calls (p less than 0.001), informing patients that the doctor was accessible by telephone (p less than 0.00001), and the number of periods when calls were accepted (p less than 0.00001). On average there were 3659 patients per incoming line; the number of patients per incoming line rose significantly as practice size increased (p less than 0.00001). CONCLUSIONS--The apparent willingness of general practitioners to accept calls was not reflected in the number of calls received. Reserving time, increasing periods of availability, and publicising telephone access increased the number of doctor-patient telephone contacts. Line congestion may be a problem, and impartial advice and guidance on telephone organisation and line requirements would be helpful.     

Nurse practitioners in accident and emergency departments: what do they do?

OBJECTIVE--To determine the distribution and scope of nurse practitioner schemes in accident and emergency departments in England and Wales; to describe the caseloads of doctors and nurse practitioners on two representative days; and to estimate the number of patients managed by nurse practitioners in the year to 31 March 1991. DESIGN--A postal survey of accident and emergency departments and a content analysis of case notes of new patients attending a representative sample of accident and emergency departments on two days. SETTING--All accident and emergency departments in England and Wales. PARTICIPANTS--Survey: 560 nurses in charge of accident and emergency departments. Census: case notes of 5814 patients in 37 accident and emergency departments. MAIN OUTCOME MEASURES--Survey: number of accident and emergency departments with nurse practitioner schemes. Census: demographic and clinical characteristics of new patients attending and whether nurse practitioner or doctor made diagnoses and ordered investigations, treatments, referrals, discharges. RESULTS--513 replies (92%) from 465 surveyed functioning accident and emergency departments and 48 departments recently closed. 27 (6%) departments used designated nurse practitioners and 159 (34%) "unofficial" nurse practitioners. Only 530 (9%) of the 5814 patients in the census were managed entirely or mainly by nurse practitioners, with higher proportions in ophthalmic departments (nearly 30%) and minor casualty departments (over 40%) than in major departments (3%). Most patients managed by nurse practitioners (86%) had minor trauma. In the year ending 31 March 1991 an estimated 390,000 (95% confidence interval 260,000 to 520,000) patients out of a total of 12.5 million (3.1%, 2.1% to 4.1%) were clinically managed by a nurse practitioner. CONCLUSIONS--Designated nurse practitioner schemes are rare. The volume and range of nurse practitioner work in major general accident and emergency departments is small compared with those in specialised and minor accident and emergency departments.     

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.     

Drug users in contact with general practice.

A group of heroin users who are in contact with a general practice in north west Edinburgh are described. The study group was younger and included more women than previous studies. These people used a large variety of drugs and mainly purchased them locally. Frequent and often prolonged abstinent periods occurred with no prescribed opiate treatment. The group had experienced a high rate of drug related medical disorders. All these points raise the possibility that opiate users who are known to general practitioners may be a distinctly different population from those who attend drug dependency clinics. The frequency of remission and the prevalence of polydrug use have profound implications for planning and evaluating an effective medical response.     

Substance use in remand prisoners: a consecutive case study.

OBJECTIVES: To determine the prevalence of drug and alcohol use among newly remanded prisoners, assess the effectiveness of prison reception screening, and examine the clinical management of substance misusers among remand prisoners. DESIGN: A consecutive case study of remand prisoners screened at reception for substance misuse and treatment needs and comparison of findings with those of prison reception screening and treatment provision. SETTING: A large adult male remand prison (Durham). SUBJECTS: 548 men aged 21 and over awaiting trial. MAIN OUTCOME MEASURES: Prevalence of substance misuse; treatment needs of substance misusers; effectiveness of prison reception screening for substance misuse; provision of detoxification programmes. RESULTS: Before remand 312 (57%) men were using illicit drugs and 181 (33%) met DSM-IV drug misuse or dependence criteria; 177 (32%) men met misuse or dependence criteria for alcohol. 391 (71%) men were judged to require help directed at their drug or alcohol use and 197 (36%) were judged to require a detoxification programme. The prison reception screen identified recent illicit drug use in 131 (24%) of 536 men and problem drinking in 103 (19%). Drug use was more likely to be identified by prison screening if an inmate was using multiple substances, using opiates, or had a diagnosis of abuse or dependence. 47 (9%) of 536 inmates were prescribed treatment to ease the symptoms of substance withdrawal. CONCLUSIONS: The prevalence of substance misuse in newly remanded prisoners is high. Prison reception health screening consistently underestimated drug and alcohol use. In many cases in which substance use is identified the quantities and numbers of different substances being used are underestimated. Initial management of inmates identified by prison screening as having problems with dependence producing substances is poor. Few receive a detoxification programme, so that many are left with the option of continuing to use drugs in prison or facing untreated withdrawal.     

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.     

Census of single homeless people in Sheffield.

OBJECTIVE--To determine the number of single homeless people in Sheffield and to examine their demography and social and medical details. DESIGN--Census carried out between 8 am and 8 pm on one day. Participants completed a questionnaire designed to provide data relating to employment history, contact with welfare and health services, social state, prison history, medical history, and health state. SETTING--Sites in Sheffield identified by local workers as being places of residence of homeless people. SUBJECTS--340 single homeless people. MAIN OUTCOME MEASURES--Self reported history of alcohol or drug misuse, existence of a chronic medical condition, and use of general practitioner and hospital services. RESULTS--The mean age of the population was 42.5 years and a quarter of the population were aged less than 30; there were 48 women. Significant differences were noted between men and women with respect to self reported psychiatric illness (77/266 men v 27/42 women), self reported alcoholism (83/273 v 4/44), prison history (152/255 v 8/41), and registration with a general practitioner (73/275 v 38/46). Various chronic medical conditions were reported, and the perceived health state of the population was low; 129 claimed to have been admitted to a psychiatric hospital. 220 people were registered with a general practitioner, and 179 claimed to see their doctor. Sixty five had attended or been admitted to a general hospital in the month preceding the study, 45 for accident and emergency services. CONCLUSIONS--The homeless in this population were younger than those found in previous studies. The prevalence of psychiatric illness was high in the population, and the overall health state was poor. Most subjects obtained health services from general practitioners.     

What are health authorities doing about the health problems caused by unemployment?

Unemployment is over three million in Britain, and unemployment is known to be associated with poor health. It has been suggested that health authorities should produce a comprehensive response to the health problems caused by unemployment, and a survey was undertaken to find how many had done so. All the regional and district health authorities in England, the health boards of Wales, Scotland, and Northern Ireland, and the family practitioner committees of England and Wales were asked by letter what they were doing to respond to the health problems of unemployment. A list of suggestions of what they might be doing was enclosed. The overall response rate was 77% (255/331), and 50% (127/255) of the respondents were doing something--33.3% (3/9) of the regional health authorities, 64% (101/158) of the district health authorities and health boards, and 26% (23/88) of the family practitioner committees. The paper describes what they were doing. A relation was sought between the level of unemployment in an area and the extent of the response, and a significant association was found. Half of Britain''s health authorities are now responding in some way to the health problems associated with unemployment.     

General-practitioner Hospital Beds: A Review

This paper reviews literature related to general-practitioner hospital beds. In England and Wales 21% of all maternity beds are controlled by general practitioners rather than consultants, and the proportion has increased considerably since 1955. Nearly one in five of these 21% are sited in the wards of a consultant hospital. General-practitioner beds, other than maternity, represent 3% of all hospital beds (excluding psychiatric beds) and this proportion has remained constant over the past 15 years. Only about 1% of these general-practitioner beds are located in a consultant hospital.In the discussion three questions are raised: Will general-practitioner inpatient care have a useful function in the future? What might that function be? Where should the care be located? The broader issue of the future role of the general practitioner needs to be considered before these questions can be satisfactorily answered. Unless a “hospital orientated” role of the general practitioner prevails there seems little place for practitioner inpatient care in urban areas. In the more rural areas, however, whatever the role of the practitioner becomes, certain groups of patients might advantageously receive inpatient care from their practitioners. Firmer answers to the questions raised cannot be given until a co-ordinated programme of research and development concerning different patterns of care is started.     

Specialist outreach clinics in general practice.

OBJECTIVES--To establish the extent and nature of specialist outreach clinics in primary care and to describe specialists'' and general practitioners'' views on outreach clinics. DESIGN--Telephone interviews with hospital managers. Postal questionnaire surveys of specialists and general practitioners. SETTING--50 hospitals in England and Wales. SUBJECTS--50 hospital managers, all of whom responded. 96 specialists and 88 general practitioners involved in outreach clinics in general practice, of whom 69 (72%) and 46 (52%) respectively completed questionnaires. 122 additional general practitioner fundholders, of whom 72 (59%) completed questionnaires. MAIN OUTCOME MEASURES--Number of specialist outreach clinics; organisation and referral mechanism; waiting times; perceived benefits and problems. RESULTS--28 of the hospitals had a total of 96 outreach clinics, and 32 fundholders identified a further 61 clinics. These clinics covered psychiatry (43), medical specialties (38), and surgical specialties (76). Patients were seen by the consultant in 96% (107) of clinics and general practitioners attended at only six clinics. 61 outreach clinics had shorter waiting times for first outpatient appointment than hospital clinics. The most commonly reported benefits for patients were ease of access and shorter waiting times. CONCLUSIONS--Specialist outreach clinics cover a wide range of specialties and are popular, especially in fundholding practices. These clinics do not seem to have increased the interaction between general practitioners and specialists.     

General practitioners' perceptions of the tolerability of antidepressant drugs: a comparison of selective serotonin reuptake inhibitors and tricyclic antidepressants.

OBJECTIVE: To examine inceptions and discontinuations of antidepressants in general practice. DESIGN: An observational study analysing data from an ongoing cross sectional postal survey. Every three months a representative sample of 250 doctors recorded prescribing activity for four weeks. This provided 4000 general practitioner weeks of recording per year. SETTING: A representative panel of general practitioners in England, Wales, and Scotland. SUBJECTS: Patients who began a new course of an antidepressant or had their treatment stopped or changed by the general practitioner between 1 July 1990 and 30 June 1995. MAIN OUTCOME MEASURES: Numbers of patients prescribed a new course of antidepressant; numbers discontinuing treatment; the ratio of antidepressant discontinuations to antidepressant inceptions; reasons for discontinuation; proportion of switches to another antidepressant. RESULTS: There were 13,619 inceptions and 3934 discontinuations of selective serotonin reuptake inhibitors and tricyclic antidepressants during the study. The number of newly prescribed courses of antidepressants increased by 116%, mostly due to an increase in prescribing of serotonin reuptake inhibitors. The ratio of total discontinuations to inceptions was significantly lower for serotonin reuptake inhibitors (22%) than for tricyclic antidepressants (33%). Differences persisted when controlled for age and sex of patients and severity of depression. However, there was more switching away from selective serotonin reuptake inhibitors when they failed (72%) than from tricyclic antidepressants (58%). CONCLUSIONS: Selective serotonin reuptake inhibitors are less likely than tricyclic antidepressants to be discontinued. A prospective study is needed in general practice to assess the implications of differences in discontinuation rates and switches on clinical and economic outcomes.