Need and demand for primary health care: a comparative survey approach.

OBJECTIVE--To develop general practice profiles of needs and demand for primary health care. DESIGN--Postal survey of a stratified random sample of 3478 people registered with five general practices. Data from a single practice were compared with data from the remaining four to identify areas of comparative need. SETTING--Five general practices in Lothian. MAIN OUTCOME MEASURES--Differences between the single practice and the comparison practices in terms of social and economic circumstances, limiting long term illness, specific ongoing conditions, minor illness or symptoms, psychosocial problems, discussion of lifestyle, associated use of services. RESULTS--Respondents from the single practice reported higher rates than those in the four comparison practices of ongoing mental health and respiratory problems and use of antidepressants, tranquillisers, or sleeping tablets. Although rates of limiting long term illness and other specific ongoing conditions were comparable, the rates of minor illness or symptoms and psychosocial difficulties were higher in the single practice. Respondents from the single practice were more likely to consult frequently, to have contacted the practice out of normal working hours, and to have discussed psychosocial difficulties with a general practitioner. For any specific ongoing condition or "minor" illness, respondents from the single practice were no more likely to consult. CONCLUSIONS--A comparative survey approach is a useful method of developing an understanding of patterns of need and demand among general practice populations. It has the potential to inform planning within individual general practices and the process of commissioning among general practices within a given area.     

Equity and consultation rates in general practice.

An attempt was made to distinguish different types of consultations and their variation by social class by a secondary analysis of the second national morbidity survey in general practice. The greatest difference in consultation rates, comparing patients in social classes IV and V with those in classes I and II, was for life threatening, urgent, chronic, or incapacitating conditions, thus matching the presumed difference in need. For more trivial conditions and for symptoms not specifically diagnosed the difference between social classes was less, and for married women in various ways consultation rates suggested less care seeking by patients in the lower social classes. The different uses made of primary care is more illuminating and more relevant to the question of equality in use of services than crude overall consulting rates by social class.     

Audit of terminal care in a general practice.

OBJECTIVE--To determine satisfaction of relatives and general practitioners with care of patients during terminal illness and make recommendations on improving terminal care in general practice. DESIGN--Interviews with available relatives of patients who had had terminal illnesses and died in 1987, supplemented by questionnaires; questionnaire survey of general practitioners after review of case notes of all their patients who had died of terminal illnesses in 1987. SETTING--One urban general practice. SUBJECTS--34 Relatives of patients with terminal illnesses who died in 1987; five general practitioners from one practice. RESULTS--In six cases relatives were dissatisfied, mainly because of lack of communication; in eight cases doctors were dissatisfied because of communication, poor symptom control, and inadequate care. IMPLICATIONS--There is a need for improved communication between relatives and the health professionals involved in terminal care as well as better advice on services and benefits available to both patients and relatives. Bereavement counselling should be better organised.     

Measles immunisation: profit and loss in a general practice.

A survey in one general practice of the occurrence of measles and of immunisation in patients who were born between 1963 and 1982 showed that immunisation not only brought some financial reward to the practice, but by preventing measles reduced the number of consultations related to measles by 40%. Although practice policy often entailed a home visit to immunise a patient, measles disease was three times more likely to require a visit. It is surprising that, considering the efficacy and safety of measles immunisation, in Britain measles has not become the rarity it now is in the United States.     

Do personal computers make doctors less personal?

Ten months after the installation of a computer in a general practice surgery a postal survey (piloted questionnaire) was sent to 390 patients. The patients'' views of their relationship with their doctor after the computer was introduced were compared with their view of their relationship before the installation of the computer. More than 96% of the patients (n=263) stated that contact with their doctor was as easy and as personal as before. Most stated that the computer did not influence the duration of the consultation. Eighty one patients (30%) stated, however, that they thought that their privacy was reduced.Unlike studies of patients'' attitudes performed before any actual experience of use of a computer in general practice, this study found that patients have little difficulty in accepting the presence of a computer in the consultation room. Nevertheless, doctors should inform their patients about any connections between their computer and other, external computers to allay fears about a decrease in privacy.     

Feasibility of contact surveys in general practice.

Surveys to evaluate risk factors for disease in the general population are popular with health authorities for assessing the effectiveness of their preventive measures. A contact survey of the lifestyles of 2000 randomly selected patients aged 25-64 was conducted in five general practices over 18 months; the medical records of the patients selected were tagged, and when the patients first visited the surgery they were given a questionnaire by the receptionists, which they completed in the waiting room. Over the 18 months at least 1400 of these patients visited the practices, of whom 1106 (55%) completed a questionnaire and 20 refused to do so; 896 (81%) completed it within one year. Information on the patients who were not surveyed was obtained by sending the questionnaire by post and by audit of medical records. The population surveyed on contact with the surgeries contained a higher proportion of young women, and possibly a higher proportion of patients from social classes IIIM-V, than the other patients. No important or consistent bias towards unhealthy patients at high risk was identified in the contact survey. A one year contact survey of a random, tagged sample is feasible in estimating the risk factors in a population and may be the method of choice in general practice because of its low cost and adaptability.     

How do people choose their doctor?

The white paper Working for Patients assumes that patients choose general practitioners on the basis of the service that they provide and that increased competition among doctors will raise standards. To investigate these assumptions a postal questionnaire survey was carried out of 447 people who had recently registered with a new general practitioner. The results disclosed a remarkable lack of consumerist behaviour. Most people registered with their nearest doctor, and many did not register until they were already ill. Many people knew nothing about their new practice but seemed unworried by this and showed little inclination to seek information. These findings suggest that competition among general practitioners is unlikely in itself to raise standards of care.     

Training for general practice: a national survey.

OBJECTIVES--(a) To compare current vocational training in general practice with that ascertained by a survey in 1980; (b) to compare the training of trainees in formal training schemes with that of trainees arranging their own hospital and general practice posts. DESIGN--National questionnaire survey of United Kingdom and armed services trainees who were in a training practice on 1 April 1989. Questionnaires were distributed by course organisers. SETTING--Research project set up after an ad hoc meeting of trainees at the 1988 national trainee conference. SUBJECTS--2132 Of the 2281 trainees (93%) known to be in a training practice on 1 April 1989. RESULTS--1657 Trainees returned the questionnaires, representing 73% of all trainees known to be in a training practice on 1 April 1989. Between 1980 and 1989 there were significant improvements in the trainee year, and there was also evidence of improvements in general practice study release courses. There was no evidence of improvement in other aspects of training. General practice trainees spent an average of three years in junior hospital posts, which provided very little opportunity for study related to general practice. Training received during tenure of hospital posts differed significantly between trainees in formal schemes and those arranging their own hospital posts. During the trainee year training was almost the same for those in formal schemes and those arranging their own posts. Regions varied significantly in virtually all aspects of general practice training. CONCLUSIONS--The trainee year could be improved further by enforcing the guidelines of the Joint Committee on Postgraduate Training for General Practice. The poor training in junior hospital posts reflected the low priority that training is generally given during tenure of these posts. A higher proportion of general practice trainees should be attached to vocational training schemes. More hospital trainees could attend general practice study release courses if these were designed specifically with the needs of hospital doctors in mind.     

Prevalence of symptoms of Raynaud's phenomenon in general practice.

OBJECTIVE--To investigate the prevalence of Raynaud''s phenomenon in the populations of five general practices. DESIGN--Two populations studied. A questionnaire was given to all new patients attending five general practices over four weeks, and the same questionnaire was sent by post to a random sample of adults from two of the practices. SETTING--General practices in inner London, Merseyside, and Cheshire. SUBJECTS--1532 Patients who completed questionnaires (1119 who attended the surgeries (response rate unknown) and 413 respondents to the postal survey (response rate 69%)). MAIN OUTCOME MEASURES--Response to questionnaire on symptoms of Raynaud''s phenomenon: patients were regarded as having the disease if they had episodes of blanching of the fingers that were precipitated by cold and accompanied by sensory symptoms (pins and needles or numbness). Subsequent interview and clinical appraisal of patients with the disease according to their responses to the questionnaire. RESULTS--The prevalence of Raynaud''s phenomenon was 11% (26/231) and 19% (34/182) respectively in men and women who completed the postal questionnaire and 16% (56/357) and 21% (157/762) respectively in those who completed the questionnaire when attending their general practice. Thus the overall rates were slightly higher in women, but there was no effect of age even after adjustment of the rates for practice and method of survey. CONCLUSION--The prevalence of Raynaud''s phenomenon is high compared with the low number of patients who seek treatment for the disease.     

Patients in acute surgical wards: a survey in Glasgow.

A survey was made of all patients in general surgical, urological, and orthopaedic and accident wards in Glasgow on one day in June 1975. Its purpose was to define features of acute surgical practice of relevance to the future planning of resources, particularly bed numbers. Over 40% of the patients in both surgical and orthopaedic wards were over 65 years. Most patients had serious conditions and could not have been treated other than by admission to an acute surgical ward. But a substantial minority no longer needed such facilities and could have been transferred to second-line beds, although many still required skilled nursing care. Delay in the discharge of elderly patients from acute surgical wards as a consequence of non-surgical (often medical or social) problems results in a proportion of acute surgical beds fulfilling a second-line function. Unless arrangements for the earlier discharge of these patients are made any reduction in acute surgical beds is likely to restrict elective surgery, especially in orthopaedics.     

Screening for cervical cancer: a new scope for general practitioners? Results of the first year of colposcopy in general practice.

A survey was carried out over one year of all the women who attended a colposcopy clinic in a general practice. During the year 1254 women underwent cytological screening in the practice and 197 of these underwent colposcopy. Of 79 women with abnormal smears that suggested cervical intraepithelial neoplasia, 62 (79%) were confirmed by biopsy to have cervical premalignancy. In addition, the remaining 118 women with normal or inflammatory smears underwent colposcopy either because of their history or because they requested the investigation. A general underestimate of cervical intraepithelial neoplasia when cytology alone was used was discovered. Seven out of 28 women with inflammatory smears were found to have important cervical premalignancy. Mildly dyskaryotic smears led to a falsely reassuring estimate of the degree of severity of cervical lesions. Seven out of 13 patients who underwent colposcopy because they were thought to be at high risk of neoplasia because of a history of genital warts, unexplained recurrent cystitis, heroin abuse, or immunosuppression had cervical intraepithelial neoplasia proved at biopsy. This report shows that both in screening for and in the follow up of known cervical disease a normal smear cannot guarantee normal pathology. Diagnostic colposcopy is a valuable complementary investigation that could be carried out in a general practice.     

Assessment of psychological care in general practice.

OBJECTIVE--To pilot a method of assessing psychological care by general practitioners. DESIGN--Prospective examination of psychological care given in general practice by using general health questionnaire with predetermined quantifiable and case specific indices of outcome established at the original consultation. SETTING--Rural general practice in Clwyd, North Wales. SUBJECTS--447 consecutive adult general practice attenders. MAIN OUTCOME MEASURES--Three month follow up consultation rates, one year retrospective consultation rates, continuity of care, changes in general health questionnaire scores at follow up, general satisfaction, and acceptability of outcome measures. RESULTS--The principal and trainee identified 72 patients with psychological problems, 46 of whom had new conditions. 133 patients scored over 6 on the 28 item general health questionnaire, 33 of whom were identified as new cases by the general practitioners. 62 patients were seen at follow up, including 23 patients identified by the questionnaire but not by the doctor. The doctors used diagnostic terms to describe the presenting condition in 38 cases. At three month follow up the general health questionnaire scores had fallen by more than 5 points in 22/39 patients identified and managed by doctors and 11/23 identified by the questionnaire. The agreed index of good outcome was almost or completely achieved by 20 of the 39 patients managed by doctors. CONCLUSION--Quantifiable methods of evaluating the quality of the structure, process, and outcome of psychological care can be achieved in general practice.     

Are general practitioners prepared to share information about their patients and their work?

A questionnaire survey of the 44 general practices in Central Nottinghamshire Health District elicited 43 responses. Ten scenarios on sharing information were graded on a five point scale by each practice according to its willingness to share the information. Responses varied from 41 practices that would at least “probably” give the number of their young chronic sick patients to the local district health authority to 17 practices that were positive towards sharing with a local charity the names of elderly patients living alone. This second example raises profound issues of confidentiality. The extent to which practices were prepared theoretically to share practice generated information with outside bodies was generally high and showed a willingness to do so if the reasons were sound and the requesting body was acceptable.     

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.     

Socioeconomic determinants of rates of consultation in general practice based on fourth national morbidity survey of general practices.

OBJECTIVE--To identify the socioeconomic determinants of consultation rates in general practice. DESIGN--Analysis of data from the fourth national morbidity survey of general practices (MSGP4) including sociodemographic details of individual patients and small area statistics from the 1991 census. Multilevel modelling techniques were used to take account of both individual patient data and small area statistics to relate socioeconomic and health status factors directly to a measure of general practitioner workload. RESULTS--Higher rates of consultations were found in patients who were classified as permanently sick, unemployed (especially those who became unemployed during the study year), living in rented accommodation, from the Indian subcontinent, living with a spouse or partner (women only), children living with two parents (girls only), and living in urban areas, especially those living relatively near the practice. When characteristics of individual patients are known and controlled for the role of "indices of deprivation" is considerably reduced. The effect of individual sociodemographic characteristics were shown to vary between different areas. CONCLUSIONS--Demographic and socioeconomic factors can act as powerful predictors of consultation patterns. Though it will always be necessary to retain some local planning discretion, the sets of coefficients estimated for individual level factors, area level characteristics, and for practice groupings may be sufficient to provide an indicative level of demand for general medical services. Although the problems in using socioeconomic data from individual patients would be substantial, these results are relevant to the development of a resource allocation formula for general practice.     

Use of thermometers in general practice.

OBJECTIVE--To identify the attitudes of general practitioners towards the use of thermometers in general practice. DESIGN--Postal questionnaire survey. SETTING--All general practitioners in the catchment area of Frimley Park Hospital, Surrey. SUBJECTS--145 general practitioners. MAIN OUTCOME MEASURES--Answers to questions covering a variety of aspects concerning the use of thermometers in general practice. RESULTS--116 (80%) doctors replied. Seven doctors did not have any method of taking a patient''s temperature; up to 12 more doctors did not use their thermometers and 56 doctors used them infrequently, less than once a fortnight. Mercury glass thermometers were most commonly used (80 doctors; 69%), but only 8% of doctors used them correctly. Six doctors failed to clean their thermometers between patients. The study failed to identify the roles of axillary and rectal temperature readings. CONCLUSION--There is a wide variation in attitudes towards the use of thermometers in general practice.     

Study of diagnostic accord between general practitioners and an ophthalmologist.

OBJECTIVES--To identify diagnostic accord and disagreement between general practitioners and an ophthalmologist and thereby determine how undergraduate and non-specialist postgraduate ophthalmic training could be improved. DESIGN--Comparison of diagnosis of presenting conditions by general practitioners and one ophthalmologist in patients consulting general practitioners for ophthalmic problems during March 1989 to February 1990. SETTING--12 general practices in west Nottingham. PATIENTS--1474 patients presenting to the study general practitioners with new ophthalmic conditions or new episodes of recurrent conditions. MAIN OUTCOME MEASURES--Diagnoses of general practitioners and ophthalmologist. RESULTS--1121 (76%) of patients with eye problems agreed to see the ophthalmologist and most were seen within three days. Sufficient data for comparison were available on 1103 patients. Diagnostic agreement was found in 638 cases (58%), but potentially serious misdiagnosis was found in only 15 cases; management in three of these cases would have ensured later identification. Most commonly confused conditions were infective and allergic conjunctivitis, blepharitis, and dry eyes. General practitioners assessed visual acuity in only 114 cases yet eight of the 15 patients seriously misdiagnosed had reduced acuity, an important diagnostic sign. CONCLUSIONS--Most ophthalmic disease seen in general practice does not require specialised equipment for diagnosis. Most cases of misdiagnosis have no serious consequences for the patient. Undergraduate and postgraduate training in ophthalmology should ensure that common conditions can be easily differentiated and more serious conditions identified and referred.     

A Two-Year Follow-up of Persons with Non-Tuberculous Chest Disease Found at “Operation Doorstep”, Vancouver 1964

Eight hundred and fifty-four patients of 928 who had attended a mass radiographic tuberculosis survey and in whom the diagnosis of non-tuberculous lung disease had been made, were located two years after the survey. This was the second follow-up survey of this group, the first having been at four months. The majority of patients were well, but 247 were ill and 101 had died. Serious non-tuberculous chest disease can be diagnosed with accuracy at mass surveys but the benefit to the patient of having these conditions detected is less clear. Serious progressive conditions that lead to death or ill health within two years appear to become symptomatic and force the sufferer to seek medical advice at about the same time that they are detected at mass surveys. This fact, coupled with the low yield of previously unknown tuberculosis, makes the future use of general mass radiographic surveys questionable in areas with good medical services. Evidence is presented that suggests screening directed to specific age groups may be more productive.     

Citizens' advice in general practice.

OBJECTIVE--To examine the introduction of citizens advice bureau sessions into general practice. DESIGN--Prospective survey of 150 consecutive attenders. SETTING--10 Practices in south Birmingham that volunteered to participate. OUTCOME MEASURES--The social characteristics of the population attending, the problems presented, the social security and other payments obtained, and the health problems mentioned during the sessions. RESULTS--Advice requested covered the whole range offered by the citizens advice bureaus. Thirty nine of 150 attenders obtained payments totalling 58,300.58 pounds for year 1991-2, of which 54,929.58 pounds was recurring. People mentioning health problems were significantly more likely to be entitled to unclaimed benefits. CONCLUSIONS--The provision of citizens advice bureau sessions in general practice is an effective way of providing advice on life problems and securing proper payment of benefits, particularly to patients with health problems. This service complements rather than detracts from other citizens advice bureau activities.