Consultations in general practice: a comparison of patients' and doctors' satisfaction.

OBJECTIVE--To provide an objective means of assessing patients'' and doctors'' satisfaction with a consultation. DESIGN--Questionnaire study of patients and general practitioners after consultations. SETTING--Urban general practice. SUBJECTS--250 Patients attending consecutive consultations conducted by five general practitioners. MAIN OUTCOME MEASURE--Identification of deficiencies within a consultation as perceived by both doctors and patients. RESULTS--The doctor''s and patient''s questionnaires for each consultation were matched and the results analysed on a group basis. The response rate for individual questions was high (81-89%). The doctors and patients significantly disagreed about the doctors'' ability to assess and put patients at ease, to offer explanations and advice on treatment, and to allow expression of emotional feelings and about the overall benefit that the patients gained from the consultation. In all cases of disagreement the doctor had a more negative view of the consultation than the patient. CONCLUSIONS--The results of giving structured questionnaires on consultations to both patients and doctors could be a useful teaching tool for established doctors or those in training to improve the quality and sensitivity of care they provide.     

Children seen frequently out of hours in one general practice.

OBJECTIVE--To identify reasons why some children receive more out of hours visits than most. DESIGN--A one year prospective study to identify the study group. This was followed by a case-control study involving a record search and personal interviews. SETTING--One three doctor urban general practice in West Lothian with 4812 patients. SUBJECTS--40 children aged under 10 years identified as high users of the out of hours service (more than two visits a year) and 40 age and sex matched controls. MAIN OUTCOME MEASURES--Numbers of visits; social factors such as lone motherhood, low educational attainment; score for management response to clinical vignette. RESULTS--147/756 (19%) out of hours visits in the study year were to children aged under 10 years; 109 (74%) to 41 children (6%). Problems seen were mainly minor, and little active management was required. Family and social factors which were significantly more common for the cases than for the controls included a lone mother (15 v 4), low educational attainment by the mother (25 v 14), receipt of income support (22 v 7), and non-ownership of the home (45 v 22) or a car (19 v 9). Mothers of the cases were more likely to choose to contact a doctor when presented with vignettes describing common childhood illnesses (median score for 16 vignettes 16.5 for cases v 14.5 for controls, Wilcoxon signed rank test, p = 0.01). CONCLUSIONS--Children seen more frequently than expected out of hours came from more socially disadvantaged families and their mothers were more likely to seek medical advice about minor childhood illness. Maternal education, to promote confidence in managing minor illness, may reduce their use of the out of hours service.     

Patients' assessment of out of hours care in general practice

A sample of 177 patients drawn from 13 north London practices were interviewed shortly after they had sought help from their practice outside normal surgery hours. Patients were asked to describe the process and outcome of their out of hours call, to comment on specific aspects of the consultation, and to access their overall satisfaction with the encounter.Parents seeking consultations for children were least satisfied with the consultation; those aged over 60 responded most positively. Visits from general practitioners were more acceptable than visits from deputising doctors for patients aged under 60, but for patients aged over 60 visits from general practitioners and deputising doctors were equally acceptable.Monitoring of patients'' views of out of hours consultations is feasible, and the findings of this study suggest that practices should regularly review the organisation of their out of hours care and discuss strategies for minimising conflict in out of hours calls—particularly those concerning children.     

Relation of out of hours activity by general practice and accident and emergency services with deprivation in Nottingham: longitudinal survey.

OBJECTIVES: To investigate the relation between out of hours activity of general practice and accident and emergency services with deprivation and distance from accident and emergency department. DESIGN: Six month longitudinal study. SETTING: Six general practices and the sole accident and emergency department in Nottingham. SUBJECTS: 4745 out of hours contacts generated by 45,182 patients from 23 electoral wards registered with six practices. MAIN OUTCOME MEASURES: Rates of out of hours contacts for general practice and accident and emergency services calculated by electoral ward; Jarman and Townsend deprivation scores and distance from accident and emergency department of electoral wards. RESULTS: Distances of wards from accident and emergency department ranged from 0.8 to 9 km, and Jarman deprivation scores ranged from -23.4 to 51.8. Out of hours contacts varied by ward from 110 to 350 events/1000 patients/year, and 58% of this variation was explained by the Jarman score. General practice and accident and emergency rates were positively correlated (Pearson coefficient 0.50, P = 0.015). Proximity to accident and emergency department was not significantly associated with increased activity when deprivation was included in regression analysis. One practice had substantially higher out of hours activity (B coefficient 124 (95% confidence interval 67 to 181)) even when deprivation was included in regression analysis. CONCLUSIONS: A disproportionate amount of out of hours workload fell on deprived inner city practices. High general practice and high accident and emergency activity occurred in the same areas rather than one service substituting for the other.     

Future provision of out of hours primary medical care: a survey with two general practitioner research networks.

OBJECTIVE--To ascertain general practitioners'' views about the future provision of out of hours primary medical care. DESIGN--Self completing postal questionnaire survey. SETTING--Wessex and north east England. SUBJECTS--116 general practitioners in the Wessex Primary Care Research Network and 83 in the Northern Primary Care Research Network. MAIN OUTCOME MEASURES--Intention to reduce or opt out of on call; plans for changing out of hours arrangements; the three most important changes needed to out of hours care; willingness to try, and perceived strengths and limitations of, three alternative out of hours care models--primary care emergency centres, telephone triage services, and cooperatives. RESULTS--The overall response rate was 74% (Wessex research network 77% (89/116), northern research network 71% (59/83)). Eighty three per cent of respondents (123/148) were willing to try at least one service model, primary care emergency centres being the most popular option. Key considerations were the potential for a model to reduce time on call and workload, to maintain continuity of care, and to fit the practice context. Sixty one per cent (91/148) hoped to reduce time on call and 25% (37/148) hoped to opt out completely. CONCLUSIONS--General practitioners were keen to try alternative arrangements for out of hours care delivery, despite the lack of formal trials. The increased flexibility in funding brought about by the recent agreement between the General Medical Services Committee and the Department of Health is likely to lead to a proliferation of different schemes. Careful monitoring will be necessary, and formal trials of new service models are needed urgently.     

Patients' accounts of calling the doctor out of hours: qualitative study in one general practice.

OBJECTIVE: To investigate patients'' accounts of calling the doctor out of hours. DESIGN: Qualitative analysis of semi-structured interviews with two groups of patients who called their doctors out of hours from one general practice. SUBJECTS: 23 people who had called the doctor on their behalf or on behalf of another adult and 23 people who had called on behalf of a child between 6 pm and 8 am on a week day (omitting the weekend from 6 pm on Friday to 8 am on Monday). RESULTS: although respondents described symptoms as the main reason for the call, they also described a range of other factors that led to the call, including their feelings, concerns about specific illnesses, their responsibility for others, and their previous attempts to manage the problem themselves. They also described past experiences with health services that were important in explaining the current out of hours call or explaining their general approach to using services. CONCLUSIONS: The pursuit of a model of out of hours care based on medical necessity that neglects the psychosocial context of illness may not be appropriate. The importance of previous experiences of health services and contacts with health professionals in explaining current service use requires wider acknowledgement by health professionals across sectors. Separate educational programmes to encourage patients to use out of hours services more appropriately that neglect these issues may be too simplistic.     

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.     

Out of hours workload of a suburban general practice: deprivation or expectation.

The out of hours workload of a training practice in a suburban and semirural area on the south coast of England was studied for one year. An overall rate of contact of 273/1000 patients was found, which indicated a workload greater than that reported in most other studies. The duty doctor received over 35 telephone calls from patients during some Saturdays (1200 Saturday to 0800 Sunday) and Sundays (0800 to 0800 Monday), up to five being between 2300 and 0700. Of the patients who contacted a general practitioner, 44% were given advice by telephone and 4.9% were admitted to hospital. The admission rate was lower than that given in other studies. A considerable proportion of the workload arose from doctors covering the casualty department of a cottage hospital. Patients having a high expectation of 24 hour care by general practitioners in an area of comparative affluence (Jarman indices -13.8 to 1.7) may account for this aspect of the workload.