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.     

Simulated patients in general practice: a different look at the consultation.

To develop a better empirical basis for developing quality assessment in general practice three simulated patients made appointments with 48 general practitioners during actual surgery hours and collected facts about their performance. The simulated patients were indistinguishable from real patients and presented a standardised story of a symptomatic urinary tract infection. Two months later the same general practitioners received a written simulation about a patient who had the same urinary tract infection and were asked how they would handle this in real practice. Both results were scored against an existing consensus standard. The overall score for both methods did not show any substantial differences. A more differentiated analysis, however, showed that general practitioners performed significantly better with simulated patients. It also showed that general practitioners answering the written simulation performed significantly more unnecessary and superfluous actions. The results of this study show that the use of simulated patients seems to show the efficient performance of general practitioners in practice.     

Assessing the consultation: methods of observing trainees in general practice.

We compared two different methods of observing trainees at work in general practice: the traditional one of a senior or training general practitioner sitting in during selected surgeries and the more modern video recording, with the patients'' written consent. Patients who had experienced the presence of a second doctor during the consultation were less likely to show an increase in arousal after their consultations than those who had been recorded on video. Patients who refused consent to be recorded were more highly stressed than those who agreed and showed smaller decreases in stress after consultations. The presence of two doctors generated fewer reductions in stress after the consultation than video recording did, but this was a non-significant trend. The group that was recorded on video did not differ appreciably from a control group in changes in stress or arousal.     

Characteristics of patients aged over 75 not seen during one year in general practice.

A study was carried out in two large urban practices to determine the number of patients aged over 75 years who had had no contact with the primary care team during one year and to examine their medical and social characteristics. Although their general health was considered to be good, over half needed treatment or other action and half had no identifiable career.     

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.     

Methadone maintenance in general practice: patients,workload, and outcomes.

OBJECTIVE--To assess recruitment to and work-load associated with methadone maintenance clinics in general practice; to investigate the characteristics of patients and outcomes associated with treatment. DESIGN--Study of case notes. SETTING--Methadone maintenance clinics run jointly by general practitioners and drug counsellors in two practices in Glasgow. PARTICIPANTS--46 injecting drug users receiving methadone maintenance during an 18 month period, 31 of whom were recruited to clinic based methadone maintenance treatment and 15 of whom were already receiving methadone maintenance treatment from the general practitioners. Mean (SD) age of patients entering treatment was 29.6 (5.5) years; 29 were male. They had been injecting opiates for a mean 9.9 (5.1) years, and most had a concurrent history of benzodiazepine misuse. Average reported daily intake of heroin was approximately 0.75 g. Participants in treatment had high levels of preexisting morbidity, and most stated that they committed crime daily. RESULTS--2232 patient weeks of treatment were studied. Mean duration of treatment during the study period was 50.7 (21.1) weeks and retention in treatment at 26 weeks was 83%. No evidence of illicit opiate use was obtained at an average of 78% of patients'' consultations where methadone had been prescribed in the previous week; for opiate injection the corresponding figure was 86%. CONCLUSIONS--Providing methadone maintenance in general practice is feasible. Although costs are considerable, the reduction in drug use, especially of intravenous opiates, is encouraging. Attending clinics also allows this population, in which morbidity is considerable, to receive other health care.     

Evidence based general practice: a retrospective study of interventions in one training practice.

OBJECTIVES--To estimate the proportion of interventions in general practice that are based on evidence from clinical trials and to assess the appropriateness of such an evaluation. DESIGN--Retrospective review of case notes. SETTING--One suburban training general practice. SUBJECTS--122 consecutive doctor-patient consultations over two days. MAIN OUTCOME MEASURES--Proportions of interventions based on randomised controlled trials (from literature search with Medline, pharmaceutical databases, and standard textbooks), on convincing non-experimental evidence, and without substantial evidence. RESULTS--21 of the 122 consultations recorded were excluded due to insufficient data; 31 of the interventions were based on randomised controlled trial evidence and 51 based on convincing non-experimental evidence. Hence 82/101 (81%) of interventions were based on evidence meeting our criteria. CONCLUSIONS--Most interventions within general practice are based on evidence from clinical trials, but the methods used in such trials may not be the most appropriate to apply to this setting.     

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.     

Relation between night visit rates and deprivation measures in one general practice.

OBJECTIVE--To compare night visit rates in different electoral wards of one general practice with the Jarman and Townsend deprivation scores and unemployment rates. DESIGN--Analysis of computerised workload data. SETTING--General practice in centre of Mansfield, Nottinghamshire. OUTCOME MEASURE--Visits made in 588 nights to the 11,998 patients on the practice list. RESULTS--Night visit rates in 15 electoral wards varied from 19.6 to 55.3 visits per 1000 patients per year. The rates showed a significant association with the Townsend score (p = 0.004) and the unemployment rate (p = 0.03) but not with the Jarman score (p = 0.3). The Townsend score explained 49% of the variability; unemployment explained 31% and the Jarman score explained 9%. CONCLUSIONS--Even in a general practice not eligible for deprivation payments there was a 2.8-fold variation in night visit rates between wards. In this practice the Townsend score was significantly better at predicting night visit rates than the Jarman score. This method of looking at internal variation in workloads in computerised practices could give more direct data on the relation between deprivation and general practice workload than has previously been available.     

Health library for patients in general practice.

We describe the establishment of a health lending library for patients in a suburban general practice. The library is housed in the surgery waiting room and comprises 413 books and 35 audio tapes on topics related to health. Analysis of the first year''s use showed 703 borrowings (677 books and 26 audio cassettes). Borrowers ranged the spectrum of social class and educational status but women predominated, and borrowers included many who admitted that they seldom read books. Most borrowings were opportunistic, though some were planned by the patient and a few recommended by a health care professional. Most readers claimed to have learned from their reading and to have found their reading useful. We think that a health library is a useful tool of primary care, particularly for prevention.     

Low levels of ill health among elderly non-consulters in general practice.

The characteristics of random samples of elderly patients (over 65 years of age), designated as consulters (n = 200) and non-consulters (n = 196), in a group general practice were compared using a postal questionnaire that was validated by comparison with findings by general practitioners in a random sample of 58 responders. A response rate of 90% was obtained, and all non-responders were visited by their general practitioner. The questionnaire had a sensitivity of 79% and a specificity of 82% when compared with general practitioner findings. The use of hospital and social services by non-consulters was low in this practice. Measures of disability and state of health showed that non-consulters were a fit group of the aged. Case finding for problems among elderly people should initially be confined to consulters, who have a high prevalence of problems. Non-consulters are a low risk group that can be assessed only with special effort and extra resources. Once an effective case finding system has been developed it might then be reasonable to consider ways of finding the few patients who have problems but do not consult their doctor.