Comparative Study of District and Community Hospitals

Opinions conflict on whether there is a place in the Health Service for general practitioner (community) hospitals in which the patients'' treatment is mainly the responsibility of their family doctors. The authors therefore analysed a sample of the patients admitted in the course of a year to a group of two general district hospitals with a comparable sample of the patients admitted to a general practitioner hospital. The aim was to analyse the type of care provided in the general practitioner hospital, to assess whether it was appropriate for the type of cases treated, and to decide whether the patients would have been better off in the district general hospital (and vice versa). The main conclusions are that a district hospital is best for serious illnesses needing skilled decisions and assessments but that most of the work of these hospitals is not of this kind and a community hospital staffed by general practitioners offers many advantages to patients—provided the work being done is constantly under critical assessment. The authors plead for special refresher courses under the N.H.S. for general practitioners working in community hospitals.     

Facilitating care of patients with HIV infection by hospital and primary care teams.

To complement the role of primary care teams working with patients with HIV disease and AIDS within greater London and to ease the load on the special hospital units a home support team was developed. It comprises six specialist nurses, a general practitioner trained medical officer, and a receptionist and is funded from regional and district sources and charities. A nurse is available for out of hours and emergency weekend calls, with support from the patient''s general practitioner or the attached medical officer. During the first 18 months 249 patients were seen; the mean duration of care was five months. Nearly a third (18/50, 30%) of patients who were terminally ill died at home. The team''s activities included practical nursing care, emotional support for carers and patients, and advice and guidance to primary care teams. Problems in providing care in patients'' homes included issues relating to confidentiality and 24 hour cover. With the increasing incidence of HIV infection the home support team may be a useful model for care of large numbers of patients with symptomatic HIV disease, especially in large urban areas.     

Psychiatry in General Practice

Psychiatrists should include the family doctor in their plans for future psychiatric services. The general practitioner now treats most of the patients who seek help for psychiatric disorder and he could not give up his psychiatric practice even if he wanted to. Furthermore, there are not now nor will there ever be enough psychiatrists to take over all patients with mental ills. Most emotionally disturbed patients can be better handled by their family physicians than by a specialist.To provide the best care for emotionally disturbed people the communication between family doctors and psychiatrists must be improved. The specialist must acknowledge the importance of the general practitioner''s role in psychiatric diagnosis and treatment and give him more help. Medical schools must provide better undergraduate and postgraduate psychiatric training for the students who will become family doctors. Health plans and other prepayment agencies should properly compensate the general practitioner for giving psychiatric treatment. The specialist in psychiatry should consult more readily with the general practitioner and help him carry out some of the therapy. General hospitals should permit family doctors to admit mental patients to psychiatric wards in a general hospital and to carry out psychiatric treatment with the help of the specialist in psychiatry.     

Community care service for diabetics in the Poole area.

Because of an increasing work load at the hospital diabetic clinic in Poole general practitioners were asked to help in a community care service for diabetics. In this, general practitioners typically care for non-ketotic patients with maturity onset diabetes who are well controlled on diet or diet and oral hypoglycaemic agents, while the clinic concentrates on more difficult cases and screens patients for long-term complications. The hospital laboratory''s work load has been eased because patients may attend for two-hour interval blood sugar estimations when they like; most patients appreciate this flexibility and prefer being looked after by their own doctor. The service has not increased the general practitioners'' work load unduly, but it has heightened their awareness of diabetes in the community, thus allowing the diabetic consultant to deal with the problems for which he has been trained. The service has thus provided improved care for all diabetics in the Poole area.     

Anglo-Canadian Exchange in General Practice: British View of Canadian General Practice

The Canadian general practitioner is remunerated by an item-of-service system of payment which encourages servicing demands rather than needs, discourages delegation of work to paramedical workers, and involves his staff in a massive amount of paper work. He has an excellent hospital attachment, which unfortunately is overdone. His community facilities are piecemeal and his office organization is rudimentary. There are few incentives for good general practice in the community. He spends an inordinate amount of time examining well people. The university departments of general practice are extremely good and much should be heard from them very quickly. The patient''s attitude towards his doctor is quite different from the one prevailing currently in Britain.I returned happily to British general practice.     

First year of an inner city general practitioner community hospital.

The first inner city general practitioner community hospital opened on 4 January 1982. This paper describes the operation of the hospital over the first 12 months. There were 316 admissions, with an average length of stay of 13 days. The average age of the patients was 73 and the most common reason for admission was disease of the respiratory system. Thirty five per cent of patients were admitted because of an acute illness and 37% were admitted on the same day as the request for admission. The policies of intermittent or phased care allowed for the admission of patients at regular intervals to relieve carers, and the assessment of the home circumstances of all patients allowed for planning the patient''s return home.     

Prospective regional study of planned home births. Home Birth Study Steering Group.

OBJECTIVE: To collect data from a cohort of women requesting a home birth and examine the experience and outcome of pregnancy, the indications for hospital transfer, and the attitudes of mothers, midwives, and general practitioners. DESIGN: Follow up study with anonymised postal questionnaires. SETTING: Northern Regional Health Authority area. SUBJECTS: The 256 women resident in the Northern region who expected to deliver in 1993 and whose request for a home birth became known to one of the local supervisors of midwives. Limited cross validating information was also collected retrospectively on all other women delivering a baby outside hospital in 1993. MAIN OUTCOME MEASURES: Rate of and reason for transferred care; maternal, midwifery, and general practitioner views; perinatal outcome. RESULTS: Five women miscarried, leaving 251 in the study. Of these, 142 (57%) delivered at home. There were 17 (7%) caesarean sections but no perinatal deaths. General practitioners had reservations about half of the booking requests. Two thirds of the women thought they had not been offered any option about place of birth, 74 (29%) were referred to hospital for delivery before the onset of labour, and 35 (14%) were referred to hospital during labour. Intrapartum transfers were uneventful, and half the mothers commented spontaneously that they valued having spent even part of their labour at home. CONCLUSIONS: Home birth is valued for its family setting. General practitioners'' support is sought and influential but uncommon, possibly because of a lack of understanding of the responsibilities of the midwife and general practitioner.     

Audit of surgical practice in a community hospital.

The results of a prospective analysis of one year''s surgery on inpatients in a busy community hospital showed that a high quality of surgery may be achieved with safety and low rates of complications. The results of a retrospective analysis of certain aspects of surgery was just as encouraging. Surgery that is performed in a community hospital is convenient for the patient, provides continuity of care by the general practitioner, and waiting list times are short. Surgical facilities can form an integral part of the comprehensive service provided by a community hospital and can lighten the caseload for minor surgery at the district general hospital. Close liaison between the two hospitals is essential.     

The psychological and social effects of myocardial infarction on wives.

Eighty-two wives of men suffering a first myocardial infarction were interviewed while their husbands were in hospital, and again two months and a year after they went home. The wives had substantial and persistent psychological symptoms, and the husbands'' illness had continuing effects on their work, leisure and social activities, and family life and marriage, their psychosocial disability being comparable to that of the patients. Measures of psychosocial adjustment before the illness and the quality of the marriage and of family life were good predictors of outcome for the wives. The women had a major role in the patients'' readjustment during convalescence, and their attitudes and behaviour as well as the general quality of family life were important determinants of the rate and extent of the patients'' recovery. The wives of patients with myocardial infarction should have more practical help and advice during the hospital period, and the whole family should be given advice and help throughout the convalescence.     

The Bradford community stroke trial: results at six months.

OBJECTIVE--Comparison of day hospital attendance and home physiotherapy for stroke patients leaving hospital to determine which service produces greater functional and social improvement for the patient, reduces emotional stress for the care giver, and lessens the need for community support. DESIGN--Stratified, randomised trial of stroke patients attending day hospital two days a week or receiving home treatment from a community physiotherapist. The six month assessment results are reported in this paper. SUBJECTS--Patients over 60 years old resident within the Bradford metropolitan district discharged home after a new stroke with residual disability. SETTING--Four day hospitals in two health authorities and domiciliary work undertaken by experienced community physiotherapists. MAIN OUTCOME MEASURES--Barthel index, functional ambulatory categories, Motor Club assessment, Frenchay activities index, and Nottingham health profile were used. Carers'' stress was indicated by the general health questionnaire. Treatment given and community care provided were recorded. RESULTS--Of 124 patients recruited, 108 were available for reassessment at six months. Both treatment groups had significantly improved in functional abilities between discharge and six months. The improvements were significantly greater for patients treated at home (Mann-Whitney test; Barthel index, median difference 2 (95% confidence interval 0 to 3) p = 0.01; Motor Club assessment, median difference 2 (1 to 5), p = 0.01). The home treated patients received less treatment (median difference 16 (11 to 21) treatments, p less than 0.001). More than a third of patients in both groups showed depressed mood, and a quarter of care givers were emotionally distressed. CONCLUSIONS--Home physiotherapy seems to be slightly more effective and more resource efficient than day hospital attendance and should be the preferred rehabilitation method for aftercare of stroke patients. New strategies are needed to address psychosocial function for both patients and care givers.     

Medical patients aged 65 and over admitted to an accident and emergency department.

A study of 100 consecutive emergency medical admissions to Oldchurch Hospital was made to establish if the mode of referral--either by the general practitioner or self referral--influenced the presentation and severity of illness and the eventual outcome. Of the 94 cases analysed, 55 were self referred and 39 were sent in by their general practitioners. No significant differences were found between the two groups of patients, which suggests that the patient (or the patient''s family or companion) is as discriminating as the general practitioner in deciding when emergency referral to hospital is necessary.     

A Taxonomy of Continuing Medical Education Endeavour

Five basic forms of continuing educational endeavour by physicians are listed in rank order. These components constitute an indivisible unit bound together by self-learning. The scholarly habit of planned daily reading and study in a home library-sanctuary as an integral part of a physician''s workday heads the list. Day-to-day informal and formal colleague-association in patient care in the community and teaching hospital, in group practice and by consultation is the present major form of continuing educational endeavour. Emphasized is the sabbatical return every three to five years for three months at least to the teaching hospital to reinforce scholarly motivation and attitudes and to acquire new skills and knowledge. Attendance at scientific sessions of learned professional societies and short courses should be accompanied by presession and post-session guided reading to be undertaken in the physician''s home library-sanctuary.     

Is the Jarman underprivileged area score valid?

A recently published validation of an underprivileged area score, which is intended to reflect factors that increase general practice workload or pressure on their services, was incomplete; a validation based on criteria other than the opinion of general practitioners is also required. Areas with higher mortality from diseases where general practitioner intervention can reduce mortality substantially are likely to have a greater need for general practice services. Similarly, the need for general practitioner services should be higher where the incidence of such treatable conditions is higher. This paper describes the association between Jarman''s score and (a) mortality from causes that are amenable to general practice intervention and (b) incidence of two diseases where general practice intervention is important. Using these data the score appears to have external criterion validity and thus is likely to reflect, at least crudely, the need for general practitioner services.     

General practitioners' continuing medical education within and outside their practice.

To study continuing medical education 96 out of 101 general practitioners chosen at random from the list held by a family practitioner committee were interviewed. The results provided little evidence of regular attendance at local postgraduate centre meetings, though practice based educational meetings were common. Thirty one of the general practitioners worked in practices that held one or more practice based educational meetings each month at which the doctors provided the main educational content. Performance review was undertaken in the practices of 51 of the general practitioners, and 80 of the doctors recognised its value. The general practitioners considered that the most valuable educational activities occurred within the practice, the most valued being contact with partners. They asked for increased contact with hospital doctors. The development of general practitioners'' continuing medical education should be based on the content of the individual general practitioner''s day to day work and entail contact with his or her professional colleagues.     

Making access to health care more equal: the role of general medical services.

The Resource Allocation Working Party (RAWP) recognised the need to consider both health authority and primary care services in achieving its objective. RAWP and the subsequent Advisory Group on Resource Allocation (AGRA) found (but did not publish) considerable variation in resources used by both services but could not find a clear relation between them. Statistics provided by the DHSS were used to compare spending by 80 area health authorities in 1980-1 with expenditure per head on general medical services by their corresponding family practitioner committees. There was considerable variation in the provision of resources for both services and no clear relation between the variations in spending on each service. Only 40 of the 80 areas had both health authority and family practitioner committee spending levels within 10% of "target." Subregional inequalities in resources tend to be related to variations in admission rates, which in turn are related to general practitioners'' referral behaviour. These results emphasise the importance of finding out more about inequalities in the provision of general medical services and their relation to the use of hospital services. They also suggest that RAWP''s aim of equality of opportunity of access to health care resources may be achieved only if general medical services are brought into the equation as well.     

Aftercare of State Hospital Patients—The Role of the General Practitioner

Of all the problems facing patients released from a state hospital, the most serious one is adjustment. Failure here means a return to the hospital. The present aftercare program of the Department of Mental Hygiene does not and is not intended to meet all of the patient''s needs. It must rely upon other agencies to assist. It must rely upon the general practitioner to provide the continuity of care which is so important to successful rehabilitation.The general practitioner can often make return to a state hospital unnecessary by an accurate assessment of the patient''s problems, by effective intervention, by utilizing available consultation and by judicious referral. When services are not available, he can do much to make them available through the effective use of his professional channels.     

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.     

General practitioner response to elderly patients discharged from hospital.

OBJECTIVE--To determine the effect of discharge information given to general practitioners on their management of newly discharged elderly patients. DESIGN--A random sample of 133 elderly patients who had unplanned readmission to a district general hospital within 28 days of discharge was compared with a matched control sample of patients who were not readmitted. Information was gathered from the hospital, the patients, the carers, and the general practitioners about the information that the hospital had sent the general practitioner and the general practitioners'' response to this information. SETTING--All specialties in a district general hospital. PATIENTS--266 Patients aged over 65 representative in the main demographic indices of the population of elderly patients admitted to hospital. RESULTS--Ten weeks after discharge the doctors had received notice of discharge about 169 of the patients, but fewer than half the discharge notices were received within the first week. General practitioners were dissatisfied with the information in 60 cases. A general practitioner visited 174 of the patients after their discharge from hospital and three quarters of the visits took place within two weeks of the discharge. These visits were more likely to have been initiated by patients or families than by the doctor, and this was not influenced by the doctor receiving notice of the patient''s discharge. Older patients and those who had carers were the most likely to be visited. Nearly half of the carers were dissatisfied with some aspect of general practitioner care, problems with home visiting being the commonest source of complaint. CONCLUSIONS--Hospital communications to general practitioners about the discharge of elderly patients still cause concern, particularly in the time they take to arrive. Written instruction to vulnerable elderly patients asking them to inform their general practitioner of the discharge might be helpful. Carers complained of lack of support, and it is clearly important for someone (either the general practitioner or another health worker) to visit elderly people shortly after their discharge.