Family Health Services Authority Research Articles

Association of the platelet Pl(A) polymorphism of glycoprotein IIb/IIIa and the fibrinogen Bbeta 448 polymorphism with myocardial infarction and extent of coronary artery disease.

Platelets and fibrinogen play an integral role in the development of thrombosis and are implicated in the process of atherosclerosis. The fibrinogen Bbeta 448 polymorphism and the Pl(A) polymorphism of platelet glycoprotein IIIa are reported to be independently associated with coronary artery disease. The aim of this study was to determine the association of the fibrinogen Bbeta 448 and the platelet glycoprotein IIIa Pl(A) polymorphisms in relation to extent of coronary atheroma as characterized by angiography and a past history of myocardial infarction (MI) as assessed by World Health Organization criteria. Caucasian patients (n=405) admitted for routine angiography for investigation of chest pain or suspected coronary artery disease were recruited. Caucasian control subjects (n=216) were recruited from local Family Health Services Authority general practice registers. Fibrinogen levels were higher (P=.04) in male patients (3.24 g/L; CI, 3.14 to 3.35) than male control subjects (3.06 g/L; CI, 2.91 to 3.21). There was a trend toward a difference (P=.06) in fibrinogen genotype distributions between female patients (1/1=93, 1/2=31, and 2/2=1) and female control subjects (1/1=67, 1/2=34, and 2/2=5). In logistic regression models the Pl(A2) genotype was associated with MI (odds ratio, 1.66; CI, 1.15 to 2.39; P=.007) and stenosis of more than one vessel (odds ratio, 1.5; CI, 1.01 to 2.26; P=.04). In men suffering an MI before the age of 47 years there was a 50% incidence of the Pl(A2) allele (P=.05), and in these subjects there was evidence of an interaction with cholesterol (P=.04). We found evidence of an association of the Pl(A2) polymorphism in MI and multiple-vessel stenosis. The association with MI was strongest in young men, in whom there was also evidence of an interaction with cholesterol.

Partnership changes in English general practice from 1990 to 1994.

The objective of this study was to quantify the rate of partnership change among general practitioners (GPs) in the National Health Service (NHS) in England from 1990 to 1994. Time series data on English GPs were analysed on 1 October for the years 1990-1994. The main outcome measures include: (1) proportion of GPs practising in an unchanged partnership from 1 October 1990 to 1 October 1994; (2) proportion of partnerships that were unchanged over the study period; (3) the average yearly rate of partnership changes for England and per Family Health Service Authority (FHSA), calculated using both the individual GP and the practice as the unit of analysis. A total of 6532 (27.1 per cent) of the 24,107 unrestricted GPs practising full time on 1 October 1990 were still practising in the identical partnership on 1 October 1994; 3539 (35.7 per cent) of the 9918 practices in England were unchanged over the same period. The average yearly partnership change rate for all England was 23.1 per cent when calculated using the individual GP as the unit of analysis, and 23.4 per cent when calculated using the practice as the unit of analysis. There is threefold variation found in the average yearly partnership change rate by FHSA, with similar rank ordering of health authorities when using either the individual GP or practice as unit of analysis. Changes in partnerships are commonplace. The possible influence of such changes on primary care in the NHS should be further investigated.

Screening immigrants for tuberculosis in Newcastle upon Tyne.

Successive national guidelines on the control of tuberculosis in the United Kingdom have included recommendations for screening immigrants coming from countries with a high prevalence of tuberculosis. As there has been only one other study on the process and outcome of screening immigrants at a district level the aim of this study was to assess the contribution of screening immigrants to the control of tuberculosis in Newcastle. The Port of Arrival (POA) forms were used to identify all new immigrants for screening in Newcastle during 1993. The Family Health Services Authority (FHSA) register was used to identify additional new immigrants from the Indian sub-continent. For all new immigrants identified by the POA forms and FHSA register, hospital and practice records were reviewed for evidence of screening and its outcome up to the end of 1994. There were 252 POA forms in 1993, 100 of which were for immigrants from the Indian sub-continent. This represents less than a third of all new immigrants from the Indian sub-continent. Of all immigrants identified by POA forms, 99 (39 per cent) had been screened. This resulted in the detection of one active case of tuberculosis. The POA system alone is inadequate for identifying immigrants for screening. The published evidence on screening immigrants for tuberculosis suggests that the system does not work well and the yield of new cases is low. To assess the effectiveness of screening immigrants a national audit is needed.

GP fundholding and prescribing in UK general practice: evidence from two rural, English Family Health Services Authorities

Background: Two separate prescribing budget regimes (part of GP fundholding and the indicative prescribing scheme) were introduced into UK general practice in April 1991 in an attempt to contain the growth in NHS expenditure on prescribed drugs. Objectives: The aims of this study are (i) to examine whether the fundholding scheme has been more effective at containing prescribing cost growth than the indicative prescribing scheme and (ii) to ascertain whether its implementation, at a practice level, has been affected by local circumstances and conditions. Methods: Prescribing cost data were collected from two rural, English Family Health Services Authorities for the financial years 1990/1991 to 1993/1994. Exploratory analysis was performed using regression analysis and non-parametric statistical techniques. Results and conclusions: Initially, the fundholding scheme has been the more effective at containing expenditure on prescribed drugs. However, the implementation of the schemes in rural areas has probably been affected by the existence of practices with permission to dispense drugs to their own patients, due to a lack of pharmacies in such areas.

Attitude, subjective norm and perceived behavioural control as predictors of women's intentions to take hormone replacement therapy

Objectives. To examine women's attitudes towards the use of hormone replacement therapy (HRT) and to predict intention to take it in a sample of 1200 women using the theory of planned behaviour (Ajzen, 1988) and a measure of similar prior behaviour.Design. The design was cross‐sectional. A postal survey was carried out.Methods. Questionnaires were sent to a random sample of 1200 women aged between 38 and 58 generated from the Kent Family Health Services Authority records. Questions based on the theory of planned behaviour were used to predict women's intentions to take HRT. Information was also collected about the women's sources of information on the menopause, their experience of the menopause and the time leading up to it, their general health, and their sociodemographic circumstances.Results. Analysis was carried out on the responses of the 641 women who were not yet taking and had never taken HRT. Hierarchical multiple regression analysis showed that similar prior behaviour made a small independent contribution to the prediction of behavioural intention when entered after the components of the model. Structural equation modelling was carried out to show the paths between the variables. When age was included, similar prior behaviour was shown to influence behaviour through perceived behavioural control and attitude.Conclusions. In predicting women's intention to take HRT, the beliefs of significant others, the women's personal beliefs, their degree of confidence in their ability to carry out the behaviour and the experience of similar prior behaviour are important considerations.

Prevalence of dementia and depression among elderly people in black and ethnic minorities.

This study was designed to identify all elderly people of ethnic minorities living in a defined geographical area in inner-city Liverpool and to identify psychiatric morbidity and barriers to use of services. This paper reports the prevalence of dementia and depression. A survey of the community was carried out using the Geriatric Mental State Examination, AGECAT and ethnically matched interviewers. The sampling frame consisted of Family Health Services Authority lists as a basis, with additional information from community lists, 'snow-balling' and a door-to-door survey. 418 people were interviewed, with a high percentage (55%) of young elderly (65-74) men. The prevalence of dementia ranged from 2 to 9% and of depression from 5 to 19%, and there were no significant differences in levels between English-speaking ethnic groups and the indigenous population. Higher levels of dementia were found among non-English-speaking groups. A complete enumeration of the elderly in ethnic minority groups is best achieved by using several different methods. Diagnosis of dementia may be misleading among those who do not speak the dominant language.

Knowledge of and preference for the DOMINO delivery option

Objective: to examine women's knowledge of and preference for the DOMINO (Domiciliary In and Out) delivery option in order to explain why uptake is lower than might be expected. Design: descriptive study using a self completion postal questionnaire. Setting: Mid Staffordshire Health Authority (now part of South Staffordshire Health Authority). Subjects: a systematic random sample of 1568 women aged 16–44 drawn from the Staffordshire Family Health Services Authority register of patients registered with a general practitioner. All women were included, regardless of childbirth experience. Main outcome measures: preference and knowledge levels for this delivery option. Main findings: the response rate was 74%. Thirty-nine per cent had heard of the DOMINO option prior to receiving the questionnaire. Sixteen per cent expressed a preference for this option (95% C1 11.1–21.9). Some women who expressed a preference were excluded owing to high risk factors, giving an adjusted preference of 11% (95% C1 5.2–16.4). Preference was not related to either age, pregnancy experience or previous knowledge. Conclusions: more women expressed a preference for the option than would be expected from examination of national and local uptake figures. Lack of knowledge appears to be an important factor in explaining the low uptake. Purchasers, therefore, need to set contracts reflecting more realistic preferences and ensure that women have information on all options available to them, so that at the beginning of pregnancy women are enabled to make a shared decision on the choice of delivery. Both purchasers and providers need to monitor uptake and levels of knowledge.

The changing relationship between prescribing and unemployment at family health service authority level in England, 1983-92.

STUDY OBJECTIVE: To investigate the relationship between unemployment and prescribing costs over time. DESIGN: This was a longitudinal study. SETTING: All 90 family health service authorities in England, 1983-92. PARTICIPANTS:...

GP fundholding and prescribing in UK general practice evidence from two rural, English Family Health Services Authorities

Two separate prescribing budget regimes (part of GP fundholding and the indicative prescribing scheme) were introduced into UK general practice in April 1991 in an attempt to contain the growth in NHS expenditure on prescribed drugs. The aims of this study are (i) to examine whether the fundholding scheme has been more effective at containing prescribing cost growth than the indicative prescribing scheme and (ii) to ascertain whether its implementation, at a practice level, has been affected by local circumstances and conditions. Prescribing cost data were collected from two rural, English Family Health Services Authorities for the financial years 1990/1991 to 1993/1994. Exploratory analysis was performed using regression analysis and nonparametric statistical techniques. Initially, the fundholding scheme has been the more effective at containing expenditure on prescribed drugs. However, the implementation of the schemes in rural areas has probably been affected by the existence of practices with permission to dispense drugs to their own patients, due to a lack of pharmacies in such areas.

Challenges to medicine: the case of prescribing

Abstract This paper examines recent developments in primary care prescribing as potential challenges to the dominance of medicine. These developments, as possible forces for the deprofes‐sionalisation and proletarianisation of medicine, were examined using unstructured interviews with five Family Health Service Authority (FHSA) medical advisors and 23 general practitioners (GPs). Three themes emerged from the data. First, GPs did not find the role of the FHSA advisor to be either constraining or inappropriate in relation to prescribing. Secondly, GPs recognised prescribing as a crucial discretionary power in which the prescription was used ‘irrationally’ to cope with a variety of patient, practice or workload pressures. Thus, the only serious managerial threat came from the possibility that such ‘irrational’ prescribing could be curtailed. Finally, GPs felt most concerned by the growing demands and expectations of patients, exacerbated by government policies endorsing greater consumerism. The greatest perceived challenge to clinical autonomy comes, not from proletarianisation in the sense of greater managerial control over medicine's work, but from deprofessionalisation through lay challenges to general practitioners' professional medical expertise.

Accuracy of the family health services authority register in Newcastle upon Tyne, UK as a sampling frame for population studies.

addresst deceasedchanges made No(%) No(%) No(%) No No No(%) No(%) No(%) No(%) No(%) Females(n=200) 0(0.0) 11(5.5) 2(1.0) 200 176 0(0.0) 2(1.0) 0(0.0) 13(6.5) 15(7.5) 55-64(n=200) 2(1.0) 6(3.0) 5(2.5) 197 179...

Lifestyle surveys--the complete answer?

STUDY OBJECTIVES: These were as follows: to study incompleteness of data, herein called item non-response, generated by a self completion questionnaire; to identify the characteristics of item non-responders and the...

Methodology for assessing the prevalence of angina in primary care using practice based information in northern England.

OBJECTIVES: The study aimed to consider the value of nitrate prescriptions issued by general practices as an indicator of coronary heart disease and to compare this with the use of...

Satisfaction with information and advice received by stroke patients

To determine levels of satisfaction with information and advice received about stroke disease and relevant issues by community-dwelling stroke survivors. An interview questionnaire survey. A family health services authority area in northern England. Stroke survivors identified by a valid screening questionnaire from a stratified random sample of 2000 subjects aged 45 years and over. Proportion of subjects interviewed responding positively to the question 'Do you think you have received enough advice and information on ...?' eighteen topics considered relevant to stroke survivors. The screening process identified 116 stroke survivors, of whom 76 agreed to be interviewed. The majority (> 80%) of patients were satisfied with information and advice received on lifestyle and health promotion issues, incontinence and their current treatment. However, satisfaction was poor for the areas of stroke disease in general, its effects, available services, and legal and financial affairs (range, 28-75% satisfied). Deficits in the provision of adequate information and advice to stroke patients on relevant issues have beer identified in this study of a representative sample of community-dwelling stroke survivors. These deficits need to be addressed by those providing care for stroke patients in order to improve patients satisfaction.

Factors influencing the attendance rate at accident and emergency departments in East London: the contributions of practice organization, population characteristics and distance.

To examine the contribution of general practice organisation, population characteristics and distance to practice attendance rates at four local accident and emergency departments. Practice-based study examining variations in accident and emergency department attendance rates in 105 practices, using routine data from the Family Health Services Authority (FHSA), the District Health Authority and the 1991 Census. East London and the City Health Authority, covering practices based in the inner city boroughs of Hackney, Tower Hamlets and Newham, and the City of London. Practice-based, age-standardized, adult attendance rates at accident and emergency departments in the year to 31 March 1994. Annual age-standardized practice accident and emergency department attendance rates ranged from 10.3 to 29.4 per 100 population. The mean practice attendance rate was 17.6 per 100 (95% CI 16.8-18.4). No significant relationship was found between attendance rates and practice characteristics (number and sex of general practitioner (GP) principals, presence of practice manager or nurse, computerization and training status). There were strong positive relationships between attendance rates and households not owner-occupied (R = 0.55, P < 0.001) and pensioners living alone (R = 0.55, P < 0.001). There were negative correlations with Asian ethnicity (R = -0.31, P = 0.002) and residents lacking amenities (R = -0.26, P = 0.007). The distance to the nearest accident and emergency department also correlated negatively with attendance (R = -0.27, P = 0.006). A backwards multiple regression model showed that 48% of the variation in attendance rates could be accounted for by six factors: percentage of households not owner occupied, percentage living in households without a car, percentage living in households lacking amenities, percentage of pensioners living alone, percentage of Asian ethnicity, and percentage living in households with a head born in the New Commonwealth and Pakistan. Optimal subsets regression identified a number of alternative models with similar explanatory value. Social deprivation is strongly linked with attendance rates at accident and emergency departments in East London. In contrast, the organizational characteristics of general practices appear to have no bearing on the rates. Both purchasers and providers need to take account of these findings when planning accident and emergency provision.

What is the way forward for a user-led approach to the delivery of mental health services in primary care?

This paper describes a piece of action research which obtained users and GPs' views on the delivery of primary mental health care in Birmingham and integrated this feedback into service developments through the Practice Service Development Plan, a document submitted by all practices in Birmingham to the Family Health Services Authority (FHSA).The plan is a means whereby resources are allocated and data are collected across the city relating to practice activity. The interviews revealed that service users and GPs recognised the need for an improvement in service delivery, although the groups differed to some extent regarding which service features they wanted to see available in general practice. Despite the small numbers involved, the research has provided an essential starting point by identifying multi-professional training needs and facilitating the direct provision of funds and information to practices in order to enable the primary health care team develop a more systematic approach to mental health care which is also ultimately sensitive to the needs of service users.

Drug Misuse and HIV Prevention: Attitudes and Practices of Community Pharmacists with Respect to two London Family Health Services Authorities

This study investigated community pharmacists' attitudes, knowledge and involvement in service provision to drug misusers. A postal questionnaire was sent to all community pharmacies in two central London Family Health Service Authorities (N = 285). A 54% response rate was obtained. Over one half were involved in dispensing controlled drugs and selling sterile injecting equipment and 13% involved in needle exchange. However, there was evidence that respondents negatively stigmatised drug misusers and this tendency was greater the longer the respondent had been a community pharmacist, but those providing services to drug misusers had more positive attitudes towards persons with HIV and drug misusers when compared to non-providers. Service provision was positively associated with confidence in one's knowledge about HIV and drug misuse with regard to counselling clients. Issues surrounding professional training are discussed.

Buccaling under the pressure: influence of secondary care establishments on the prescribing of glyceryl trinitrate buccal tablets in primary care.

To determine which characteristics were the best predictors of high rates of prescribing of glyceryl trinitrate buccal tablets. Practice and patient characteristics from 197 practices were examined, and a multiple regression analysis was performed to examine which variables were important in predicting this prescribing. Former family health services authority (197 practices). Volume of prescribing of glyceryl trinitrate buccal tablets. Four variables contributed significantly to a multiple regression model: the catchment area of the secondary care establishment; the number of partners in a practice; the level of practice deprivation; and whether the practice served an urban or a rural area. The model suggests that the most important variable was the catchment area of the secondary care establishment in which the practice was located. Although only the prescribing of short acting glyceryl trinitrate buccal tablets was studied, an impact of this size on primary care prescribing may have extensive implications for all drug expenditure in primary care.

Old age in the inner city: an analysis of data from over 75 GP screening assessments

The imposition of the 1990 GP contract required GPs to undertake annual assessments of all their patients aged 75 and over. In the North Kensington part of Kensington & Chelsea and Westminster Family Health Services Authority, a standardised assessment schedule administered by trained workers was used to undertake the assessment. Data from these assessments carried out between 1991 and 1993 has been used to consider if older people resident in a disadvantaged inner city district show significantly different patterns of access to health, material and caring resources than a national sample of people aged 75 and over. During the study period there were 1442 first assessments; a response rate of approximately 60%. The inner city population showed very high rates of solo living, demonstrated prevalence rates for chronic health problems and activities of daily living similar to the national sample but had fewer financial resources other than the state pension and fewer social contacts. We speculate that older people in inner city districts have no greater problems in managing the basic activities of daily living (e.g. shopping and cooking), but they have few material resources to pay for help and lower levels of social contact and informal care to provide help. In the absence of informal care formal services are being used. Recognition of this increased burden being placed upon the formal sector is obviously required.

Exercise as therapy? Results from group interviews with general practice teams involved in an inner-London 'prescription for exercise' scheme

As part of an inner-London 'prescription for exercise' scheme, group interviews were conducted with clinical and support staff from participating general practices. Interviews took place between August and November 1995 to identify the practices' reasons for joining the scheme, the perceived health benefits to patients of the scheme, and criteria for selection and referral of patients onto the scheme. The results showed that the referring practice members saw exercise promotion as a therapeutic option, rather than an instrument for primary prevention. They were cautious in their referral criteria because of family health services authority guidelines. If future schemes are to develop they must distinguish between these perspectives in their promotion of physical activity.