Family Health Services Authority Research Articles

Postal survey of management of cervical Chlamydia trachomatis infection in English and Welsh general practices.

Chlamydia trachomatis infection in women is common, often asymptomatic, and may cause pelvic inflammatory disease, tubal infertility, or ectopic pregnancy. Screening for chlamydia in Britain is haphazard, and the management of infected people is sometimes inadequate.1 However, despite recommendations for expansion of chlamydia testing in primary care,2 little is known about the diagnosis and management of cervical chlamydia infection in general practice. We did a cross sectional survey of general practices to find out how many offer chlamydia testing and how they would manage a woman found to have chlamydia infection. In June 1994 we sent a confidential postal questionnaire to a random stratified sample of 500 general practices drawn from all 98 family health services authorities in England and Wales. The introductory letter was addressed to the practice managers, who were asked to give …

Is the ratio of inhaled corticosteroid to bronchodilator a good indicator of the quality of asthma prescribing? Cross sectional study linking prescribing data to data on admissions.

To investigate the ratio of inhaled corticosteroid to bronchodilator as a measure of the quality of asthma prescribing by general practitioners. Ecological cross sectional study linking general practitioner asthma prescribing with hospital admission data and a measure of deprivation. 11 family health services authorities in the West Midlands region and 99 general practices in North Staffordshire. Hospital admission rates for asthma; the ratio of inhaled corticosteroid to bronchodilator; and Townsend deprivation scores. No overall significant correlation was found between admission rates for asthma and corticosteroid:bronchodilator ratios for family health services authorities (Spearman's rs = -0.109, P = 0.750) or general practices (rs = -0.084, P = 0.407). In deprived family health services authority areas and general practices an inverse non-significant correlation existed between admission rates for asthma and corticosteroid:bronchodilator ratios (rs = -0.300, P = 0.624; rs = -0.218, P = 0.136). In contrast, in more affluent areas and general practices a positive non-significant correlation existed between admission rates and corticosteroid:bronchodilator ratios (rs = 0.371, P = 0.468; rs = 0.038, P = 0.792). Although the corticosteroid:bronchodilator ratio may be a valid indicator of the quality of prescribing for individual patients with asthma, caution should be applied in interpreting aggregated ratios. Differences in the severity of asthma or the prevalence of chronic obstructive pulmonary disease may explain inconsistent associations between admission rates for asthma and corticosteroid:bronchodilator ratios in family health services authorities and general practices with different deprivation scores.

Non-melanoma skin cancer and solar keratoses. I. Methods and descriptive results of the South Wales Skin Cancer Study.

This study aimed to describe the prevalence and incidence of solar keratoses and skin cancers and the natural history of solar keratoses in a random population sample. It was a cross-sectional study, with follow-up, conducted in South Wales, and involved 1034 subjects aged 60 years and over drawn from the Family Health Services Authority register. The main outcome measures were detection of the presence of solar keratoses and skin cancers on sun-exposed skin and photographic validation of solar keratoses and biopsy confirmation of cancers wherever possible. We found that solar keratosis prevalence was 23% (95% confidence interval 19.5-26.5) and that of skin cancer (all types) 2% (95% confidence interval 1.0-3.5). The incidence rate of solar keratoses was 149 lesions per 1000 person-years and of non-melanoma skin cancer 9 per 1000 person-years. In all 21% (95% CL 16-26) of solar keratoses regressed spontaneously during follow-up. None underwent malignant change. We believe that the failure of individuals to seek medical advice and the variable under-registration of non-melanoma skin cancer makes population-based study important. The high prevalence and incidence of malignant and pre-malignant skin lesions in this random sample raise major public health concerns. The high rate of spontaneous regression of solar keratoses and the low rate of malignant change challenges conventional views about the need for routine treatment of these lesions.

Cervical screening in the inner cities: is the opportunistic approach still worthwhile?

Since the national call and recall cervical screening programme was set up in 1988, population coverage has improved.1 Geographical differences persist, however, and many inner city areas have a 40-60% response rate.2 Factors associated with low acceptance rates for screening include unemployment, overcrowding, ethnic minority, population mobility, and inaccuracy of the patient registers of family health services authorities.3 Also, women may not perceive themselves to be at risk or may not wish to attend their doctor's surgery or the local clinic. The inner London Borough of Wandsworth has a multicultural population of all social classes. In 1992-3 the uptake of cervical screening was 60%. The Women's Nationwide Cancer Control Campaign (WNCCC) has over 25 years' experience in providing mobile units for both public and workplace screening, which have been shown to improve …

Negotiating the role of the practice nurse in general practice.

The debate about the role of the practice nurse is not only about practice nursing per se, but raises broader issues about the organization of primary health care. Two related issues emerge as significant: the role of the practice nurse in providing primary health care; and the effective use of the practice nurse resource in the 'new' National Health Service. This paper, by drawing on material from a qualitative study, specifically examines the type of work performed by practice nurses and the factors that influence this. The responses of practice nurses, general practitioners, Family Health Service Authority (FHSA) advisers, community nurse purchasers and managers of community nursing provider units suggest that a consensus on the future development of practice nursing is unlikely. The different stakeholders emphasized different issues, reflecting their own priorities and backgrounds. Practice nurses' accounts of the future, for example, focused on professional issues. General practitioners stressed the importance of role development which met their General Medical Service responsibilities. Purchasing agencies, provider units and FHSAs adopted a wider perspective and were more concerned to develop an effective and integrated primary health care service. The tensions generated by their different interests and perspectives, and the subsequent organizational and policy initiatives that emerge, will provide the context in which the role of practice nurses will be negotiated.

Utilization of appetite suppressants in England: a putative indicator of poor prescribing practice.

The use of appetite suppressants, a putative inverse marker of prescribing quality, was analysed in the former Northern Regional Health Authority (RHA) and in England using National Health Service prescribing data and sales and patient-linked prescribing data supplied by Intercontinental Medical Statistics (IMS). The number (in thousands) of National Health Service prescriptions for appetite suppressants dispensed fell from 393 in 1991 to 235 in 1994. Per capita prescribing frequency varied threefold between different RHA and between individual Family Health Service Authorities (FHSA) within the former Northern RHA (NRHA). Prescribing frequency was higher in the spring and summer quarters and reduced in the winter quarter. Of 532 general practices in the NRHA, 82 (15%) prescribed no appetite suppressants between April 1993 and March 1994, while 70 (13%) prescribed more than 500 defined daily doses (DDDs) per 1000 patients, accounting for 47% of all prescribing. Only 53% of pharmacy purchases of appetite suppressants were accounted for by NHS prescribing and as little as 21% for phentermine, indicating substantial prescribing outwith the NHS. In 1991, 73,759 DDDs were supplied to pharmacies each day, the majority being diethylpropion (31,226) and phentermine (24,349). The fall in NHS prescribing is welcome as these drugs are of dubious clinical value and may be associated with serious adverse effects. Because of substantial non-NHS prescribing, routinely available prescribing data does not accurately quantify total prescribing of these agents.

Community pharmacy health promotion activity in England: a survey of policy and practice

A telephone survey of pharmaceutical advisers in English Family Health Services Authorities (FHSAs) examined the extent of, and influences on, the development of health promotion activities based in community pharmacies. A variety of activities were found to be taking place. The largest barrier was reported to be financial. The time the adviser had for community pharmacy, and the relationship of the FHSA with the local health promotion department and the local pharmaceutical committee, also had a bearing. Forty respondents (51 per cent) reported that they had been influenced by the Barnet FHSA High Street Health Scheme, and 65 (84 per cent) had heard of it. FHSAs could consider the features of successful schemes and create an appropriate climate for development.

The problems of fundholding

General practitioner fundholding is not the unqualified success that the British government would have us believe. That is the verdict of Britain's Audit Commission, which has recently reported the results of a major investigation into fundholding.1 A research team from the commission surveyed all known fund and practice managers in 1994-5 and one in five fundholders in 1995-6. They also surveyed some of the larger non-fundholding practices. They analysed financial returns and audited fundholders' accounts. They searched the literature for studies related to fundholding. They made site visits to a large number of fundholding practices, family health services authorities, district health authorities, and trusts to collect qualitative data. The report confirms the success of fundholding in reducing waiting times and outpatient follow up visits. Many fundholding practices report better communication with hospital services, more “primary care friendly” pathology and radiology services, and the development of practice based services for physiotherapy, dietetics, chiropody, psychiatric nursing, and psychology. Many fundholding practices made savings on their drugs budgets in their first fundholding year, but the effect was not maintained. Although fundholders generally spent less on drugs than non-fundholders, these differences may have predated fundholding. The report does not present the material that …

Estimating the efficacy of screening by auditing smear histories of women with and without cervical cancer. The National Co-ordinating Network for Cervical Screening Working Group.

The screening histories of all 348 women with invasive cervical cancer diagnosed in 1992 in 24 self-selected district health authorities and health boards in England, Wales and Scotland were compared with those of 677 age- and residency-matched controls. The controls were randomly selected from the family health services authority (FHSA) register. Screening histories, comprising the dates and results of all smears taken before the date of diagnosis of the patient's cancer, were determined from the FHSA computer and laboratory records. We estimate that the number of cases of cervical cancer in participating districts in 1992 would have been 57% (95% confidence interval 28-86%) greater if there had been no previous screening. In women under the age of 70 it would have been approximately 75% (31-115%) greater. Extrapolation of the results from this pilot suggests that screening prevented between 1100 and 3900 cases of invasive cervical cancer in the UK in 1992. Women with stage 1B cancer or worse were more likely to have no record of previous screening than controls: 47% of these women under the age of 70 had been adequately screened according to current (5 yearly screening) guidelines, compared with 75% of matched controls. Thirteen per cent of all patients under age 70 had screening histories indicative of inadequate follow-up of smears requiring colposcopy. The proportion of microinvasive cases with screening predating diagnosis was similar to the proportion of controls. There was a strong correlation between stage and age: 56% of cancers in women under 35 were microinvasive compared with just 9% in women 65 years or over. The 'relative protection' following a negative smear was greatest in the first 12 months and fell off towards the end of the fifth year. These data suggest that full adherence to current guidelines could perhaps have prevented another 1250 cases, but additional steps would have been required to prevent some of the 2300 remaining cases in women under the age of 70.

Problems with recruitment in a randomized controlled trial of counselling in general practice: causes and implications.

To evaluate the effectiveness of counselling in the management of minor psychiatric morbidity in general practice, and to explore the reasons for difficulties in recruiting patients to such an evaluation. We attempted to conduct a randomized controlled trial of counselling in eight general practices in one NHS family health services authority area in England. Having experienced significant problems recruiting patients, we conducted semi-structured telephone interviews (n = 8) with participating GPs to explore the reasons for these difficulties. Five months after the start of the study only one patient had been recruited. The main reasons identified as contributing to the recruitment problems were: general practitioners' motivation for involvement in the study; their ethical doubts about the randomization process; the perceived lack of a viable non-counselling intervention; and their existing practical commitment to counselling. Although methodological modification might enhance the potential for success in future studies of this sort, more fundamental difficulties concerning general practitioners' attitudes to research and their professional responsibilities lie at the heart of our recruitment problems.

Over the counter drugs. The interface between the community pharmacist and patients.

Pharmacists play an important part in primary health care, and their accessibility is a key factor. Their NHS payments relate predominantly to the dispensing of prescribed medicines; to recognise the service element of their advisory role, an NHS funded professional fee could be built into the cost structure for pharmacy medicines. The increased number of medicines available over the counter has highlighted the need for training for counter assistants; it will become compulsory in July 1996, and some family health services authorities are providing this. The shift to care in the community could mean that pharmacists will have an even greater role in the primary health care team. Encouraging the public to seek advice from the community pharmacist may lead to a greater proportion of visits to doctors resulting from referrals from the pharmacist. Joint development by pharmacists and doctors of guidelines for advice on, and recommendation of, over the counter medicines is needed.

General practitioners' views on over the counter sales by community pharmacists

More over the counter medications have been made available recently. We carried out a survey of general practitioners' views on various drugs being dispensed by community pharmacists without a prescription to determine whether these views have changed since 1990.1 Details of 1301 general practices were obtained from eight family health service authorities throughout England. All 250 fundholding practices were included in the study together with a random sample of 250 urban and 350 rural non-fundholding practices to permit comparisons between fundholding (mainly rural) and rural non-fundholding general practices and between urban and rural non-fundholding practices. The larger number of rural non-fundholding practices were included so as to increase the statistical power of the study. In November 1994 a questionnaire was dispatched to one randomly selected doctor from each practice. It sought information on basic characteristics of the practice and the responding general practitioner. The section …

Selection bias in GP fundholding.

This paper uses a logistic regression model based on 1993 data for general practices in a single Family Health Services Authority (Lincolnshire) to analyse the differences in characteristics between existing fundholding (up to and including wave three) and non-fundholding practices. A high degree of classification accuracy is obtained. Fundholders are revealed to be more likely than non-fundholders to meet a number of the various quality criteria laid down by central government following the 1990 National Health Services Act, for example, with respect to prescribing cost control, minor surgery and cervical screening uptake. The model is employed to forecast the fourth wave of fundholding and poor predictions suggest the existence of a structural break in the characteristics of fundholders between those in the first three waves and those of wave four. The evidence presented also supports the existence of selection bias in the first three waves of fundholding, although further logistic regression analysis reveals a form of such bias in the fourth wave also.

Selection bias in GP fundholding

This paper uses a logistic regression model based on 1993 data for general practices in a single Family Health Services Authority (Lincolnshire) to analyse the differences in characteristics between existing fundholding (up to and including wave three) and non-fundholding practices. A high degree of classification accuracy is obtained. Fundholders are revealed to be more likely than non-fundholders to meet a number of the various quality criteria laid down by central government following the 1990 National Health Services Act, for example, with respect to prescribing cost control, minor surgery and cervical screening uptake. The model is employed to forecast the fourth wave of fundholding and poor predictions suggest the existence of a structural break in the characteristics of fundholders between those in the first three waves and those of wave four. The evidence presented also supports the existence of selection bias in the first three waves of fundholding, although further logistic regression analysis reveals a form of such bias in the fourth wave also.

Access to health care in England: continuing inequalities in the distribution of GPs.

One of the successes of the National Health Service is that the distribution of general practitioners (GPs) corresponds much more closely to the size of the local communities than it did before 1948. However, more should be done to reflect the fact that different populations have variable needs for GPs. The aim of this paper is to estimate the relative need for GPs by linking evidence from individual utilization data to the characteristics of small areas. Statistical models of GP utilization were developed from household survey data on 12729 adults representative of the English population. The odds ratios derived from the models were combined with Census information for Family Health Services Authorities (FHSAs) to calculate a need indicator, which was used to estimate the number of GPs 'needed' in an area for comparison with the actual distribution. The utilization of GPs is associated with morbidity, demographic and socioeconomic variables. The needs indicator derived from the model of GP utilization varies from 1.66 to 2.40 with a mean of 2. Substantial changes in the distribution of Gans are required to reflect the relative need for them. For example, in relative terms, Cornwall and the Isles of Scilly has an excess of GPs of almost one-fifth whereas Rotherham has a shortfall of more than one-third. The findings in this paper suggest that there are still considerable inequalities in access to GP services in England in relation to need.

Explaining variations in general practice prescribing costs per ASTRO-PU (age, sex, and temporary resident originated prescribing unit).

In the light of evidence which suggests that the use of medicines is in some degree predictable from the demographic structure of practice populations,1 a move has been made towards the use of a weighted capitation formula in determining general practitioners' prescribing budgets. One recently devised weighting structure, the age, sex, and temporary resident originated prescribing unit (ASTRO-PU), allocates individual weightings to nine age groups for each sex, plus one for temporary residents, in the practice list.2 Family health services authorities were advised that they might use weightings based on ASTRO-PUs to adjust the prescribing allocations, otherwise based on historic costs, for the financial year 1994-5.3 Over and above a budgetary allocation so determined, scope will always exist for discretionary or “soft” factors, reflecting particular patient need …

Immigration rules hit potential GP registrars Labour promises power to all GPs Review body report 1996 Who will give medical advice?

# Immigration rules hit potential GP registrars {#article-title-2} Overseas doctors from countries outside the European Economic Area (EEA) who want to train in general practice in Britain may face immigration restrictions, which may lead to their being unable to complete their training. Overseas doctors working as general practice registrars must hold training and work experience scheme work permits, and a condition of these is that the holder must leave Britain at the end of the agreed period. A transfer to ordinary employment in Britain is not allowed. The permits have to be applied for by the potential employer—that is, the trainer—through the Department for Education and Employment. Family health services authorities are prohibited from reimbursing the salary of any general practice registrar who is unable to continue to practise in Britain. Any overseas nationals wanting to work as registrars should, therefore, have an alternative source of funding for their salaries and related costs, such as their own government. The position is different for overseas doctors from outside the EEA who do their postgraduate training in hospitals. They should …

BMA writes to NHS trusts about confidentiality Supraregional services have new advisers BMA is worried about reserve forces' training GPs to have guidance on care in the community BMA updates its briefing on private finance initiative

# BMA writes to NHS trusts about confidentiality {#article-title-2} Until the NHS adopts a comprehensive and security policy for protecting the confidentiality of identifiable health information the BMA is advising doctors to defer considering links to the NHS wide network. The BMA has published its own security policy document (13 January, p 109) but after the Department of Health refused to amend its proposals the chairman of the BMA council, Dr Sandy Macara, wrote to chief executives of NHS trusts, executive directors of health authorities and family health services authorities, and directors of public health warning them that the current proposals for the NHS wide network would “permanently destroy the individual's right to privacy and radically alter the nature of the doctor/patient relationship.” Dr Macara says that widespread concerns about the risks are shared by patient and health care professional organisations alike. He explains that the BMA, whose members are bound by the General Medical Council to protect patient confidentiality, has actively pursued its concerns by developing a security policy, which lays down a series of principles applicable to both paper and computer based information systems. As we went to press a confidentiality bill was due to have its first reading in the House of Lords on 30 January. The Disclosure and Use of Personal Health Information Bill, which will be introduced by Lord Walton of Detchant, a former president of the BMA, was drafted by the association to clarify the law in England and Wales relating to the collection, use, and disclosure of personal health information. Nothing …

Creation of a District Diabetes Register using the DIALOG system

A District Diabetes Register has been created using the Family Health Services Computer Unit system, DIALOG, linked to the Family Health Services Authority (FHSA) population register. Initial informal discussions between the Diabetes Centre, Public Health, and the FHSA led to a formal proposal being accepted by the Local Diabetes Services Advisory Group to pilot the DIALOG software. Following installation of DIALOG on a separate computer, electronically linked to the main FHSA system, the register was compiled. This was approached in three ways. The existing Diabetes Centre Register was downloaded into DIALOG and patients matched with the FHSA register. A 'diabetes roadshow' was mounted, with Postgraduate Education Allowance approval, to individually visit every general practice in the district to explain the aims and objectives of creating a diabetes register and to enlist the support of these practices. Where practices already held their own diabetes register this was similarly transferred, if not, assistance was provided to identify their patients with diabetes. All patients were notified in writing that their names were being placed upon a diabetes register and that clinical data would be held against their entry. This notification included an opportunity to opt out. Additionally, a self registrations scheme was introduced whereby all retail pharmacists dispensing any diabetes related product and all optometrists seeing a person with diabetes, gave the patient a leaflet, describing the register and its purposes and inviting them to register themselves. A 'Data Ownership Committee' was established to control the use and interpretation of all clinical data held upon the register. The process of diabetes annual review is now being prompted across both primary and secondary care and clinical data is being returned to the register.

Creation of a District Diabetes Register using the DIALOG system

A District Diabetes Register has been created using the Family Health Services Computer Unit system, DIALOG, linked to the Family Health Services Authority (FHSA) population register. Initial informal discussions between the Diabetes Centre, Public Health, and the FHSA led to a formal proposal being accepted by the Local Diabetes Services Advisory Group to pilot the DIALOG software. Following installation of DIALOG on a separate computer, electronically linked to the main FHSA system, the register was compiled. This was approached in three ways. The existing Diabetes Centre Register was downloaded into DIALOG and patients matched with the FHSA register. A ‘diabetes roadshow’ was mounted, with Postgraduate Education Allowance approval, to individually visit every general practice in the district to explain the aims and objectives of creating a diabetes register and to enlist the support of these practices. Where practices already held their own diabetes register this was similarly transferred, if not, assistance was provided to identify their patients with diabetes. All patients were notified in writing that their names were being placed upon a diabetes register and that clinical data would be held against their entry. This notification included an opportunity to opt out. Additionally, a self registration scheme was introduced whereby all retail pharmacists dispensing any diabetes related product and all optometrists seeing a person with diabetes, gave the patient a leaflet, describing the register and its purposes and inviting them to register themselves. A ‘Data Ownership Committee’ was established to control the use and interpretation of all clinical data held upon the register. The process of diabetes annual review is now being prompted across both primary and secondary care and clinical data is being returned to the register.