Full-time General Practitioners Research Articles

The Effects of the Additional Roles Reimbursement Scheme (ARRS) staff in England on Prescription Patterns and Patient Satisfaction.

In 2019, the Additional Roles Reimbursement Scheme (ARRS) was introduced in England as a crucial component of the government's manifesto pledge to enhance access to general practice. The primary objective was to recruit 26,000 extra personnel through new roles into general practice. This study aimed to analyse the effects of ARRS staff on prescription rates and patient satisfaction. The study was a retrospective panel data analysis combining data from the General Workforce Minimum Dataset and National Health Service (NHS) Digital datasets about primary care practices and their activity from 2018 until 2022. The study included data from more than 6000 general practices. A linear regression analysis was conducted to determine the association between ARRS staff and prescription rates and patient satisfaction, controlling for patient and practice characteristics. The results showed that ARSS roles tend to be more frequent in larger general practices, with fewer full-time general practitioners per patient, and with more overseas trained general practitioners. The use of ARRS staff was significantly associated with lower prescription rates (β=-0.52, p<0.000) and higher patient satisfaction (β=3.2, p<0.000), after controlling for patient and practice characteristics. This study suggests that ARRS has the potential to have a positive role in primary care, notably through reduced prescription rates and improved patient satisfaction. Further research is needed to explore the long-term effects of ARRS on primary care, including patient outcomes and health care costs, and the potential barriers to its implementation.

List size disequilibria and service provision in general practice

Abstract: Several Nordic countries remunerate general practice by a mix of capitation and fee-for-service. From the literature we know that capitation-based payments come with a risk of undersupply of services, whereas fee-for-service comes with a risk of overprovision of services. Previous studies from the Nordic countries assess potential overprovision of services in general practices that are falling short of enlisted patients. However, today the main challenge in general practice is physician shortages, which comes with a risk of underprovision of services. Little is known about whether physician shortage in fact leads to underprovision of services. Using the two-way Mundlak regression on a panel of Danish general practices in 2016-17, this study assesses whether holding a longer than preferred patient list is associated with fewer services per enlisted patient. Around 100 of our sample of 1,652 practices hold longer lists than preferred. These practices have on average an excess of around 80 patients per full time general practitioner. We find little support of the hypothesis that practices with longer than preferred lists provide fewer contacts per patient. Heterogeneity analyses, however, reveal that practices with longer lists tend to provide fewer services to patients with complex needs. Policymakers should therefore be aware that there may be underprovision of services to high-need patients when there is a shortage of GPs.

PA and NP general practice employment in the Netherlands.

General practitioners (GPs) are the cornerstone of primary healthcare in the Netherlands. As a national strategy, physician associates/assistants (PAs) and NPs were introduced to address growing healthcare demand. In this study, four representative practices were analyzed quantitatively and qualitatively-two solo practices with a PA or NP and two group practices with a PA or NP. A reference group of GPs served as experts. The annual encounters per full-time GP averaged 6,839; for the NPs, 2,636; and the PAs, 4,926. Billable services were 70% to 100%, averaging 71% for NPs and 85% for PAs, and in three of the four practices, the employment of the NP or PA was cost-efficient. The qualitative data show that PAs and NPs contribute to general practice, easing the workload so that the GP has more time for complex patients. PA and NP employment was financially beneficial in 75% of cases.

PS-BPP05-4: PRESCRIPTIONS OF ANTIHYPERTENSIVE DRUGS ARE INFLUENCED BY THE CHARACTERISTICS OF GENERAL PRACTITIONERS AND THEIR PATIENTS

Background: Hypertension is associated with significant cardiovascular morbimortality. However, hypertension control is low, especially in France. The reasons influencing general practitioners (GP) prescription of antihypertensive drugs (AD) remains unclear. This study aimed at assessing the influence of GP and patient characteristics on AD prescriptions. Methods: A cross-sectional study based on a sample of 2,165 GPs working with French national health insurance was realized in Normandy (region of France) in 2019. Only GPs meeting the criteria for full-time GP practice were included. The ration of AD prescription to overall prescription volume, a relative measure of AD prescription level, was calculated for each GP and permited the low-high AD prescriber definition. Associations of this AD prescription ratio with GP age, gender, practice location, number of years of practice, number of home visits and consultations, number and age of registered patients, patient income and number of patient with a chronic condition were assessed using univariate and multivariate analysis. Results: The low prescribers GPs were 51.3 ± 11.2 year-old and were mainly women (56%) and practiced in urban context (53%). They prescribed less antihypertensives drugs (4% vs 8%, p &lt; 0.001) and had more low-income patients (6% vs 4%, p &lt; 0.001). In the multivariate analysis, low prescribers were associated to urban practice (OR: 1.47, 95%CI: 1.14;1.88), GP younger age (OR: 1.87, 95%CI:1.42;2.44), patients younger age (OR: 3.39, 95%CI: 2.77;4.15), more patients consultations (OR: 1.33,95%CI: 1.11;1.61), more low-income patients (OR: 1.44, 95%CI: 1.17;1.76) and less diabetes mellitus patients (OR: 0.72, 95%CI:0.59;0.88). Conclusions: Our study described a profile of the typical low er AD prescriber GP. In future work, a more detailed assessment of all components of the consultation (in particular home blood pressure monitoring use) is necessary to explain AD prescription in general practice.

Exploring the diverse career trajectories of general practice graduates in the French-speaking part of Belgium: An interview study

Background Several European countries face a shortage of general practitioners (GPs), in part due to GP attrition. Most studies of GP attrition have focussed on why GPs decide to leave. Yet understanding why GPs decide to remain may also elicit potential interventions to reduce attrition. Objectives This study examined GP graduates’ career trajectories and underlying decisions to elucidate the factors influencing GP attrition. Methods We conducted semi-structured interviews of early to mid-career general practice graduates having completed training in Belgian French-speaking universities between 1999 and 2013. We sampled participants from three categories: full-time GPs, part-time GPs, no longer working as GPs. We analysed each participant’s career trajectory and broke it down into major phases. We performed thematic analysis of the factors influencing participants’ trajectories. We compared and contrasted trajectories to develop a typology of career trajectories. Results We identified six types of career trajectories: ‘stable’ (never considered leaving general practice), ‘reaffirmed’ (had considered leaving but made substantial changes whilst remaining), ‘reactional reorientations’ (had left to escape the challenges of general practice), ‘inspired reorientations’ (had left to pursue a different job), ‘reorientations out of loyalty’ (had never wanted to practice as GPs and had remained true to their original professional aspirations) and ‘mobiles’ (valued change and did not want to set-up practice). Conclusion Reasons GPs leave the profession are multiple. The typology that emerged indicates that only some of the career trajectories would benefit from interventions to reduce attrition such as improving working conditions and providing psychological support for GPs.

Contemporary Trends in the Level of Staffing by General Practitioners in Krasnodar Krai

Aim. To evaluate the level of staffing by general practitioners (GP) in medical organizations in Krasnodar Krai.Materials and methods. Indicators characterizing the level of staffing by GPs in Krasnodar Krai hospitals were analysed using data from the state statistical observation form No. 30 “Information about a medical organization” for the 2009–2019 period. According to the data derived from the Krasnodar Krai Patient Register as of 01.01.2020, all GPs were divided into groups in terms of the ratio of the number of served population and the recommended values. Using the data of the Regional Register of Medical Workers as of 01.01.2020, the age composition of GPs was analysed.Results. As of 01.01.2020, Krasnodar Krai featured 228 medical organizations subordinate to the Krasnodar Krai Ministry of Healthcare. Of these, 58 have full-time GP positions. The overall number of GP positions comprises 294, which are currently taken by 198 specialists (1.1% of the total number of doctors and 1.9% of doctors providing medical care on an outpatient basis). Over the studied period, stable indicators of the provision of the Krasnodar Krai population by GPs were noted; however, the level of staffing by GPs in hospitals was decreasing. This indicates a growing trend in the lack of GPs. An analysis of the actual load of 198 GPs showed that, on average, 1 GP serves 1219 people. For 26.8% of GPs, the number of served population increased the recommended values by 1.5 times or more. As a result, over 100,000 adults in the region are served under the conditions of excessive workload on GPs. The average age of GP is 50.1 ± 0.9 years. Currently, more than 25% of GPs are working retirees by age. In the medium term, this value may exceed 50%. Considering specialists who are about to retire, the estimated need for GPs is 146 doctors.Conclusion. In order to provide affordable and high-quality primary health care to the population in Krasnodar Krai, the number of GPs should be increased. In addition, measures should be taken to raise the attractiveness of work in Krasnodar Krai hospitals.

A Survey of the Opinion and Experience of UK Dentists: Part 1: The Incidence and Cause of Iatrogenic Trigeminal Nerve Injuries Related to Dental Implant Surgery.

Dental implant-related iatrogenic trigeminal nerve (TG) injuries are proportionally increasing with dental implant surgery. This study, which is presented in greater detail over a series of articles, assessed the experience of implant-related TG nerve injuries among UK dentists. Incidence and cause of inferior alveolar nerve (IAN), mental nerve (MN), and lingual nerve (LN) injuries, together with preoperative assessment and the consent process, are presented in this article. A survey was distributed among 405 dentists attending an Association of Dental Implantology congress in the United Kingdom, of which 187 completed the survey. Most responding dentists were full-time general practitioners. Implant dentistry training was predominately through industry-organized courses. Eighty dentists encountered implant-related IAN injuries, whereas 8 encountered LN injuries. Inaccurate radiological identification of the IAN/MN and their anatomical variations (48%) were seen to be the most frequent cause of TG injuries. Disclosure of the relative risk and benefits of alternative implant treatment strategies as part of the informed consent process was not deemed to be essential by 47 (25%) of the participants. Inadequate radiological assessment was the most common cause of TG nerve injury. The use of small field of view cone beam computer tomography (CBCT) is therefore recommended when placing implants in the posterior mandible. Implant surgeons should acquire evidence-based skills in the prevention, diagnosis, and management of TG nerve injury as well as specific training on justification and interpretation of CBCT scans.

Polypharmazie: ein hausärztliches Dilemma?

Due to the aging population and the associated increase in multi-morbidity, polypharmacy will become an important issue. Little is known about general practitioners' perception of polypharmacy. We have explored this issue within the framework of a research course organised by the German Society for General Practice and Family Medicine (Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin, DEGAM.) A total of 21 participants were divided in three homogeneous groups and one heterogeneous group according to their professional concentration (full-time general practitioners, junior researchers, senior researchers). Each group was supervised by two non-directing moderators. A two-step analysis was performed. In a fist step, mind maps were generated and in a second step, mind maps were interpreted according to the grounded theory. We identified three core aspects of polypharmacy in general practice: overview of prescribed medication, communication between doctors, patients and other health care professionals as well as evidence for managing multi-morbidity. General practitioners are torn between providing individual medical care and guideline stipulations. Pharmacotherapy is influenced by interprofessional communication, prescriptions by multiple physicians, patient expectations, adherence, advertisements, guidelines and costs. One's view on polypharmacy is influenced by professional background and experience. From the general practitioner's perspective, interprofessional and doctor-patient communication are highly important for a good medication overview as well as dealing with uncertainties in daily medical care. Simply improving evidence for the care of patients with multi-morbidities in the form of meta-guidelines would not be sufficient to overcome the effects of the many other influencing factors.

Acute Conjunctivitis

Acute conjunctivitis is common. About 2–5% of general practice consultations are related to eye conditions and approximately 40% of these are concerned with conjunctivitis. Thus, on average, a full-time general practitioner sees a patient with conjunctivitis every week. The most common presentation is with a red eye. The main tasks are to exclude potentially serious causes of a red eye and then decide whether the conjunctivitis is infective, allergic or due to other causes so that suitable management can be initiated.

PHP4 PATIENT PREFERENCES TOWARD HEALTH SERVICES PROVIDED BY THE GENERAL PRACTIONER

OBJECTIVES: In the Dutch health care system, like many other countries, the general practitioner (GP) plays a key role in securing equity and effectiveness in delivering health care. Nowadays, GPs are often part of primary care centers and it is foreseen that these centers will play an even more important role in future health service delivery. A European comparison in nine different countries concluded patients favour small practices and full time GPs. The percentage of GPs working in small practices varies between countries. In the UK the percentage is 16% whereas in Belgium the percentage is 69% and in Netherlands the percentage is 39%. Continuity of care and access is highly appreciated by patients. For instance, it has been shown that patients are more satisfied with primary care if they always have the same GP and if they experience short waiting times. Given the development of larger primary care centers, people are hesitant if the current GP service levels can be maintained. On the other hand, an advantage of primary care centers is that they do offer multiple medical services like pharmacy and physiotherapy. The purpose of this study was two-fold. First, it was questioned which type of services is preferred by patients in three different GP settings and if people would be willing to pay for these services. Second, we wish to investigate differences between patients in different GP settings. The selected GP settings were 1) a single person GP practice (SP); 2) a healthservice with multiple independent GPs (GP); and 3) a multi-disciplinary and comprehensive primary care center supervised by one management (PCC). METHODS: A discrete choice experiment (DCE) was carried out among 164 patients in the three different GP settings. The DCE comprised 6 attributes including 1) time to appointment; 2) choice of time; 3) access by telephone; 4) consultation time; 5) availability of other medical services and; 6) WTP. Sample size for the DCE was estimated at about 45 patients in each GP setting. The DCE included 6 attributes. The maximum number of levels for an attribute was three, allowing 72 choice combinations. The DCE survey used 15 random and 2 fixed choicesets. Following the DCE, all 164 and an extra group of 114 patients (278 in total) were interviewed by a research assistent. Sampling was carried out to obtain equal group sizes (approx. 55) in each of the GP settings (SP, GP and PCC). DCE data were analyzed using sawtooth software. This abstract reports the first preliminary analyses of the complete dataset. RESULTS: Socioeconomic (income and education) and demographic data (age and gender) of patients in each of the GP settings were comparable. The DCE showed preference for improved telephone services and time to appointment as most important attributes. Except for “time to appointment” no large differences were found between the GP settings. Only patients in the GP group accepted longer waiting times compared to SP and PCC. SP and PCC patients did prefer to have access within 24 hours, whereas GP patients accepted longer waiting times. Overall, most important attributes were “time to appointment”, “access of service by telephone” and “WTP”. The availability of pharmacy services was preferred by all patients. About 50% of all patients werent willing to pay for additional services. However, some 35% was willing to pay an extra amount of €9 for each consult if they would receive additional services. CONCLUSIONS: This study shows a similar outcome compared to previous studies on access to GP services. “Time to first appointment” and “access by telephone” are most important factors to consider by patients. However, an interesting finding was that one third of all patients were willing to pay for improved services. The DCE study didn’t show big differences in preferences between patients in the different GP settings. In some aspects (e.g. accessability) the SP scored better compared to PCC and GP.

Primary health care in the Kimberley: Is the doctor shortage much bigger than we think?

This study describes the extent to which general practitioners in the Kimberley region are available for doctor-provided primary care and relates primary care availability to need and standardised population. Data collection and analysis was based on government statistics and interviews with general practitioners, local managers and regional employers and organisations. A shortfall of 20.6 full time general practitioner positions was identified and this was aggravated by a significant number of unfilled positions in the areas of greatest need. Overall the region had only half the primary care general practitioners needed. The Shire of Halls Creek at the time of survey had less than a quarter of the doctors required based on this analysis. Steps to increase the Australian medical workforce have begun but resources to recruit, support and sustain this workforce are required. Aboriginal health workers and locally trained nurses competently provide much of the primary care but need greater resources to support the available medical care.

Keeping patient appointments to seven minutes

As an inner city, full time general practitioner raising three children, writing books, and running courses, I need to manage my time efficiently. Here are my tips on how to keep patient appointments to seven minutes. They should apply whether you're in general practice or in a hospital outpatient clinic.

Proactive, targeted benefits advice for older people in general practice: a feasibility study.

The aim of the present project was to assess a welfare benefits and advice screening programme offered in a systematic and inclusive way to all patients aged 80 years and over registered with a single general practice. The setting was an inner-city National Health Service group practice with a total of seven full-time general practitioners (GPs) and a list size of 12 000 patients. A total of 280 patients were identified as aged 80 years and over. Using a combination of telephone calls, surgery attendances and home visits, an advice worker contacted as many of these patients as possible. A wide range of advice and assistance of both a statutory and non-statutory nature was offered. Follow-up contacts and liaison with the patients' own GPs were arranged as necessary. Contact was made with a total of 206 patients. In total, the adviser made 98 home visits and carried out 82 consultations in the surgery, as well as undertaking 109 interviews over the phone. The findings indicate that an overall total of pound 137 819 was gained in increased annual income amongst the screened patients; in addition, a further pound 11 433 was awarded in one-off payments. A wide range of other benefits and help, including referral to other services and organisations, was gained. Elderly patients within the practice were under-claiming benefits and had many previously unidentified needs. Adopting a proactive and inclusive approach to offering welfare and advice takes time and expense, but the resulting benefits make it worthwhile. Primary care is an effective base from which advice can be delivered and the development of closer working relationships between primary care and advice services can be an effective and efficient way of helping patients.

Inequitable distribution of general practitioners in Australia: analysis by state and territory using census data.

The objective of this study was to describe the distribution of general practitioners in each State and Territory, stratified by statistical division and adjusted for estimated community need. The location of general practitioners was obtained from the 1996 Census of Population and Housing. Community need was estimated from crude death rates supplied by the Australian Bureau of Statistics. On average there are 920 people per full-time general practitioner in Australia. Three States are relatively oversupplied by up to 5% (Australian Capital Territory) and the rest are relatively undersupplied by up to 12% (Western Australia). Adjusted for estimated need, the Australian Capital Territory is oversupplied by 71% compared with all of Australia, while Western Australia is undersupplied by 15%. More marked differences occur within the States, with the statistical division containing each capital city in each State that is relatively overserved. The greatest oversupply is in Sydney, where 33% fewer people share a full-time general practitioner than the whole of New South Wales (adjusted for need, oversupply in Sydney is 63%). Relative undersupply is greatest in Queensland, with 133% more people sharing each general practitioner in the north-west statistical division compared with the whole State. The distribution of general practitioners between and within States and Territories is unequal and inequitable. In each State, capital cities tend to be relatively oversupplied compared with more rural areas. While these data do not inform the absolute level of service needed in a community; they do suggest that strategies to redress the inequitable distribution are required.

High demand, low control, and impaired general health: working conditions in a sample of Swedish general practitioners.

This cross-sectional survey of 1,004 Swedish general practitioners (GPs) aged 32 64 years analyses the extent to which low control, high work demand, and other work-related conditions are associated with self-rated impaired general health and impaired quality of life among Swedish GPs. The first part of the questionnaire contained "SF-36 Health Survey", from which we chose five psychosocial multi-item scales as dependent variables. The second part of the questionnaire had questions about working conditions from "The Swedish Survey of Living Conditions". Unconditional logistic regression was used. Female and male GPs with high job strain, i.e. low control and high work demand, exhibited a more than threefold increased risk of impaired general health compared with those with medium job strain. Low job strain among male GPs was associated with a low risk of impaired health. The finding of significant associations between psychosocial working conditions and impaired general health and impaired, quality of life in GPs in 1996 highlights the need to improve working conditions in Swedish primary healthcare, for example, by reducing number of inhabitants per full-time GP to 1,500.

Developing a funding model for an after-hours primary medical care service in a rural town.

The study described in this paper aimed to determine a funding model for an after-hours primary medical care service in the rural town of Moe, a socioeconomically disadvantaged area of Victoria suffering the rigours of industry restructuring and privatisation. It has 12.5 equivalent full-time general practitioners servicing 21,966 persons. A break-even analysis of the financial viability compared the expected costs of providing the service with the anticipated income. A mixed funding model is recommended. This would incorporate a general practitioner incentive scheme and State Government underwriting of infrastructure and basic non-medical staffing costs during the business development phase to supplement the income from the Health Insurance Commission.

The shortage of rural general practitioners in north-western New South Wales.

The objective of this study was to provide the Tamworth Rural Training Unit with a clear understanding and practical strategic directions for contributing to an equitable distribution of rural general practitioners in the New England Area Health Service. A survey was sent to all 139 general practitioners practising in this region. The best and worst features of rural practice, both professionally and personally, were surveyed, as well as ways to attract more general practitioners to rural areas. It was found that this region required an additional 46 full-time general practitioners in 1995 if equity and social justice principles were to be met. Projecting to the year 2005, the total shortfall of full-time general practitioners in the New England Area Health Service amounts to 90. It is recommended that this critical shortage of rural general practitioners be assessed within two distinct time frames, namely short-term strategies (1996-1998) and medium-term strategies (1999-2005).

Correlates of Physician Counseling Associated with Obesity and Smoking

Background.Patient, physician, and consultation variables associated with overweight and smoking counseling in general practice consultations were examined.Methods.A random sample of full-time general practitioners was used. The sample consisted of 7,160 patients from 230 GPs who attended for consultations on consecutive days, and self-reported information from the doctor and the patient was collected via questionaire. The aim of this paper is to identify variables associated with the doctor's identification of overweight and smoking status and with the occurrence of counseling for these two behavioral risk factors.Results.Forty percent of patients were overweight (BMI ≥24) and 25% were self-reported smokers. Doctors identified 59% of overweight patients and 66% of smokers. Doctors only counseled patients identified as having the risk factor, counseling 36% of identified overweight patients and 49% of identified smokers. Identification of overweight was associated with being female, being heavier, having been previously counseled, being less well educated, presenting with an associated condition, and visiting a doctor who is younger and knows the patient's medical history well. Counseling for overweight was associated with being younger, being previously counseled, presenting with an associated condition, presenting for a routine checkup, visiting a GP who generally has longer consultations, having BP measured in the consultations, visiting an older doctor and visiting a doctor who considers identification of risk behaviors important. Identification of smokers was associated with being a heavier smoker, with those who had been previously counseled, with marital status other than single or married, with a BP measurement being taken in the consultation, and with a doctor who believed it possible to influence lifestyle change. Counseling for smoking was associated with younger patients, longer consultations, previous counseling, BP measurement, presenting with an associated condition, and not presenting frequently.Conclusions.We have identified factors associated with counseling about behavioral risk factors which provide a framework for planning education programs to increase the level of primary preventive activities within general practice.

True believers? Characteristics of general practitioners in Victorian community health centres

General practitioners have been part of multidisciplinary services in Victoria Community Health Centres (CHCs) for 20 years. This model institutionalizes a high degree of integration between general practitioners and other primary care and community service personnel. Of 51 eligible full-time general practitioners in Victorian CHCs, 46 were interviewed, using a structured questionnaire. General practitioners in CHCs were younger, less experienced and more likely to be female than other general practitioners. Nearly three-quarters were salaried. The philosophy of practice and the conditions of employment were the commonest reasons for entering CHC practice. Teamwork and the conditions of employment were felt to be the biggest advantages of CHC practice, while difficulties with management and the perceived loss of professional ownership and control were the commonest disadvantages. None reported interference from the CHC management in their clinical practice. Nearly a quarter of full-time CHC general practitioners do not undertake any formal community health promotion activities. Forty-five per cent of respondents intended to leave their CHC within the next five years. Universal health insurance has diminished the impact of CHC general practice. The philosophy of CHCs and the salaried nature of the employment continues to attract general practitioners. High staff turnover is a feature of CHC general practice, in part related to young doctors making an initial, but not long-term commitment to CHC practice. However, the loss of professional control and management difficulties should be addressed, as these may contribute to the high turnover.

Patient-management problems as a learning tool for the continuing medical education of general practitioners.

The value of Patient-Management Problems (PMPs as a learning tool for continuing medical education was studied by using two frequently seen cardiovascular problems (angina and high blood pressure) and a province-wide sample of full-time general practitioners. The results indicate that PMPs can be a motivating and effective means of CME for the general practitioner; that knowledge was gained through the successive resolution of three pmps; that corrective feedback enhanced learning; and, that most of the knowledge gained on the paper cases was transferred to practice as reported by the participants on a questionnaire. Furthermore, while cueing may be a confounding factor when PMPs are used for evaluation purposes, it was shown to facilitate learning in the present learning context.