Group Of General Practitioners Research Articles

German ambulatory care physicians' perspectives on clinical guidelines – a national survey

BackgroundThere has been little systematic research about the extent to which German physicians accept or reject the concept and practice ofa) clinical practice guidelines (CPG) andb) evidence based medicine (EBM)The aim of this study was to investigate German office-based physicians' perspective on CPGs and EBM and their application in medical practice.MethodsStructured national telephone survey of ambulatory care physicians, four thematic blocks with 21 questions (5 point Likert scale). 511 office-based general practitioners and specialists. Main outcome measures were the application of Clinical Practice Guidelines in daily practice, preference for sources of guidelines and degree of knowledge and acceptance of EBM. In the data analysis Pearson's correlation coefficient was used for explorative analysis of correlations. The comparison of groups was performed by Student's t-test. Chi2 test was used to investigate distribution of two or more categorical variables.ResultsOf the total study population 55.3% of physicians reported already using guidelines in the treatment of patients. Physicians in group practices (GrP) as well as general practitioners (GP) agreed significantly more with the usefulness of guidelines as a basis for patient care than doctors in single practices (SP) or specialists (S) (Student's t-test mean GP 2.57, S 2.84, p < 0.01; mean GrP 2.55, SP 2.80, p < 0.05). 33.1% of the participants demonstrated a strong rejection to the application of guidelines in patient care. Acceptance of guidelines from a governmental institution was substantially lower than from physician networks or medical societies (36.2% vs. 53.4% vs. 62.0%). 73.8% of doctors interpret EBM as a combination of scientific research and individual medical knowledge; 80% regard EBM as the best basis for patient care.ConclusionDespite a majority of physicians accepting and applying CPGs a large group remains that is critical and opposed to the utilization of CPGs in daily practice and to the concept of EBM in general. Doctors in single practice and specialists appear to be more critical than physicians in group practices and GPs. Future research is needed to evaluate the willingness to acquire necessary knowledge and skills for the promotion and routine application of CPGs.

Chronic heart failure home-based management with a telecardiology system: A comparison between patients followed by general practitioners and by a cardiology department

A group of patients with chronic heart failure (CHF) were followed by general practitioners (GPs) with a telecardiology system, and a second group of patients were followed by a home-based telemonitoring (HBT) protocol with medical and nursing supervision. The 212 GP patients were older than the 226 HBT patients, mostly women, with CHF secondary to chronic hypertension, less self-sufficient and with a non-optimized therapy. The mean number of telephone calls was 2.6 per patient in the GP group and 16.6 per patient in the HBT group (P<0.001). These preliminary data suggest the applicability and the efficacy of both management models for CHF patients.

Direct Access Colonoscopy for General Practitioners in the Netherlands Is Feasible and Has a High Diagnostic Yield

General practitioners (GP) have a central role in the Dutch health care system. Patients can only visit hospital specialists after referral by a GP. Although GP can usually order sigmoidoscopies and gastroscopies directly, colonoscopies can only be ordered by gastroenterologists after referral to the gastroenterology outpatient clinic. We assessed the feasibility of a direct access colonoscopy (DAC) program for GP. In addition, we retrospectively analysed the diagnostic yield of a DAC. Materials and Methods: With intervals of 2-6 months five groups of GP (totaling 130 GP) were formally trained about indications, contraindications and potential complications of colonoscopies.

Variations in the ability of general medical practitioners to apply two methods of clinical audit: a five‐year study of assessment by peer review

Clinical audit has a central role in the NHS clinical governance agenda and the professional appraisal of medical practitioners in the UK. However, concerns have been raised about the poor design and impact of clinical audit studies and the ability of practitioners to apply audit methods. One method of making informed judgements on audit performance is by peer review. In the west of Scotland a voluntary peer review model has been open to general practitioners since 1999, while general practice trainees are compelled to participate as part of summative assessment. The study aimed to compare the outcomes of peer review for two methods of audit undertaken by different professional and academic groups of doctors. Participants submitted a criterion audit or significant event analysis in standard formats for review by two informed general practitioners (GPs) using appropriate instruments. Peer review outcome data and the professional status of doctors participating were generated by computer search. Differences in proportions of those gaining a satisfactory peer review for each group were calculated. Of 1002 criterion audit submissions, 552 (55%) were judged to be satisfactory. GP registrars were significantly more likely than GP trainers (P < 0.001) and other established GP groups (P < 0.001) to gain a satisfactory peer review. GPs in non-training practices were less likely to achieve a satisfactory review than registrars (P < 0.001) and colleagues in training practices (P < 0.001). Of 883 SEA submissions, 541 (65%) were judged as satisfactory, with all groups gaining a similar proportion of satisfactory assessments, although GP registrars may have outperformed non-training practice GPs (P = 0.05). A significant proportion of GPs may be unable to adequately apply audit methods, potentially raising serious questions about the effectiveness of clinical audit as a health care improvement policy in general medical practice.

Postal surveys of physicians gave superior response rates over telephone interviews in a randomized trial

Background and Objectives To compare general practitioner (GP) response to a telephone interview with response to a postal survey with three reminders in a randomized controlled trial. Methods GPs were randomly assigned to either a telephone interview or a postal survey. GPs in the telephone group were mailed a letter of invitation and asked to undertake a telephone interview. GPs in the postal group were mailed a letter of invitation and questionnaire. Non-responders were sent up to three reminders, the final by registered post. Response rates were calculated for each group. Results 416 GPs were randomized to the telephone interview and 451 to the postal survey. Eighty-six in the telephone group and 30 in the postal were ineligible. One hundred thirty-four GPs completed the telephone interview with a response rate of 40.6% (95% confidence interval [CI]: 35.3%, 46.1%). Two hundred fifty-two GPs completed the postal survey with a response rate of 59.9% (95%CI: 55.0%, 64.6%). The difference in response was 19.3% (95%CI: 12.2%, 26.3%). Conclusions These results show that postal surveys with three reminders can have superior response rates compared with a telephone interview.

Supporting Mental Health in the Community: New Systems for General Practice

General practitioners (GPs) manage nearly one-third of Australians seeking help for mental health problems, and frequently express their need for consultant psychiatric support in this work. The introduction of new Medical Benefits Schedule Item Numbers 291 and 293 to provide "one-off" psychiatric assessments on referral from GPs offered the potential for providing this support, and a single point-of-entry scheme was organised to provide ease of access to appointments. The aims were to establish a single point of entry for psychiatrist assessment using Item 291, to evaluate the take-up rates of Item 291 in South Australia (SA) through this service and to evaluate the acceptability to GPs and psychiatrists of a psychiatric primary care consultation-liaison (c-l) model. Results were: 26 psychiatrists joined the project; 64 GPs referred 78 patients for assessment, providing 24% of the Australian take-up rate for Item 291, for 8% of the population; evaluation showed high approval ratings from GPs who particularly appreciated the single contact point; and positive evaluation by psychiatrists of the primary care c-l model. The conclusions were that a single contact point provided ease of access to psychiatrists for GPs; GP and psychiatrist groups evaluated Item 291 very positively; and consumer and carer evaluation are essential for further primary care c-l development.

Variabilidad de la prescripción antibiótica en las infecciones respiratorias en dos países de Europa

Treatment for respiratory tract infections (RTI) in the primary care setting is empirical. Antibiotic prescribing patterns differ among countries and are based on the prevalence of antibiotic resistance in the geographical area. The aim of this study was to compare the antibiotics prescribed by general practitioners (GPs) for RTIs between Spain and Denmark.Observational multicenter survey carried out in the primary healthcare setting. Two groups of GPs in Spain and Denmark recorded all contacts with RTI patients during a 3-week period between November 2001 and January 2002.A total of 2833 RTI cases were registered. Broad-spectrum penicillins and combinations of these drugs plus beta-lactamase inhibitors were the antibiotics most frequently prescribed by Spanish GPs (62.3%), followed by macrolides (22.3%). In contrast, narrow-spectrum penicillins were most commonly prescribed by Danish GPs (58% of all prescriptions), followed by macrolides (29%) (P < .001). Antibiotics most frequently prescribed for ear, tonsillar, sinus and bronchopulmonary infections were broad-spectrum penicillins among Spanish GPs and narrow-spectrum penicillins in Denmark. Spanish GPs prescribed penicillin V only for tonsillitis, accounting for 5.1% of the antibiotics used for this condition, whereas this drug accounted for 91.7% of the prescriptions by their Danish colleagues for the same indication.The substantial differences in RTI management between the participating GPs should make us reflect on the rational use of antibiotics. The discrepancies disclosed may indicate dissimilarities in recommendations, traditions, habits, or antibiotic pressures between the countries studied.

Trainingmodels for Psychiatry in Primary Care: A New Frontier

Under policies implemented by the Australian Government, the success of community mental health care has increasingly relied upon general practitioners (GPs) assuming an enhanced role in the delivery of evidence-based psychological treatment. In undertaking this role, it is crucial that GPs significantly build upon limited training in evidence-based psychological therapies such as cognitive behaviour therapy (CBT). This pilot study investigates the potential role of CBT group supervision as a training model. Two groups of GPs (n = 9) and one comparison group of psychiatric registrars (n = 4) completed eight 1.5 h sessions of CBT group supervision over an 8 month period. Pre- to post-training measures were taken of GP performance (skills, knowledge and confidence) and the mental health outcomes of their patients. On the completion of group supervision, focus groups were conducted for in-depth feedback. Randomization tests indicated that GPs' confidence and knowledge in using CBT had improved over the course of group supervision. Results from focus groups confirmed that GPs' CBT skills had improved. Findings suggest that group supervision is a promising training model for psychiatry in primary care. Cognitive behaviour therapy should be replaced, however, with a briefer therapy model, such as brief CBT, better suited to a general practice environment. Future research needs to replicate these findings on a larger scale.

Training models for psychiatry in primary care: a new frontier

Objective: Under policies implemented by the Australian Government, the success of community mental health care has increasingly relied upon general practitioners (GPs) assuming an enhanced role in the delivery of evidence-based psychological treatment. In undertaking this role, it is crucial that GPs significantly build upon limited training in evidence-based psychological therapies such as cognitive behaviour therapy (CBT). This pilot study investigates the potential role of CBT group supervision as a training model. Method: Two groups of GPs (n = 9) and one comparison group of psychiatric registrars (n = 4) completed eight 1.5 h sessions of CBT group supervision over an 8 month period. Pre- to post-training measures were taken of GP performance (skills, knowledge and confidence) and the mental health outcomes of their patients. On the completion of group supervision, focus groups were conducted for in-depth feedback. Results: Randomization tests indicated that GPs' confidence and knowledge in using CBT had improved over the course of group supervision. Results from focus groups confirmed that GPs' CBT skills had improved. Conclusions: Findings suggest that group supervision is a promising training model for psychiatry in primary care. Cognitive behaviour therapy should be replaced, however, with a briefer therapy model, such as brief CBT, better suited to a general practice environment. Future research needs to replicate these findings on a larger scale.

Ability of primary care physician's to break bad news: A performance based assessment of an educational intervention

Objective We have previously described a breaking bad news (BBN) training program for primary care physicians [Ungar L, Alperin M, Amiel GE, Beharier Z, Reis S. Breaking bad news: structured training for family medicine residents. Patient Educ Couns 2002;48:63–68]. In this paper, we present the assessment of an educational intervention aimed at improving this important skill. Methods The assessment tool was an eight station objective structured clinical examination (OSCE) utilizing standardized patients (SPs). Intervention and control groups of 17 general practitioners (GP) each were evaluated before and after an educational intervention, or a Balint group (control). Results Intervention group GPs significantly increased their average grade on the post-test as compared to the pre-test (58.5, S.D. 12.7 versus 68.4, S.D. 9.2), effect size 0.94. Improvement in the control group was minimal (pre-test 57, S.D. 10.4 versus 58.1, S.D. 9.5 for the post-test), effect size 0.23. Reliability of the OSCE was α = 0.81. Conclusion The performance assessment used in this study proved to be a reliable and valid tool to assess the ability of physicians to break bad news. It provided evidence of the effectiveness of the intervention. Practice implications BBN training can and should be evaluated by valid and reliable measures. SPs can serve as reliable evaluators of BBN training.

Motivations and perceived influences on rural and urban general practitioners when prescribing conventional non-steroidal anti-inflammatory drugs or COX-2 inhibitors

Prescribers in rural and remote locations perceive that there are different influences on their prescribing compared with those experienced by urban prescribers. The aim of this study was to compare the motivations and perceived influences on general practitioners (GPs) when prescribing COX-2 inhibitors rather than conventional non-steroidal anti-inflammatory drugs (NSAIDs) between rural and urban-based GPs in Queensland, Australia. A questionnaire was administered to two geographically distinct groups of GPs, one urban (n=67) and one rural (n=67), investigating the reasons that the GP would prescribe a COX-2 inhibitor rather than a conventional NSAID or vice versa and also focusing on patients requesting a prescription for a COX-2 inhibitor. A 51% response rate (n=68) was achieved. The difference between the rural and the urban GPs was that the urban GPs were more likely to perceive that they were influenced to prescribe COX-2 inhibitors by their patients' knowledge of these new (at the time) drugs. GPs in both the rural and urban areas perceived the COX-2 selective inhibitors to be safer than conventional NSAIDs, and that there was little difference in terms of efficacy between the two drug classes. However, GPs from both of the study areas stated that conventional NSAIDs were preferred over COX-2 selective inhibitors, primarily due to their expense, if their patients were not at risk for developing a GI bleed. The motivations and perceived influences to prescribe a COX-2 inhibitor in rural and in urban areas of Queensland, Australia were very similar. Almost all surveyed GPs in rural and urban areas had patients request a prescription, or enquire about the COX-2 inhibitors. Urban GPs were more likely to feel pressured to prescribe a COX-2 inhibitor than their rural counterparts, agreeing with other research which found that patient pressure to prescribe appears to be greater in urban general practice.

Cost-effectiveness of nutritional counseling for obese patients and patients at risk of ischemic heart disease

Obesity and dyslipidemia are risk factors for ischemic heart disease, and prevention and treatment in primary care can reduce these risks. The objective of this cost-effectiveness analysis was to compare the costs and effects (in terms of life years gained) of providing nutritional counseling by a general practitioner (GP) or a dietician. A total of 60 GPs, who accepted to participate, were randomized either to give nutritional counseling or to refer patients to a dietician for counseling. The life years gained was estimated using a Cox regression model. Costs were estimated on the basis of registered use of time (dieticians) or agreed salaries (GPs). The effect of nutritional counseling comparing GPs and dieticians is greatest when counseling is performed by a GP--0.0919 years versus 0.0274 years. These effects appear to be moderate, but they are significant. It is also proven that the GP group was the most cost-effective-the cost of gaining 1 extra life year was estimated to be 8213 DKK compared with the dietician group, for which the incremental cost-effectiveness ratio was estimated to be 59,987 DKK. The effects were moderate, but other studies of other patient groups and interventions report effects within the same magnitude. The GP group was the most cost-effective, but it must be concluded that both counseling strategies were relatively cost-effective. Even though the cost of gaining an extra life year was estimated to be 59,987 DKK in the dietician group, this might be an acceptable price.

General practitioners (GPs) and palliative care: perceived tasks and barriers in daily practice

General practitioners (GPs) play a crucial part in palliative care. The quality of care can be improved by investigating and addressing barriers perceived by GPs in daily practice. The aim of this study was to investigate GPs' task perception and barriers involved in palliative care. Qualitative focus group study. We gathered together a group of GPs representing a broad range of experience in palliative care. Content analysis was performed to derive a comprehensive view of tasks and barriers in daily palliative care. GPs described their palliative care tasks as satisfactory and varied, but burdensome. Palliative care tasks included somatic and psychosocial care. Opinions differed with respect to whether the coordination of care belonged to the primary GP tasks. Barriers were classified according to three levels: (1) personal: barriers related to knowledge, skills, emotions; (2) relational: barriers concerning communication and collaboration; (3) organizational: barriers related to the organization of care and compartmentalization in healthcare. This study revealed a complex web of tasks and barriers. It may be possible to trace back a problem (lack of knowledge, for example) on the personal level to an isolated knowledge gap, but the problem may well have originated from communication or compartmentalization problems. To maintain GPs' feeling of being at ease with palliative care requires helping them acquire the appropriate balance between technical and organizational interventions and a compassionate orientation to their terminally ill patients.

Variation in requests for imaging investigations by general practitioners: A multilevel analysis

To describe the variation in the numbers of imaging investigations requested by general practitioners (GPs) and to find likely explanations for this variation. Cross-sectional survey of the use of eight imaging investigations by 229 GPs collaborating in 40 local GP groups from five regions in the Netherlands during 1997. A multivariable, multilevel regression analysis was used to link these data with survey data on professional characteristics such as knowledge about and attitude towards test ordering, and with data on contextual factors such as practice type or experience with feedback on test-ordering data. Data for 221 GPs (97%) were available. After adjustment for practice size and working time, the median number of imaging investigations ordered per GP was 148 (interquartile range 71 to 300), with large differences (up to twofold) between the regions (P<0.001). Overall, chest X-rays were the largest single category (median = 48 interquartile range 17 to 100). GPs working in a group practice requested, on average, 34% fewer investigations than their colleagues working in single-person practices (95% confidence interval 17 to 48%). Only practice type was found to be associated with the number of imaging investigations requested, adjusted for practice size and working time factor. No further explanations were found for the inter-regional differences. Future studies on the ordering of imaging investigations by GPs should attempt to delineate contextual from regional factors.

Effects of distance learning on clinical management of LUTS in primary care: a randomised trial

Aim: To determine the effect of a distance learning programme on general practice management of men with lower urinary tract symptoms (LUTS). Methods: A cluster randomised controlled trial was performed. General practitioners (GPs) were randomised to a distance learning programme accompanied with educational materials or to a control group only receiving mailed clinical guidelines on LUTS. Clinical management was considered as outcome. Results: Sixty-three GPs registered care management of 187 patients older than 50 years attending the practice because of LUTS. The intervention group showed a lower referral rate to a urologist (OR: 0.08 (95% CI: 0.02–0.40)), but no effect on PSA testing or prescription of medication. PSA testing tended to be requested more frequently by intervention group GPs. Secondary analysis showed patients in the intervention group received more educational materials (OR: 75.6 (95% CI: 13.60–419.90)). Conclusions: The educational programme had impact on clinical management without changing PSA testing. Distance learning is an promising method for continuing education. Practice implications: Activating distance learning packages are a potentially effective method for improving professional performance. Emotional matters as PSA testing probably need a more complex approach.

Nutritional counselling in primary health care: a randomized comparison of an intervention by general practitioner or dietician

To compare health effects and risk reduction in two different strategies of nutritional counselling in primary health care for patients at high risk of ischaemic heart disease. In a cluster-randomized trial 60 general practitioners (GPs) in the Copenhagen County were randomized to give nutritional counselling or to refer patients to a dietician. Patients were included after opportunistically screening (n=503 patients), and received nutritional counselling by GP or dietician over 12 months. Health effects were measured by changes in weight, waist circumference and blood lipids. Risk of cardiovascular disease was calculated by The Copenhagen Risk Score. Data on use of medicine and primary health care was obtained from central registers. Altogether 339 (67%) patients completed the intervention. Weight loss was larger in the dietician group (mean 4.5 kg vs. 2.4 kg), and increase of HDL-cholesterol was larger in the GP group (mean 0.13 mmol/l vs. 0.03 mmol/l). The reduction of the cardiovascular risk score was significantly larger in the GP group (P=0.0005). Other health outcomes were not significantly different. GPs were aware of substantial risk factors of cardiovascular disease and addressed these when counselling. The guidance from a GP was of significant importance for risk reduction in relation to IHD. However, a long-term lifestyle intervention by GP was difficult to implement. In the case of obesity it was effective to refer to long-term nutritional counselling by a dietician.

Managing chronic conditions in a South African primary care context: exploring the applicability of Brief Motivational Interviewing

Background: Brief Motivational Interviewing (BMI) is an approach to motivating behaviour change in general health care settings. The relevance and applicability of BMI has not been fully assessed in low- or middle-income country settings. This study explored the application of BMI by general practitioners (GPs) in a public sector primary care setting in Cape Town, South Africa. Methods: How BMI should be adapted and applied was explored by means of a cooperative inquiry group of GPs. This participatory action research involved four action-reflection cycles over a five-month period during which GPs were trained to use BMI skills in their practice and to document and reflect on their experience. Results: GPs found the emphasis on self-evaluation, personal choice and control particularly useful. Skills in open questioning, exchanging information carefully, assessing ambivalence and readiness to change were also helpful. They had mixed experiences with skills for agenda setting and reducing resistance. The use of specific scaling questions and decision balance sheets were not useful. Conclusions: BMI has great potential, as the skills learnt were mostly useful and the process had benefits for the participants. If the full potential of BMI is to be realised, the content will need to be adapted to local clinical conditions. BMI needs to be taught using a participatory educational style and its implementation must be accompanied by support from colleagues and management. Future research on this issue should evaluate the process of implementing BMI skills in different primary care settings and sustaining any positive changes that may occur.

The quality of GP consultation in two different salary systemsA Finnish experience

Objective – To compare the quality of consultations between two Finnish employment contract systems: the capitation-based contract (CB) and the time-based contract (TB). Design – Cross-sectional study based on paired questionnaires answered by patients and general practitioners (GPs). Setting and subjects – 81 GPs with their patients from four health care centres in Finland, 2191 encounters. Main outcome measures – Both patients’ and GPs’ opinions on the role of personal doctor, medico-professional quality, quality of communication, consultation conditions, economic quality (= number of examinations and treatments), and duration of consultation. Results – Patients were more satisfied than the doctors with the quality of consultations. We found no differences between the groups in the patients’ opinions on the quality. The GPs in the CB group rated their work quality higher than the GPs in the TB group. The patients’ and the GPs’ understanding of the GP as a personal doctor varied so that the patients considered their GP as their personal doctor more often than the GPs in question. Conclusions – The GPs with a capitation-based contract evaluated the quality of their work higher than other GPs. Patient satisfaction was not dependent on the GP's contract.

Improving glycaemic control of patients with Type 2 diabetes in a primary care setting: a French application of the Staged Diabetes Management programme

To assess the impact of a French adaptation of the Staged Diabetes Management (SDM) programme on glycaemic control of people with Type 2 diabetes in primary care. Secondary endpoints were blood pressure, blood lipids, healthcare costs and quality of life. Prospective, randomized controlled study, of 1 years' duration. General practitioners (GPs) were recruited in four separate districts of a French region. They enrolled consecutive patients with Type 2 diabetes. GPs in the intervention group were educated in the SDM programme. GPs in the control group were asked to provide usual care. Healthcare costs were collected by medical departments of the Health Insurance systems. Quality of life was assessed with the Duke Health Profile. Three hundred and forty patients enrolled by 57 GPs completed the study, 192 in the intervention group and 148 in the control group. Patients in the intervention group were managed more adequately in accordance with the guidelines (P < 0.05 for nine out of 10 items). HbA(1c) decreased by 0.31% in the intervention group and increased by 0.56% in the control group, resulting in a difference of 0.87% by the end of the study (P = 0.001). Blood pressure and blood lipids did not differ between groups. Occurrence of major complications was low and identical in both groups. Incremental costs during the study in the intervention group were 35 euros per patient per month, and this was not significantly different in comparison with the control group. Quality of life was not affected by the intervention. Educating GPs in the French adaptation of the SDM programme improves glycaemic control in a primary care setting, without significantly increasing healthcare costs.

Direct access to physiotherapy in primary care: now?—and into the future?

Background Patient direct access to physiotherapy (self-referral), is not the routine mechanism in use within the National Health Service (NHS) although more recently it has become a topic of considerable United Kingdom (UK) and international interest. Aim To develop, implement, investigate and report on a direct access primary care based physiotherapy service. Design of study Experimental and qualitative. Setting A general practice in a health district of Scotland. Method The service was introduced and compared to the existing system of open access over a 12-month period. Demographic and clinical data were collected relating to two samples. Control year group All general practitioner (GP) referrals in the year prior to the study year. Study year group general practitioner and direct access referrals. All patients were followed up 1-month after discharge, and the number of associated general practitioner consultations collated together with clinician views of physiotherapy generally and direct access specifically. Results The control and study year groups were homogenous with regard to number of referrals (339 versus 340), patient age, gender, condition category and its severity. There were, however, significant differences between direct access and general practitioner referrals (22.4%, n=76; versus 77.6%, n=264). Direct access patients were more likely to have been: male, younger, suffering from conditions of a shorter duration, in paid employment with less work absence, more compliant with attendance, had fewer physiotherapy contacts, lower reporting of symptom severity at discharge and were more highly satisfied with their physiotherapy care and experienced less general practitioner consultations ( P<0.001). Support for direct access was strongly expressed by service users and clinicians. Conclusions Direct access to physiotherapy is an example of innovative primary care service provision that is feasible, acceptable to both users and providers and has major implications for general practitioner workload. Its efficacy, however, should be evaluated in a range of settings before being universally introduced.