General Practitioners In England Research Articles

Labour party says fundholding should evolve NHS will not fund private nursing care WMA acts on family violence GPs accused of wrong diagnoses Professions secure safeguards on comparative advertising NHS Health Advisory Service will have new role

# Labour party says fundholding should evolve {#article-title-2} The Labour party's health spokesman, Mr Chris Smith, has told the annual conference of the National Association of Fundholding Practices that fundholding should evolve rather than be abolished. From April 1997, 56% of all general practitioners in England will be fundholders caring for 58% of the population. Mr Smith told the conference, “We are not zealous ideologues. I don't think you are either. Let's see if we can map out a sensible way forward.” Although the Labour party has strongly criticised fundholding since it was introduced in 1991, Mr Smith acknowledged that the scheme had brought “substantial advantages.” The party will shortly issue detailed plans, which are likely to support multifunds but not allow budgets to remain at the level of individual practices. The chairman of the association, Dr Rhidian Morris, said that doctors wanted to keep control of their budgets so that they could continue to provide improvements in health care. “Doctors want to manage their patients' care, not be managed.” The minister for health, Mr Gerald Malone, told the conference that from April 1997 there would be no minimum entry requirements for community fundholding. This means that many small practices in rural areas with fewer than 3000 patients will be able to join the scheme. # NHS will not fund private nursing care {#article-title-3} The government has shelved a proposal endorsed by the Commons health committee that long term care in private nursing homes should be funded by the NHS to alleviate the growing problem of who …

Briefing: The number of general practitioners in England and Wales continues ...

Briefing: The number of general practitioners in England and Wales continues ...

Home visiting by general practitioners in England and Wales.

To use data from the fourth national survey of morbidity in general practice to investigate the association between home visiting rates and patients' characteristics. Survey of diagnostic data on all home visits by general practitioners. 60 general practices in England and Wales. 502 493 patients visited at home between September 1991 and August 1992. Home visiting rates per 1000 patient years and home visiting ratios standardised for age and sex. 10.1% (139 801/1 378 510) of contacts with general practitioners took place in patients' homes. The average annual home visiting rate was 299/1000 patient years. Rates showed a J shaped relation with age and were lowest in people aged 16-24 years (103/1000) and highest in people aged > or = 85 years (3009/1000). 1.3% of patients were visited five or more times and received 39% of visits. Age and sex standardised home visiting ratios increased from 69 (95% confidence interval 68 to 70) in social class I to 129 (128 to 130) in social class V. The commonest diagnostic group was diseases of the respiratory system. In older age groups, diseases of the circulatory system was also a common diagnostic group. Standardised home visiting ratios for the 60 practices in the study varied nearly eightfold, from 28 to 218 (interquartile range 67 to 126). Home visits remain an important component of general practitioners' workload. As well as the strong associations between home visiting rates and patient characteristics, there were also large differences between practices in home visiting rates. A small number of patients received a disproportionately high number of home visits. Further investigation of patients with high home visiting rates may help to explain the large differences in workload between general practices and help in allocation of resources to practices.

The impact of three influenza epidemics on primary care in England and Wales.

The numbers of persons with influenza presenting to general practitioners in England and Wales during the epidemics of late 1989, late 1993, and early 1995 are estimated to be approximately 760,00, 480,000 and 192,000, respectively. The expected numbers used to derive these estimates were obtained by averaging incidence by week over the 9 winters of 1986/87 to 1994/95, excluding those weeks in which influenza was prevalent. These 3 epidemics varied in magnitude and in the relative impact on persons in different age groups. The influenza B epidemic in 1995 scarcely affected elderly people. During the 3 epidemic periods, increased numbers of persons consulted their general practitioners with other respiratory diseases, including pneumonia, acute bronchitis and otitis media. The patterns of increase were not consistent between the epidemics, partly because of the differing impact on the various age groups and partly because of the effect of other respiratory viral illnesses prevalent at the same time. No increase occurred in the numbers of persons reported with new episodes of cerebrovascular accident or of acute myocardial infarction. A similar method was used to estimate excess deaths, which amounted to 25,000 in 1989, 13,000 in 1993, and 500 in 1995. In the periods immediately following the influenza epidemics, the observed pattern of deaths conformed to the expected, demonstrating that persons dying during the epidemics were not just dying a few weeks prematurely.

GP practice leaflets: Their content and compliance with requirements

Objectives: The aim of the study was to evaluate the content of the information leaflets provided by general practitioners in England for their patients. Provision of leaflets is a requirement of the 1990 general practitioner contract with specified minimum items for inclusion set out. The extent of provision of health promotion information and of advertising were also evaluated.Methods: Whilst interviewers were carrying out a survey of general practice in seven areas of England in the latter part of 1993, they were asked to collect a copy of the practice information leaflet. The 252 leaflets were analysed to establish the extent to which they met the requirements of the 1990 contract and to assess what additional material was included.Results: No practice leaflet contained all of the items required as a result of the 1990 contract, the highest score being 95% and the lowest 20%. Practice size and the presence of advertisements were factors related to leaflets meeting the criteria. The inclusion of health...

BMA calls for lower blood alcohollevel for drivers Number of GPs increases Public health doctors forecast required manpower New health minister appointed Government promises extra pounds sterling50m for mentally ill patients GPs clarify their role in childbirth

# BMA calls for lower blood alcohollevel for drivers {#article-title-2} The BMA and the Parliamentary Advisory Council for Transport Safety (PACTS) are calling for the legal blood alcohol limit for driving to be reduced to 10.9 mmol/l (50mg/100ml) from the current level of 17.4 mmol/l (80mg/100ml). Research has shown that the risk of becoming involved in a traffic accident greatly increases at blood alcohol levels over 50mg/100ml and the two organisations want legislation to be introduced to reflect this evidence. Some other European countries have switched to the lower level; France is the latest country to do this. In a letter to the transport secretary, Sir George Young, the BMA and PACTS say that legislation needs to be enforced if it is to be effective and that they would support measures to enhance current levels of enforcement, in particular the introduction of random breath testing. The possibility of being tested randomly is considered more likely to act as a deterrent as there is a higher chance of drivers being caught. # Number of GPs increases {#article-title-3} The number of general practitioners in England and Wales increased by 0.7% from 30416 to 30615 during the past year, with women accounting for the majority of the increase. In April 1995, 29.9% of all general practitioners were women. The average patient list size fell to 1869, compared with 2059 in 1985. The number of general practitioner registrars decreased by 3.6% between April 1994 and April 1995 (from 1611 to 1503), but the number of women registrars increased by 1.6% so that more than half of all registrars …

Prescribing costs

The cost of drugs prescribed by general practitioners in England rose by 13.4% between 1991 and 1992, bringing the total amount spent on medicines prescribed in the community last year to £2858 million. In the same period the number of items dispensed rose by 4.6%, or 4.2% per head of population, and the average cost per item increased by 8.5%, from £6.20 to £6.72. These figures are contained in the latest issue of the Statistical Bulletin,1 published annually by the Department of Health.

The future role of dental therapists in the UK: a survey of District Dental Officers and General Practitioners in England and Wales.

A postal questionnaire concerning the opinion of the dental profession as to the future role of dental therapists in the UK was sent to a random sample of 30 District Dental Officers and 70 General Dental Practitioners. In total 76 questionnaires were returned, 26 from DDOs, 50 from GDPs, giving corrected response rates of 86.7% and 57.1% respectively. Returns revealed that 69.2% of District Dental Officers predicted a future role for dental therapists in the Community Dental Service. A total of 47.5% of General Dental Practitioners stated they would like to see therapists working in general dental practice, with 40% of this group willing to employ a therapist providing the current legislation was changed. The most popular predicted role in both services appears to be an equal division between the provision of clinical care and dental health education. Recently qualified General Dental Practitioners were more in favour of the employment of therapists than older members of the profession, which suggest that with time, the demand for this auxiliary in general dental practice could increase.

PEM report number 8. Cisapride

AbstractThe gastrointestinal prokinetic agent cisapride has been studied by Prescription‐Event Monitoring (PEM) in 13,234 patients who had received prescriptions from general practitioners in England between October 1990 and April 1991. There were 58% female and 41% male; the average age was 56 years. The most common indications were oesophageal reflux, dyspepsia and hiatus hernia.The events were compared with pooled data from a population of 332,402 patients in 33 PEM studies including those of omeprazole, nizatidine and famotidine which were used to provide estimates of background rates. The events most frequently reported were related to the conditions that were being treated, mainly those affecting the gastrointestinal tract. Diarrhoea was the most noteworthy among events identified as adverse reactions to cisapride. Dermatalogical, hepatic, cardiovascular and other sub‐groups of events were examined with particular care and no unacceptable hazards were detected.The PEM data were also compared with those from clinical trials involving treatment periods from four weeks to one year in similar patients. The pattern of events revealed by the PEM study closely matched the findings of clinical trials.It was concluded that cisapride is a safe and effective prokinetic agent causing few serious side‐effects when prescribed in general practice.

PEM report number 5. Fluoxetine

AbstractThe selective serotonin reuptake inhibitor (SSRI) fluoxetine was first marketed in the United Kingdom in January 1989. It has been studied by Prescription‐Event Monitoring (PEM) in 12,692 patients who had received prescriptions from general practitioners in England between March 1989 and March 1990.There were more than twice as many females in the series as males and the average ages were 49.4 and 50.1 years respectively. The majority of patients were taking 20 mg daily (89%), but doses ranged up to 120 mg daily. Where an opinion had been given, fluoxetine was said to have been effective in 57% of patients.The events following treatment were compared with those reported after prescription of two other SSRIs, paroxetine and fluvoxamine, and with the ‘pooled’ results in 34 studies, in order to detect possible differences within the group of SSRIs and to obtain some impression of the background rates in a population of over 350,000 monitored by PEM.Coincidental with the PEM study there was much publicity, initiated in the United States by a report of suicidal and aggressive behaviour. A subsidiary study of doctors' and patients' attitudes before and after a heavily biased television programme was initiated about one‐fifth of the patients in the PEM study. There was no evidence to suggest that the frequency of aggressive or suicidal behaviour following the use of fluoxetine was increased.The overall incidence of side‐effects was low and no deaths were attributed to fluoxetine.

PEM report number 9. Omeprazole

AbstractPatients (16,204) who had been treated with omeprazole by general practitioners in England between June 1989 and June 1990 have been studied by Prescription‐Event Monitoring (PEM). The pattern of events recorded during the six months following each patient's initial prescription has been compared individually with four other drugs used for similar indications and studied by the same method — cisapride, misoprostol, famotidine and nizatidine — and with pooled data on these and other unrelated drugs.Omeprazole had been prescribed most frequently for oesophageal reflux, oesophagitis, hiatus hernia and peptic ulcer or its complications. Seventy per cent of patients used a daily dose of 20 mg and 26% used 40 mg. Where efficacy had been reported, 81% of the patients were said to have benefited.A comparison of events recorded during the first month with those recorded with other drugs produced no noteworthy ‘signals’. Diarrhoea and nausea or vomiting were the only events which produced a rate‐ratio of more than three when the rate during the first month was compared to that during months two to six. These events were probably more related to the indication than the treatment. No serious hazards were identified and no deaths were attributable to omeprazole.

PEM report number 4. Ciprofloxacin

AbstractThe fluoroquinolone antibiotic ciprofloxacin has been studied by Prescription‐Event Monitoring (PEM) in 11,477 patients who had received prescriptions from general practitioners in England between November 1988 and January 1989. There were about 50% more females in the series than males and the average ages were 53.2 and 55.5 years respectively. Chest and urinary infections were the most common indications. Forty‐five per cent of the patients used 500 mg daily and 42% 1000 mg daily. Ciprofloxacin was said to have been effective in 90.3% of patients.The events were compared with those reported in 25 other studies in order to obtain some impression of the background rates in a population of more than a quarter of a million patients monitored by PEM. The events most frequently reported were related to the infections that were being treated and the most common side‐effects were those affecting the gastrointestinal system. There were three definite and one doubtful case of photosensitivy. Among the psychiatric events, only depression and malaise or lassitude occurred at a rate which exceeded one per 1000 patients during the first 13 weeks of follow‐up. Fourteen patients suffered convulsions but only two cases were considered to be possibly related either to treatment or to pyrexia associated with urinary tract infection. No cases of pseudomem‐branous colitis were identified although diarrhoea was the most common gastrointestinal event. Following the withdrawal of temafloxacin, the ciprofloxacin data were searched for evidence of hepatic or renal damage or hypoglycaemia, but no evidence was found with ciprofloxacin, or in, as yet uncompleted, studies of enoxacin, ofloxacin or norfloxacin. No serious adverse reactions (ADRs) or deaths attributable to ciprofloxacin were recorded and no previously unrecognized hazards were identified.The PEM data were compared with selected results from clinical trials. For the most part the incidence of events encountered during a three‐month period resembled those in clinical trials very closely.It was concluded that ciprofloxacin is a safe and effective antibiotic prescribed in general practice.

Counsellors in English and Welsh general practices: their nature and distribution.

To establish the prevalence of counselling services in English and Welsh general practices and factors associated with their distribution; to describe qualifications, working arrangements, and case mix of "counsellors." Postal questionnaire and telephone interview survey of a sample of about one in 20 general practitioners in England and Wales. English and Welsh general practices. 1880 general practitioners of whom 1542 (82%) completed questionnaires. Prevalence and distribution of practice counselling services; counsellors' qualifications and funding; types of patients referred. 586 counsellors were distributed among 484 of the 1542 practices. Three types of counsellor predominated: community psychiatric nurses (187); "practice counsellors" (145); and clinical psychologists (95). Practice characteristics which independently predicted the presence of a counsellor were for community psychiatric nurses four or more partners (odds = 1.72, 95% confidence interval 1.18 to 2.26); for practice counsellors stress clinic (odds = 2.22; 1.83 to 2.61), training practice (odds = 1.70; 1.24 to 2.16), and health region (chi 2 = 55.94; df = 14; p < 0.001); and for clinical psychologists list size of > or = 10,500 (odds = 1.79; 1.09 to 2.49), training practice (odds = 1.78; 1.31 to 2.25), health region (chi 2 = 48.31; df = 14; p < 0.001). 197 counsellors had training in counselling. The qualifications of 85 were unknown to the general practitioner. The principal source of funding was the district health authority for community psychiatric nurses (150) and clinical psychologists (58) and the family health services authority for practice counsellors (76). All counsellors were referred a wide range of problems. Counselling services are wide-spread in general practice, but a high proportion of counsellors lack qualifications, and many may be referred problems outside their knowledge.

Coronary heart disease prevention: the role of the general practitioner.

The objectives of the study were to identify the level of general practitioner (GP) involvement in activities aimed at coronary heart disease prevention and to explain variations in involvement. These questions were explored through a postal survey of a random sample (n = 1696) of GPs in England of whom 64% completed questionnaires. Ninety-four per cent of GPs reported that they were involved in risk factor assessment in the consultation although these assessments most commonly involved blood pressure testing and identification of smoking. Ninety-one per cent of practices were reported by the GP to have a lifestyle risk assessment clinic where there was more evidence of systematic risk assessment. These clinics were usually run by a practice nurse as were lifestyle risk factor management clinics although GPs were more involved in hypertension and cholesterol clinics. Positive attitudes to prevention and training in health promotion were associated with higher GP involvement, and higher practice involvement was associated primarily with the number of practice nurses employed. The implication of these findings are discussed.

BARRIERS AND INCENTIVES OF PHYSICIANS AND PATIENTS TO CANCER SCREENING

It is imperative that the health care system provide mechanisms to improve cancer control. The most effective way of limiting cancer morbidity and mortality is by prevention (modification of behaviors that increase cancer risk), and by early diagnosis in the asymptomatic stage of the disease, which allows for curative therapies. This article has enumerated barriers that make preventive and early diagnostic maneuvers more difficult for both patients and physicians. Some of the barriers are common to both patients and physicians, such as discontinuity of care. The barriers were discussed from both perspectives. Suggestions were made for modification of these barriers, so that incentives might make provision of the preventive and early diagnosis more likely. The incentives are attainable; however, to make improvements on a large scale will require the efforts of the public, physicians, and the health care system. It will effect physicians from the beginning of their medical education and through their entire practice. A large amount of effort directed at a focused population by a small team of health care workers can make a large difference in preventive care. This was shown effectively by a general practitioner in England who undertook a 15-month "campaign" on a "deprived" community, and raised the level of preventive care to that of an "endowed" community. This type of effort by an individual is desirable, but much smaller individual efforts directed over an entire population can have a much greater ultimate effect. That is why the efforts must be directed toward the primary care physician. These physicians care for the majority of the population, so if each primary care doctor increased current efforts of prevention by just three patients per day, then over the entire population inestimable improvements on preventive care would result. There is some evidence that improvements in preventive care are occurring. As further research is directed at how best to provide preventive services in the physician's office, our skills and effectiveness will improve. Each physician should accept as his or her responsibility the ongoing preventive needs of the population he or she serves. The prevention and early diagnosis of cancer can be coordinated in the office with episodic care to minimize costs. The necessary knowledge and technology are available, application is the key. By applying these in a cost-effective way, we can hopefully attain control of cancer in the next decade.

The problem of diagnostic variability in general practice.

The aim was to examine the scale, source, and relevance of variation between general practices in respect of the rates with which patients consulted with illnesses falling in each of several diagnostic groups. This study involved a general practice morbidity survey conducted over two years, 1970-72. All patients who consulted their general practitioners were identified and the number of these who consulted with diagnoses attributable to each of the 18 main chapters of the International classification of diseases were counted. Patients who consulted for more than one diagnosis within a chapter were counted once only; those who consulted for one or more diagnoses in each of several chapters were counted once for each chapter. This was a national survey involving general practitioners in England and Wales. The study involved 214,524 patients from 53 selected general practices (115 doctors) who were registered with their general practitioners for the whole of the year 1970-71 and for whom their morbidity data had been linked with their social data from the 1971 census. Using the numbers of patients on the practice lists as denominators, practice patient consulting rates (PPCR) were calculated for each practice and for each ICD chapter. Variability in chapter PPCR was examined by calculating coefficients of variation and, after allowance for random variation, coefficients of residual variation. There were large interpractice (doctor) variations in all chapter rates. These variations were only marginally attributable to: chance; different age, sex and social class mixes of practice populations; geographical locations; and practice organisation. The rates were, however, consistent from one year to the next for any one practice. Approximately half of the interpractice (doctor) diagnostic variability was associated with overall patient consulting behaviour. When the effects of this behaviour were discounted, any major residual diagnostic variability was confined largely to ICD chapters I-V, XVI, and XVII, ie, those chapters where aetiology forms the basis of classification. Variations in recorded diagnostic rates are mainly due to the consistent but idiosyncratic and selective exclusion by practitioners of some components from the total set which often coexist in a new diagnosis. Because of the scale of interpractice diagnostic variability, the use of algorithms and information technology is largely precluded from outcome studies, auditing procedures, and studies of practice work loads in general. However, (1) the consistency of any individual doctor's pattern of diagnostic recording from one year to another permits studies of trends; and (2) given a reasonable number of recording practices, the population mean practice consulting rates can be estimated with sufficient accuracy for many epidemiological research and administrative uses.

Impact of an interest in asthma on prescribing costs in general practice.

To examine the effect on total prescribing costs and prescribing costs for respiratory drugs for practices with at least one general practitioner with a special interest in asthma. Postal questionnaire survey. General practitioners in England and Wales. 269 members of the General Practitioners in Asthma Group, of whom 103 agreed to participate. Individual practitioners' and their practices' PACT prescribing costs from the winter quarters of 1989-90 compared with average costs for their family health services authority (FHSA) and a notional national average of all FHSAs combined. The response rate was 57%; the average total prescribing costs for the practices of the 59 respondents were significantly lower than those of their respective FHSAs (mean difference 505 pounds per 1000 patients per quarter (95% confidence interval -934.0 to -76.2, p = 0.022) and lower than the national average. The average prescribing costs for respiratory drugs for the practices were significantly greater than those for their FHSA (195 pounds per 1000 patients per quarter (84.4 to 306.0, p = 0.001) and the national average. Both types of costs varied widely. An interest in asthma care in general practice is associated with higher average prescribing costs for respiratory drugs but no increase in overall prescribing costs compared with those for respective FHSAs and national averages. FHSAs and their medical advisors should not examine high prescribing costs for individual doctors or one therapeutic category but in the context of practice total costs.

Ethical decision making by family doctors in Canada, Britain and the United States

Family doctors in Canada and the U.S. and general practitioners in England and Wales were sent a questionnaire containing six cases that raised moral issues. The doctors were asked to select the most appropriate course of action for each case as well as reasons for that decision. The ethical problems concerned how much information to divulge to patients, how extensively a physician should become involved in the lifestyles of patients, and how to deal with a possible family problem. The respondents selected different courses of action for the cases. More U.S. than Canadian or British physicians chose to divulge information, while more British than Canadian or U.S. physicians chose not to become involved in patients' lifestyles. Physicians who chose to divulge information were likely to be young, male, live in a small community, and have no academic affiliation. Physicians who chose not to become involved in lifestyle issues were likely to be young, church attenders, and in group practice in a small community.

Images of general practice: The perceptions of the doctor

During the post second world war period there has been considerable discussion both within and outside the medical profession about what the role of the general practitioner should be. This study, drawing on data gathered from a national representative sample of general practitioners in England and Wales, explores general practitioners' own perceptions of their work role. The evidence shows that general practitioners might be divided into those who see a broad role for the general practitioner and place emphasis on the social aspects of care, and those who see a more traditional role for the general practitioner focusing specifically on organic illness. Those with a social orientation were also more likely to doubt the value of financial incentives, whereas the medical oriented doctors were more likely to say that their behaviour was influenced by financial incentives. The analysis also showed that the medically oriented were distinctly different to those with a social orientation in terms of personal characteristics and the setting in which they worked. The implications of these findings are discussed in full.

Findings of a national survey of the role of general practitioners in the treatment of opiate misuse: views on treatment.

An important component of government policy on services for drug misusers is to encourage general practitioners to take a more active role. There are, however, some indications that general practitioners regard drug misusers as undesirable patients, although no evidence is available. As part of a wider investigation of the role of general practitioners in the treatment of opiate misuse, a questionnaire, which was sent in mid-1985 to a 5% random sample of general practitioners in England and Wales, included a section designed to elicit their views on policy and treatment connected with opiate misuse. The results showed that although most general practitioners consider opiate misuse to be a priority concern for the Health Service, they also generally regard opiate misusers as especially difficult to manage, beyond their competence to treat, and less acceptable as patients than others in need of care. General practitioners who have qualified recently were somewhat less unfavourable in their views. These findings suggest that the effective implementation of government policy will require trying to modify general practitioners' attitudes and providing support for them.