Single-handed General Practitioners Research Articles

The Relationships Between Use of Quality-of-Care Feedback Reports on Chronic Diseases and Medical Engagement in General Practice.

Background:There is a limited knowledge on how medical engagement influences quality of care provided in primary care. The extent of the use of feedback reports from a national quality-of-care database can be considered as a measure of process quality. This study explores relationships between the use of feedback reports and medical engagement among general practitioners, general practitioner demographics, clinic characteristics, and services.Methods:A cross-sectional combined questionnaire and register study in a sample of 352 single-handed general practitioners in 2013. Logistic regression analysis was used to explore associations between the use of feedback reports for diabetes and chronic obstructive pulmonary disease and medical engagement.Results:For both diabetes and chronic obstructive pulmonary disease, a higher degree of medical engagement was associated with an increased use of feedback reports. Furthermore, we identified positive associations between using feedback reports and general practitioner services (spirometry, influenza vaccinations, performing annual reviews for patients with chronic diseases) and a negative association between usage of quality-of-care feedback reports and the number of consultations per patient.Conclusion:Using feedback reports for chronic diseases in general practice was positively associated with medical engagement and also with the provision of services in general practice.

The benefits of co-location in primary care practices: the perspectives of general practitioners and patients in 34 countries

BackgroundThere is no clear evidence as to whether the co-location of primary care professionals in the same facility positively influences their way of working and the quality of healthcare as perceived by patients. The aim of this study was to identify the relationships between general practitioner (GP) co-location with other GPs and/or other professionals and the GP outcomes and patients’ experiences.MethodsWe wanted to test whether GP co-location is related to a broader range of services provided, the use of clinical governance tools and inter-professional collaboration, and whether the patients of co-located GPs perceive a better quality of care in terms of accessibility, comprehensiveness and continuity of care with their GPs. The source of data was the QUALICOPC study (Quality and Costs of Primary Care in Europe), which involved surveys of GPs and their patients in 34 countries, mostly in Europe. In order to study the relationships between GP co-location and both GPs’ outcomes and patients’ experience, multilevel linear regression analysis was carried out.ResultsThe GP questionnaire was filled in by 7183 GPs and the patient experience questionnaire by 61,931 patients. Being co-located with at least one other professional is the most common situation of the GPs involved in the study. Compared with single-handed GP practices, GP co-location are positively associated with the GP outcomes. Considering the patients’ perspective, comprehensiveness of care has the strongest negative relationship of GP co-location of all the dimensions of patient experiences analysed.ConclusionsThe paper highlights that GP mono- and multi-disciplinary co-location is related to positive outcomes at a GP level, such as a broader provision of technical procedures, increased collaboration among different providers and wider coordination with secondary care. However, GP co-location, particularly in a multidisciplinary setting, is related to less positive patient experiences, especially in countries with health systems characterised by a weak primary care structure.

Do GPs want or need formal support following a patient suicide?: a mixed methods study.

Patient suicide can be a devastating event for some general practitioners (GPs). Few guidelines exist to aid or support GPs in the aftermath of patient suicide. To explore GPs views on how they are affected by a patient suicide and the formal support available to them following a patient suicide. Questionnaires and semi-structured interviews. General practices in the northwest of England. About 198 semi-structured interviews were conducted as part of a retrospective study. Interviews were transcribed verbatim and analysed using descriptive statistics and a framework thematic approach. GPs were aged between 31 and 67 years, 144 (73%) were male and the number of years in practice varied between 8 and 40 years (median = 24 years). GPs were based at 133 (67%) urban and 65 (33%) rural practices, 30 (15%) were single-handed GP practices and 168 (85%) practices had two or more GPs. About 131 (66%) GPs reported being affected by patient suicide through feelings of grief, guilt and self-scrutiny. A greater number of years in practice may have been protective against these effects. About 54 (27%) GPs reported having mostly 'informal' support from peers or colleagues and support was less available to younger and single handed GPs. Our findings suggest that the majority of GPs are affected by patient suicide and most seek informal support from their peers and colleagues. Although many indicated that informal support systems were adequate and provided a protective environment, procedures should be developed to ensure the availability of guidelines for those who may require formal support.

Medication assessment tool to detect care issues from routine data: a pilot study in primary care

Medication assessment tools (MATs) may be implemented in routine electronic data sources in order to identify patients with opportunities for optimisation of medication therapy management (MTM) and follow-up by a multi-disciplinary team. (1) To demonstrate the use of a MAT for cardiovascular conditions (MAT CVC) as a means of profiling potential opportunities for MTM optimisation in primary care and (2) to assess the performance of MAT CVC in identifying actual opportunities for better care. Members of a pharmacotherapy discussion group, i.e. two single-handed general practitioners (GPs), three GP partners, and community pharmacists (CPs) from each of two community pharmacies, in a rural part of the Netherlands. MAT CVC comprises 21 medication assessment criteria, each of which is designed to detect a specific care issue and to check whether it is 'addressed' by provision of guideline recommended care or 'open' in the presence ('open explained') or absence ('open unexplained') of pre-specified explanations for guideline deviations. (1) Relevant data was extracted from linked GP and CP electronic records and MAT CVC assessment was conducted to profile the population of CVC patients registered with both, participating CPs and GPs, in terms of 'open unexplained' care issues. (2) A purposive sample of patients with 'open unexplained' care issues was reviewed by each patient's GP. Number and proportion of 'open unexplained' care issues per MAT CVC criterion and per patient. The number of patients with MAT CVC detected 'open unexplained' care issues to be reviewed (NNR) in order to identify one that requires changes in MTM. In 1,876 target group patients, MAT CVC identified 6,915 care issues, of which 2,770 (40.1 %) were 'open unexplained'. At population level, ten MAT CVC criteria had particularly high potential for quality improvement. At patient level, 1,277 (68.1 %) target group patients had at least one 'open unexplained' care issue. For patients with four or more 'open unexplained' care issues, the NNR was 2 (95 % CI 2-2). The study demonstrates potential ways of using MA TCVC as a key component of a collaborative MTM system. Strategies that promote documentation and sharing of explanations for deviating from guideline recommendations may enhance the utility of the approach.

The association between general practitioners’ attitudes towards breast cancer screening and women’s screening participation

BackgroundBreast cancer screening in Denmark is organised by the health services in the five regions. Although general practitioners (GPs) are not directly involved in the screening process, they are often the first point of contact to the health care system and thus play an important advisory role. No previous studies, in a health care setting like the Danish system, have investigated the association between GPs’ attitudes towards breast cancer screening and women’s participation in the screening programme.MethodsData on women’s screening participation was obtained from the regional screening authorities. Data on GPs’ attitudes towards breast cancer screening was taken from a previous survey among GPs in the Central Denmark Region. This study included women aged 50-69 years who were registered with a singlehanded GP who had participated in the survey.ResultsThe survey involved 67 singlehanded GPs with a total of 13,288 women on their lists. Five GPs (7%) had a negative attitude towards breast cancer screening. Among registered women, 81% participated in the first screening round. Multivariate analyses revealed that women registered with a GP with a negative attitude towards breast cancer screening were 17% (95% CI: 2-34%) more likely to be non-participants compared with women registered with a GP with a positive attitude towards breast cancer screening.ConclusionThe GPs' attitudes may influence the participation rate even in a system where GPs are not directly involved in the screening process. However, further studies are needed to investigate this association.

Cardiovascular screening for men at high risk in Heart of Birmingham Teaching Primary Care Trust: the 'Deadly Trio' programme

The Deadly Trio programme offered cardiovascular health checks to men over 40 in inner-city Birmingham. The aim was to increase diagnosis of diabetes, cardiovascular and kidney disease among this deprived and ethnically diverse population. Either patients' own general practitioners (GPs) were paid to provide health checks or patients were invited to an alternative provider. Routine data were sought from 68 participating practices. Logistic regression analysis was undertaken to determine the patient and practice factors associated with being screened and with being added to a disease register. Data were obtained from 58 practices; 5871 (24.3%) of 24 166 eligible men were screened. Screening uptake was higher in those with a recorded phone number, South Asians and Blacks but lower in smokers. Compared to the alternative provider, uptake was higher among men registered with single-handed (but not multi-partner) GPs paid to provide health checks. South Asian, older and screened men were more often added to disease registers. Men with missing information and GP-screened men were less likely to be added to registers. The programme achieved higher screening uptake and diagnosis of disease among minority ethnic men. Single-handed GPs paid to provide screening (and their patients) were more responsive than multi-partner practices.

George Kenneth Mackenzie

George Kenneth Mackenzie (“Mac”) was born in 1911 and graduated MB ChB from Edinburgh University in 1936. He served as lieutenant surgeon in the Royal Navy in destroyers during the...

Correlates of spontaneous reporting of adverse drug reactions within primary care: the paradox of low prescribers who are high reporters.

To examine Primary Care Trust (PCT) demographics influencing general practitioner (GP) involvement in pharmacovigilance. PCT adverse drug reaction (ADR) reports to the Yellow Card scheme between April 2004 and March 2006 were obtained for the UK West Midlands region. Reports were analysed by all drugs, and most commonly reported drugs ('top drugs'). PCT data, adjusted for population size, were aggregated. Prescribing statistics and other characteristics were obtained for each PCT, and associations between these characteristics and ADR reporting rates were examined. During 2004-06, 1175 reports were received from PCTs. Two hundred and eighty (24%) of these reports were for 14 'top drugs'. The mean rate of reporting for PCTs was 213 reports per million population. A total of 153 million items were prescribed during 2004-06, of which 33% were 'top drugs'. Reports for all drugs and 'top drugs' were inversely correlated with the number of prescriptions issued per thousand population (r(s)=-0.413, 95% CI -0.673, -0.062, P < 0.05, and r=-0.420, 95% CI -0.678, -0.071, P < 0.05, respectively). Reporting was significantly negatively correlated with the percentages of male GPs within a PCT, GPs over 55 years of age, single-handed GPs within a PCT, the average list size of a GP within a PCT, the overall deprivation scores and average QOF total points. ADR reports did not correlate significantly with the proportion of the population over 65 years old. Some PCT characteristics appear to be associated with low levels of ADR reporting. The association of low prescribing areas with high ADR reporting rates replicates previous findings.

Project based approach to increasing uptake of influenza vaccine in an underachieving GP practice

Influenza is a major cause of morbidity and mortality (DH, 2006; Watson et al 2001). In the United Kingdom (UK), the policy of encouraging influenza vaccine uptake in elderly people is a central tenet of managing winter pressures in the National Health Service (NHS) and preventing ill health among older people in the community. A project based management approach was used to evaluate the organisational practice within a single-handed general practitioner (GP) practice during the 2005/06 Influenza Immunisation Programme. The project highlighted a number of problems such as a poorly structured programme, insufficient knowledge about the severity of influenza or the efficacy of the vaccine, and insufficient computer technology. A stepwise process and a number of evidence based interventions were implemented with the aim of increasing the uptake of influenza vaccine in the target population. The overall aim of the project was to show a measured practice increase in the number of older people, defined as 65 years and over, taking up influenza vaccine within one influenza campaign. An increase of 35.71% was achieved. The findings of this project have the potential to inform and enhance the design and implementation of the influenza programmes in other practices that are experiencing difficulties in achieving a good influenza immunisation uptake.

Learning by doing: a novel approach to improving general practitioners' diagnostic skills for common mental disorders

Two strategies have been proposed to increase the rather low recognition rate of common mental disorders in primary care: (1) the use of screening instruments and (2) extensive psychiatric training for general practitioners. We have chosen a "middle-of-the-road" approach to teach general practitioners by means of a time-saving psychiatric training programme how to make their own psychiatric diagnoses. This pilot study aimed at assessing the acceptance of this programme, its impact on general practitioners' knowledge of 12 ICD-10 disorders - depressive, anxiety and alcohol-related disorders - and the short-term persistence of the knowledge acquired. The training programme consisted of two 3-hour sessions four weeks apart. An educational instrument, a short interview named TRIPS (Training for Interactive Psychiatric Screening), a shortened and adapted form of PRIME-MD, was used to train single-handed general practitioners in Vienna, Austria. TRIPS had to be used by the participants in daily practice in between sessions. Five weeks after the second training session a follow-up evaluation was held to assess the persistence of the knowledge acquired. The perceived usefulness of TRIPS was assessed by a short questionnaire. Knowledge was assessed by a separate 15-item questionnaire. Of the 31 participating general practitioners 26 attended all three sessions. There was a significant increase in the mean number of correctly answered questions between baseline (5.5 of 15) and session two (9.8; p<0.0001), and a further increase between the second and the follow-up session (11.3; p<0.05). Also, general practitioners rated TRIPS as a practical and useful tool for family practice and stated that its use met with patients' approval. The format chosen was successful in its intended educational endpoints. According to participants TRIPS is appropriate for the family practice situation and is accepted by patients.

Clinical interest: a study of the influence on general practitioners' prescribing

To analyse the association between general practitioners' clinical interest and prescribing rates in four clinical areas: dyspepsia, depression, headache and diabetes. Data concerning general practitioners' prescribing during 2004 were retrieved from a pharmacy database and linked with data from a physician questionnaire and the National Health Insurance Register. To counterbalance differences in practice populations all 1-year prevalences of prescribing were standardised according to age and gender. Participants were asked 'To what extent do you find the following areas interesting from a professional point-of- view?' Four rating categories were used. The association between clinical interest and standardised prescribing rates was investigated using logistic regression, the Kruskal-Wallis test and a trend test. A total of 68 (72%) single-handed general practitioners representative of the total group completed the questionnaire. We observed a two-fold ratio between the 90% and the 10% percentiles of the 1-year prevalences of antisecretory drugs, antidepressants, migraine drugs as well as anti-diabetics. The variation in prescribing of antidepressant and antisecretory drugs was far above chance level. No significant association with clinical interest could, however, be observed for any of the four clinical areas. General practitioners' prescribing of the four classes of medical drugs varied considerably. However, only part of this variation was based on chance. This study did not confirm our hypothesis that general practitioners' level of clinical interest in one area corresponds with their prescribing of drugs used within that area.

Shipman and the Anaesthetist

Shipman and the Anaesthetist

Determinants of prescribing costs amongst single-handed general practitioners.

To investigate the contribution of patient and doctor characteristics in explaining observed variations in prescribing costs between individual doctors. Secondary analysis of data collected from general practitioners, Family Health Services Authorities, 1991 Census data set and the Prescription Pricing Authority. A multiple regression model with four variables (social class, training status, generic prescribing and length of time in general practice) explained only 16.5% of the variation in costs/ASTRO-PU. This study highlights that very little of the variation in prescribing costs can readily be explained. Further research is needed to document contributing factors.

Antibiotic prescribing by single handed general practitioners: secondary analysis of data.

To determine the contribution of various doctor and patient factors on the frequency of antibiotic prescribing. Secondary analyses of data on 155 single handed general practitioners. Three variables explained 25% of variation in antibiotic prescribing. Doctors qualified from the Indian subcontinent issued more antibiotics than U.K.-qualified doctors. Patients from the non-manual social class were issued fewer antibiotics than those from the manual class and the most deprived patients received significantly more antibiotics. Very little of prescribing of antibiotics by doctors is explained by these doctor-patient factors. Prescribing is a complex process and the search for factors must continue in order to address the rising antibiotic resistance.

Mental health teamwork in primary care

The historical context is important when considering developments which are relatively recent and still in the process of being developed. Traditionally, general practitioners dealt on their own with their clinical workload but, following the doctor’s charter of 1965, there was a rapid move towards GPs working in group practices. This predated the concept of a primary health care team, but was associated with a rapid growth in the number of community nurses and health visitors with clear links with local GPs. The increase in formal and informal links with mental health professionals has been much slower, although this is currently a growth area. However, even now, it is important to remember how much variability there is in working arrangements; although the national average for single-handed general practitioners is 10%, it is much higher than this in many inner-city areas. Research over a similar time frame, i.e. the last 30 years, has established the range and extent of psychological morbidity presenting to primary care. There is now general agreement that 25± 30% of those attending their GP will have some psychological component to their presentation, and this means that the average GP with a list size of 2,000 patients will see an average of 460 patients per year with mental health problems (Goldberg & Huxley, 1992).

Epidemiology and determinants of nocturnal calf cramps

Objectives: Nocturnal calf cramps are a health impairment frequently encountered in primary healthcare. Nevertheless, not much is known about prevalence, determinants, comorbidity and management of the condition.Methods: Survey by means of a postal, self-administered questionnaire sent to all adults who attended a single-handed general practitioner in a six-month period.Results: A total of 1675 questionnaires were sent out, the response rate was 71.4%. In the study population there was a four-week prevalence of 24.1% and an estimated incidence of 40 new cases per 1000 per year. Nocturnal calf cramps were more prevalent in older persons, in persons with a higher body mass index (BMI), in women, in patients with varicosis, diabetes, peripheral vascular disease, and in non-smokers. There was at least one self-reported incident of nocturnal calf cramps with at least level 2 pain on a 10-point pain measurement scale within the past four weeks. In a multiple logistic regression analysis, age, varicosis, diabetes, peripheral vascular disease and female gender were independent determinants for nocturnal calf cramps, while BMI and smoking habits were not determinants. In total 27.6% of cramp patients reported at least one visit to their GPs because of nocturnal cramps. A large variety of therapeutic remedies were reported, all of which had high subjective success rates.Conclusions: Nocturnal calf cramps are a health impairment with extremely high prevalence and significant morbidity in the adult population.

Time and space revisited: the creation of community in single-handed British general practice

This paper uses data from in-depth interviews with general practitioners in one area of south London to explore how a group of single-handed general practitioners construct space, time and the locality within which they practice. An examination of how ‘community’ is created in the rhetoric of general practitioners suggests some reasons for the continued existence of single-handed practice, despite its heralded demise in Britain.

B.M.A. deputizing service in Sheffield, 1970.

Seventy-four per cent. of Sheffield general practitioners and 78% of those in Nottingham used a deputizing service in 1970. In each city the deputizing service was used by about 80% of single-handed general practitioners, 90% of doctors in two-doctor practices, and 60% of those in partnerships of three or more.The Sheffield deputizing service handled 15,988 new calls in the year, an average of 106 per subscribing doctor, and in addition made 339 revisits. The median number of calls handled for single-handed doctors was 98, for those in two-doctor practices 95, and for those in partnerships of three or more 75. The growth of group practice has not eliminated the demand for deputizing services.Sixty-six per cent. of consultations were with deputies who were primarily hospital doctors, 20% with a full-time deputy, 11% with deputies who were primarily general practitioners, and 3% with the switchboard staff, who were also trained nurses. The deputies had been qualified, on average, for eight years. Seventy-two per cent. of patients attended were seen within one hour of receipt of the call.Calls handled by the deputizing service represented approximately 1% of all the subscribers' consultations, 5% of their home visits, and half their calls between midnight and 07.00 hours. At this level of activity the concept of "personal doctoring" was not threatened.

An appointment system in a practice with immigrant patients.

In the group practice of which I am a partner patients have been seen by appointment for over six years. We adopted an appointment system when the two previously separate parts of the practice joined on 1 January 1962. It was essential to do something of this nature because of the shortage of space in the waiting-room. The premises now used by the group were those originally occupied by a single-handed general practitioner with a list of 1,600 patients. The space available was barely adequate for his needs. We were able to convert two rooms into extra consulting-rooms, so that at any one time three doctors can now consult, but there was no one room bigger than that used as the waiting-room. Unless we had two waiting-spaces, which would have been difficult to administer, we had no alternative but to restrict the number of patients waiting to be seen at any one time. In that the waiting-room, which has seats for only 12 people, has rarely been full to capacity, and patients no longer have to wait in the street outside ; and in spite of there being three doctors,'each seeing up to 12 patients an hour ; and notwithstanding the fact that some patients (children always) come accompanied by at least one relative, the appoint ment system has worked. I have described elsewhere the mechanics of our system of arranging appointments (Carne, 1963). We in our group believe that patients should, whenever possible, have choice of doctor. Even more important, we believe that one doctor should normally treat every member of each family. Most important of all, we aim to arrange our bookings so that each illness episode is dealt with by the same G.P. To assist the recep tionists (we need two working full-time on a shift system plus a full-time secretary) we have colour-coded our appointment cards, and we colour-code the family medical record envelopes where one member of the group deals with their personal problems. A high proportion of the patients in the practice are immi grants (Carne, 1967). Some of the social difficulties, with particular reference to the poverty of their housing, have been described elsewhere (Carne, 1962). It was therefore thought worth while to study the utilization of an appointment system by such patients.