Single-handed Practices Research Articles

Involving South Asian patients in clinical trials.

To investigate how South Asian patients conceptualise the notion of clinical trials and to identify key processes that impact on trial participation and the extent to which communication difficulties, perceptions of risk and attitudes to authority influence these decisions. Also to identify whether 'South Asian' patients are homogeneous in these issues, and which factors differ between different South Asian subgroups and finally how professionals regard the involvement of South Asian patients and their views on strategies to increase participation. A review of the literature on minority ethnic participation in clinical trials was followed by three qualitative interview studies. Interviews were taped and transcribed (and translated if required) and subjected to framework analysis. Face-to-face interviews were conducted with 25 health professionals; 60 South Asian lay people who had not taken part in a trial and 15 South Asian trial participants. Motivations for trial participation were identified as follows: to help society, to improve own health or that of family and friends, out of obligation to the doctor and to increase scientific knowledge. Deterrents were concerns about drug side-effects, busy lifestyles, language, previous bad experiences, mistrust and feelings of not belonging to British society. There was no evidence of antipathy amongst South Asians to the concept of clinical trials and, overall, the younger respondents were more knowledgeable than the older ones. Problems are more likely to be associated with service delivery. Lack of being approached was a common response. Lay-reported factors that might affect South Asian participation in clinical trials include age, language, social class, feeling of not belonging/mistrust, culture and religion. Awareness of clinical trials varied between each group. There are more similarities than differences in attitudes towards clinical trial participation between the South Asian and the general population. Important decisions, such as participation in clinical trials, are likely to be made by those family members who are fluent in English and younger. Social class appears to be more important than ethnicity, and older South Asian people and those from working class backgrounds appear to be more mistrustful. Approachable patients (of the same gender, social class and fluent in English) tend to be 'cherry picked' to clinical trials. This practice was justified because of a lack of time and resources and inadequate support. South Asian patients might be systematically excluded from trials owing to the increased cost and time associated with their inclusion, particularly in relation to the language barrier. Under-representation might also be due to passive exclusion associated with cultural stereotypes. Other characteristics such as gender, age, educational level and social class can also affect trial inclusion. Effective strategies for South Asian recruitment to clinical trials include: using multi-recruitment strategies; defining the demographic and social profiles of the population to be included; using focus groups to identify any potential barriers; consulting representative community members to provide assistance in the study; ensuring eligibility criteria are set as wide as possible; developing educational and recruitment approaches to attract ethnic minority health professionals; ensuring health professionals are adequately trained in culturally and ethnically orientated service provision; determining the most effective mass media to use in study promotion and recruitment; and targeting inner-city, single-handed practices likely to have high ethnic minority populations. Future research should consider: responses when invited to participate; the role of methodological and organisational barriers to recruitment; the complexities of recruitment from a health professional perspective; developing culturally sensitive research methods; the magnitude of the problem of under-recruitment; strategies to encourage inner-city, single-handed GP participation; and other factors affecting trial inclusion, such as age, gender, educational level and socio-cultural background.

A population-based study of primary care predictors of non-attendance for cervical screening.

To identify and estimate the population impact of primary care service delivery factors that independently predict non-attendance for cervical screening. Screening records of all eligible women aged 30 years and over and resident in the former Manchester Health Authority area were analysed (n=72,613). Practice-level and GP-level explanatory variables, along with area-level covariates, were obtained and merged to the study data set. Logistic regression models were used to identify factors associated with having no recorded history of attending NHS cervical screening services. A multivariate model was created to identify independent predictors of non-attendance with comprehensive adjustment for women's age, area-level socio-demographic factors, and other primary care factors. Attributable fraction estimates were used to assess the population impact of the independent predictors. Large practice size (>4,000 patients), single-handed practice, South Asian male GP, part-time GP employment status, older age and birthplace overseas, and area-level measures of deprivation and transience independently predicted non-attendance. Women born overseas and registered at larger practices were especially unlikely to have ever attended. The combined population attributable fraction estimate for the independent predictors reflecting primary care service delivery was almost 40%, and that for all variables in the final model was over 70%. Independent predictors of non-attendance reflecting general practice structure, workload and GP characteristics were identified. Although relative risks were modest, the collective population impact of these factors was considerable, which has implications for the implementation of informed targeting and the development of new screening services by Primary Care Trusts.

Availability and structure of primary medical care services and population health and health care indicators in England.

BackgroundIt has been proposed that greater availability of primary medical care practitioners (GPs) contributes to better population health. We evaluated whether measures of the supply and structure of primary medical services are associated with health and health care indicators after adjusting for confounding.MethodsData for the supply and structure of primary medical services and the characteristics of registered patients were analysed for 99 health authorities in England in 1999. Health and health care indicators as dependent variables included standardised mortality ratios (SMR), standardised hospital admission rates, and conceptions under the age of 18 years. Linear regression analyses were adjusted for Townsend score, proportion of ethnic minorities and proportion of social class IV/ V.ResultsHigher proportions of registered rural patients and patients ≥ 75 years were associated with lower Townsend deprivation scores, with larger partnership sizes and with better health outcomes. A unit increase in partnership size was associated with a 4.2 (95% confidence interval 1.7 to 6.7) unit decrease in SMR for all-cause mortality at 15–64 years (P = 0.001). A 10% increase in single-handed practices was associated with a 1.5 (0.2 to 2.9) unit increase in SMR (P = 0.027). After additional adjustment for percent of rural and elderly patients, partnership size and proportion of single-handed practices, GP supply was not associated with SMR (-2.8, -6.9 to 1.3, P = 0.183).ConclusionsAfter adjusting for confounding with health needs of populations, mortality is weakly associated with the degree of organisation of practices as represented by the partnership size but not with the supply of GPs.

Trends in prescribing antibiotics for children in Dutch general practice.

To assess changes in antibiotic prescribing patterns for children between 1987 and 2001, and to identify general practice characteristics associated with higher antibiotic prescribing rates. Cross-sectional national survey of Dutch general practice in 1987 and 2001. Data were used for all children aged 0-17 years; 86 577 children in 103 participating practices in 1987, and 76 010 children in 90 participating practices in 2001. Population-based, contact-based and disease-based antibiotic prescription rates were evaluated by age, gender and diagnosis. Practice characteristics associated with inappropriate broad-spectrum antibiotic prescription were identified. Population-based prescription rates decreased from 300/1000 children (95% CI, 292-307) in 1987 to 232/1000 children in 2001 (95% CI, 228-235). In 1987, the contact-based prescription rate was 108/1000 contacts (95% CI, 106-111) and this was somewhat similar in 2001: 103/1000 contacts (95% CI, 101-105). In 2001, increased disease-based prescription rates were observed for acute otitis media, acute bronchitis, acute upper airway infections, acute tonsillitis and cough. Overall, non-recommended broad-spectrum antibiotics were prescribed more often in 2001 than in 1987 (87% in 1987 versus 90% in 2001, P < 0.001). Adjusted for other practice characteristics, general practitioners in single-handed practices prescribed 58% more broad-spectrum antibiotics inappropriately for upper airway infections than general practitioners in group practices. Antibiotic prescribing in children is still relatively low in the Netherlands. However, the prescription of broad-spectrum antibiotics for inappropriate diagnoses has increased, an unfavourable trend given the emerging bacterial resistance. Single-handed practices should especially be targeted to improve antibiotic prescribing in children.

Diabetes service provision in primary care: a baseline survey in a city primary care trust (PCT)

AbstractPrimary care trusts (PCTs) are a key plank of the modernisation of the NHS in the UK. They have a unique role in the commissioning and provision of services to local communities. A baseline assessment of diabetes service provision in primary care is vital in establishing current levels of service and in developing service models relevant to local populations. We have developed and evaluated an audit tool to baseline diabetes services in primary care. We used this tool in the Eastern Leicester PCT which serves a population of 180 000 with a high South Asian population, estimated to be around 50%. This PCT has a high number of single‐handed general practices serving a deprived population. The survey was undertaken using direct interviewing of key members of the primary health care team, using a semi‐structured interview lasting for around an hour. All practices in the PCT were involved. The results of this survey highlighted major deficiencies in current services, e.g. only 10% of the practices had a structured plan for providing education for people with diabetes. It also demonstrated how regional estimates of the prevalence of diabetes in the UK may seriously underestimate the ‘true’ prevalence in some localities. This study highlights the uphill task many PCTs will face in terms of meeting the national service framework standards and providing basic elements of diabetes care. Copyright © 2004 John Wiley &amp; Sons, Ltd.

Acupuncture in patients with valvular heart disease and prosthetic valves.

Endocarditis has been reported in patients with valvular heart disease who have undergone acupuncture treatment, although most have been associated with the use of semi-permanent needles. This has led reviewers to suggest that acupuncture may not only be contraindicated in such patients but that prophylactic antibiotics should be given. This study investigated the use of acupuncture treatment in patients with proven valvular heart disease and observed whether endocarditis developed in such patients. All patients in a single-handed GP practice with proven valvular heart disease, including those with prosthetic valves, were identified over a ten-year period. Those who had undergone acupuncture treatment underwent a clinical examination and diagnostic tests, which focused on the signs, symptoms and laboratory criteria for the diagnosis of endocarditis and included a transthoracic echocardiogram. Autopsy findings were reviewed in any patient who died. Based on these clinical and laboratory data, using the modified Duke's criteria for the diagnosis of endocarditis, patients were identified as having definite or possible endocarditis, or the diagnosis was rejected. All patients underwent brief acupuncture with no skin disinfectant and no prophylactic antibiotics were given. Semi-permanent needles were avoided. Thirty-six patients with valvular heart disease underwent a total of 479 acupuncture treatments over a ten-year period. The median number of treatments was 9 (range 1-72), with a follow-up after treatment of 5.75 years (range 0.5-10 years). Definite endocarditis was not found in any patient, but two patients had possible endocarditis, eventually discounted by both negative blood cultures and echocardiography. In conclusion, brief acupuncture was safe in this small cohort of valvular heart disease patients and no case of endocarditis was detected over a ten-year period.

Morbidity, deprivation and drug prescribing: factors affecting variations in prescribing between doctors’ practices

Analyses are reported of the prescribing quality and behaviour of 131 doctors’ practices in a South Wales health authority during the first quarter of 1997. Prescribing of specific groups of drugs are examined, namely antidepressants; bronchodilators and inhaled corticosteroids for treating asthma; and oral antidiabetics and insulin for diabetes. It is hypothesised that the volumes and costs of prescriptions are determined by the characteristics of both doctors/practices (number and age of doctors; training and fundholding status of practices; single-handed practices and doctors per patient) and their patients (age; gender; ethnicity; deprivation). The health authority's population is characterised by substantial inequalities in wealth and health. Statistical analyses reveal the consistent influence of deprivation on prescribing costs and volumes, with the exception of items of insulin. Supply factors exert more selective influences. Thus, the number of doctors per practice and per patient has a positive influence on antidepressant prescribing; fundholding status is associated with lower costs for bronchodilator prescribing; and older doctors tend to prescribe more bronchodilators and oral antidiabetics. Residuals from the statistical analyses suggest further systematic influences, notably advice from hospital consultants, as well as more localised and less consistent effects.

Neurogenic Pruritus: Treatment by Acupuncture

Introduction Notalgia paraesthetica is a condition associated with itching, and unassociated with a rash, that affects a segment of the body innervated by T2-T6 dorsal spinal nerves. It is believed to be a type of neuropathy. This single-handed practice reports one such case. It also describes a further eight cases of “neurogenic” pruritus which share similar characteristics to this condition but are in segments of the body innervated by cervical and lumbar spinal nerves. Traditional acupuncture has been described to help with skin conditions and this study was performed to see if it was successful in this type of pruritus. Patients and Methods Over a nine-year period in a practice with an average list size of 2000 patients, nine patients aged 41 to 79 years presenting with segmental itching were identified. Other causes of pruritus were excluded by clinical examination, as well as by haematological and biochemical tests. Drug induced causes were also excluded. Duration of pruritus was six weeks (range 4 – 52 weeks). In eight patients itching was restricted to dermatomes innervated by the spinal nerves of the cervical spine, in two by the dorsal spine and in two by the lumbar spine. In three patients pruritus occurred in dermatomes innervated by two separate areas of the spine. Clinical examination revealed restricted cervical or lumbar movements in seven patients. Paravertebral tenderness and/or spasm of the paravertebral muscles was found in the areas of pruritus in seven patients. Skin changes associated with sympathetic nerve over-activity were noted in five patients. Six of the nine patients had x-ray evidence of degeneration of the spine. Results All nine patients were treated by deep intramuscular stimulation of the paravertebral muscles in the dermatomes affected by pruritus. In total a median of three treatments (range 2 – 5) was required to resolve the pruritus. Recurrence of symptoms occurred in four patients within 8 to 12 months of their last treatment over a period of follow-up of 0.5 – 9 years (median one year). Repeat acupuncture treatment resolved the pruritus. Discussion The term neurogenic pruritus describes and encompasses all conditions associated with segmental itching unassociated with a rash. The clinical signs of this condition are suggestive of an early neuropathy as a result of a degenerative condition of the spine. This is the first report of symptoms of such a condition being treated successfully by acupuncture.

Diabetes UK funded surveys of the structural provision of primary care diabetes services in the UK.

To describe diabetes service provision in primary care in the UK. Postal questionnaires were sent to all UK primary care organizations (PCOs), and to a sample of general practices in England and all practices in Wales and Scotland. The data collection period ended on 30 April 2001. Seventy-nine per cent of the PCOs and 40% of the practices provided usable information. There is evidence that respondents were not significantly biased in relation to their interest in diabetes care. Diabetes was included as a Health Improvement Programme (or equivalent) priority by 62% of PCOs and had been identified as a clinical governance priority by 27%. Sixty-five per cent had information about the ethnic composition of their general population, 57% had an estimate of the number of people with diabetes. Sixty-nine per cent had a local diabetes register but this was said to cover the entire local population in only 64% of these. At least one audit of diabetes care had been carried out (in the previous 5 years) in 75% and, in 76%, clinical guidelines on diabetes care were made available to practices. In the practices, 80% had a designated lead person for diabetes. Seventy-three per cent had at least one general practitioner with a special interest and 87% at least one nurse. Seventy-two per cent of practices ran specific diabetes clinics and 51% had a screening policy. Eighty-six per cent considered that they had adequate systems in place for the delivery of diabetes care. However, only 6% were able to offer a dedicated diabetes telephone help or advice line and only 9% an evening out of hours clinic. Regular practice meetings were held to discuss diabetes in 35%, whereas 39% had a formal shared care protocol. Fourteen per cent held regular joint meetings with the hospital-based team and in 38% there was membership of Diabetes UK for at least one partner or the practice itself. A third (34%) of responding practices were unsure whether a Local Diabetes Services Advisory Group or equivalent existed in their area. Geographical differences in service provision were identified with, for example, practices in London having fewer components in place that were specifically related to the provision of diabetes care. Single-handed practices, wherever they were situated, had in place fewer staff and facilities specifically for diabetes care.

Professional development for general practitioners through fellowship by assessment.

The Royal College of General Practitioners has designed its Fellowship by Assessment (FBA) programme with the twin goals of promoting higher standards of care and offering GPs a professional challenge. By November 2000, 223 eligible doctors (2%) had opted to take FBA. This number is increasing annually. There is, however, little research to account for why GPs undertake it, or what the barriers might be. The aim of our study was to investigate GPs' experience and thinking on this issue. A total of 13 GPs who had attained Fellowship by Assessment in the Tamar and Severn Faculties were invited to participate in a qualitative study. They were identified from the list of RCGP Fellows in the Institute of General Practice, University of Exeter, and purposefully selected to include trainers and non-trainers, men and women, rural and urban practitioners, and single-handed and large practices. Analysis of in-depth interviews was informed by grounded theory. FBA served to acknowledge high standards of care. There was some variation in views about FBA, however, ranging from a perspective which prized the professional award, to the view that endorsed it as a pragmatic and useful way of structuring and monitoring improvements. Fellowship by Assessment improves the care of patients and empowers the doctors by improving their confidence. It is, however, hugely time-consuming and while our findings suggest it should be encouraged, there is a need for ways to be found whereby doctors may be supported in this form of professional development.

Evaluation of Single-handed Practice of Physiotherapists and Podiatrists

Results Twenty-three students participated (intakes 1997, 98, 99) yielding 181 valid data sets: inpatients 58%, day hospital 36%, domiciliary 18%, residential/nursing home 13%, the rest outpatients or accident and emergency. Patients’ mean age was 82 years (SD 7), range 64 to 100. Single sticks were the most common aid 45%; four-point support including wheeled models 43%; the rest used two sticks, two crutches, and a tripod. According to the patients’ responses and the therapists’ opinions the main reasons were pain 11%, justifiable postural instability 44%, anxiety and lack of confidence 32%. Additionally 8% had been told to use an aid and had never been re-assessed. Clinicians’ apparent reluctance to probe led to poverty of data and sometimes made interpretation difficult. Other issues suggested in the data were healthcare professionals’ need for collective responsibility to pro-actively review patients’ use of walking aids, and a health promotion need to encourage older people to take professional advice before starting to use a walking aid.

Do single handed practices offer poorer care? Cross sectional survey of processes and outcomes

Objectives: To determine whether there are important differences in performance between group practices and singlehanded general practitioners and the extent to which any differences are explained by practice characteristics such...

Views of Irish general practitioners on screening for cervical cancer.

A national cervical screening programme is being established in Ireland and there is little information on the level of resources required. To obtain information on attitudes of Irish general practitioners (GPs) and on the resources needed by them in relation to participation in the programme. An anonymous postal questionnaire was sent to a random sample of 600 GPs, approximately 25% of the total population of GPs in Ireland. A response rate of 87.5% was obtained. The majority (88%) would participate in a national programme. Those who would not were more likely to be in single-handed practice, aged over 44 years, have no ancillary staff, no computer and be in rural practice. GPs were in favour of a special fee for smear taking, a training programme and management guidelines on the test report. They did not want bonus payments for achieving targets or the report to be sent to the client as well as the doctor. GPs will support a national cervical screening programme but a number of organisational issues must be discussed with them to ensure a successful programme.

An audit of acupuncture in a single-handed general practice over one year.

An audit was performed over one year on all patients undergoing acupuncture for a variety of conditions in a single-handed GP practice. The patients were observed for a further year to assess the effectiveness and duration of the treatment effect. Using the 'measure yourself medical outcome profile' (MYMOP) questionnaire, the effectiveness of acupuncture treatment was measured, and patients were categorised into no effect, improved or much improved. A total of 140 patients were audited over the one-year period. No effect was seen in 31% of patients, a further 31% were improved, and 38% were much improved. Those with a shorter duration of symptoms appeared to show the most benefit. During the one-year post-treatment observation period 50% of patients required further treatment. In conclusion, acupuncture appears to have been an effective treatment in the author's General Practice population. In this audit acupuncture seems to have had a short duration of effect. It is believed that this has lead to an increase in workload, not only as a result of patient demand, but also due to recurrence of symptoms following the initial success of treatment.

General practitioner services in primary care groups in England: is there inequity between service availability and population need?

This study examined the coverage of minor surgery, child health surveillance and chronic disease management for asthma and diabetes in relation to population need and key organisational features of general practice in the 481 primary care groups (PCGs) in England. PCG-level summary scores were developed to estimate the relative availability of all four services and their relative importance in discriminating between high and low levels of service provision. The coverage of services was widespread and, in such circumstances, there was no systematic evidence of poorer service availability for PCGs with higher population need (the ‘inverse care’ law). Rather this relation was localised, being most predominant for PCGs covering London and its suburbs. In these PCGs, there was no association between indicators of lack of capacity, such as single-handed practice, and levels of service provision.

Trends in primary care antibiotic prescribing in England 1994–1998

To investigate the changing decisions to prescribe antibiotics as manifest in the patterns of prescriptions dispensed in England, and to investigate antibiotic prescribing in different types of practice. Antibiotic prescribing data and practice characteristics collected for every practice in England for the years 1994/5-1997/8. Morbidity data for common infections was also obtained from published sources. Antibiotic prescribing was related to practice characteristics, with high prescribing in deprived and single-handed practices in particular. There was a fall in antibiotic prescribing in all types of practice of practice over the period of the study. Morbidity data from other sources shows a fall in diagnosed morbidity from some infectious diseases over the same period. There were no differences in choice of antibiotic in different types of practice. The fall in antibiotic prescribing is universal across all kinds of practices and is possibly related to the fall in diagnoses. It is uncertain whether this reflects true morbidity.

Supporting GPs whose performance gives cause for concern: the North Trent experience.

The North Trent scheme to address the problem of GPs whose performance gives cause for concern was implemented in 1997. This paper describes the structure and process of the scheme and evaluates the main outcomes. We used non-participant observation and semi-structured interviews with representatives of the seven Health Authorities (HAs) of North Trent including medical and prescribing advisors and senior primary care managers. Twenty-one GPs who were members of the Performance Review Quartets (PRQs) were also interviewed. Qualitative data were analysed using a constant comparative method to identify emergent themes. Performance indicators were agreed between HAs and the profession in the seven North Trent localities. The scheme identified 18 GPs whose performance gave cause for concern, of whom 15 GPs in six practices received a formal visit. Educational plans were agreed and implemented with three GPs. The remaining 12 received administrative and clinical support. Three of the 18 GPs initially refused to co-operate with the scheme. Two of these have since agreed a practice visit following a visit by a senior local medical committee representative. The performance indicators used in the scheme have not been specific to individual GPs except those in single-handed practices. Some indicators used by PRQs related to cost effectiveness rather than quality of care for individual patients. Current resources were adequate for the small number of underperforming GPs identified by the scheme. The North Trent scheme has identified a number of underperforming GPs, 83% of whom have been willing to participate in a supportive intervention. The scheme will need some modification with the advent of primary care trusts and the proposed assessment and support centres.

Primary Care and Mental Health

Change and continuity The rate of change in primary care has never been so fast. And yet in some essential themes, continuity stretches back even beyond Bevan. Witness recent patients’ associations’ responses to the NHS National Plan (Department of Health, 2000a) which, in common with many ‘listening exercises’ (eg Department of Health, 1996), have stressed the crucial importance to individuals and families of the GP consultation. We know from mental health service users that they share those priorities. Witness also the National Plan’s concerns regarding single-handed practice: again, rightly or wrongly, continuing a line of dialogue that stretches back some considerable time. While some fundamentals remain consistent, primary care services are changing at a dramatic rate. For professionals and managers working in mental health services much of this change may be invisible and sometimes it is alarming. Despite real willingness in some areas to work together, frequently we see a ‘culture gap’ between those people working in mental health and those in primary care. This may raise obstacles to collaboration, and lead to misunderstandings. ‘Registers’, ‘urgent’, and ‘patient’ are all words that can carry quite different meanings, associations and values for primary care and mental health professionals. New primary care organisations, PCGs and primary care teams (PCTs), may, as they become engaged with the mental health agenda, offer a way into energetic and focused dialogue that will start to close that culture gap. But most are working flat out, with minimal infrastructure, across the widest gamut of clinical and organisational issues, so we can’t expect a quick miracle! But perhaps awareness of some of the key change themes in primary care may help to facilitate understanding. General practice itself is changing and many practitioners in primary care are raising fundamental questions about its role. General practice care becomes ever more organised and, while opportunistically using demand-led consultations to achieve a range of health care targets, remains a key skill. Structured, proactive care is increasingly promoted. Thus the National Service Framework for coronary heart disease (CHD) requires that GPs establish registers of diagnosed patients and effective call and recall systems, and that they work to guidelines ensuring that appropriate advice and interventions are offered wherever needed (Department of Health, 2000b). The Framework for CHD illustrates another pertinent point – the increasing importance of the ‘team’ and the consequent growing role of GPs in managing and supervising care rather than providing it. In CHD, in many parts of the country, additional funding is allowing practice nurses and nurse practitioners to play an important role in developing basic care and more sophisticated multi-practice cardiac prevention clinics, working to agreed protocols with medical support. Similarly, some of the earlier Total Purchasing Pilots (TPPs) developed multidisciplinary interagency care-planning mechanisms for older people, carrying the concept of ‘team’ one stage further, and bringing it into practices. These examples suggest that we need to think carefully about the extra resources general practice may need to develop structured mental health care

Single-handed practices--their contribution to an undergraduate teaching network in the first year of the new curriculum.

The new curriculum at King's College School of Medicine and Dentistry, which commenced in September 1996, requires all medical undergraduates to have a general practice placement throughout the 5 years of their medical education. This paper discusses recruitment, training and support of teaching practices for the new curriculum, reviews the distribution of single-handed general practices in the network and, via a selection of monitoring and evaluation procedures, discusses the implications of a policy which is inclusive of single-handed practices. The findings relate to the experience of the first semester of the first year of the new curriculum. It also examines the contributions that single-handed practices have made to the teaching network and the kind of support needed, if single-handed practices are to continue to contribute to the King's teaching network. King's College School of Medicine and Dentistry. Medical undergraduates. The findings of this paper revealed that over a third of general practice provision is via single-handed practices in South-east London. Within the undergraduate teaching network, 10% of practices are single-handed. Students are welcomed and receive a learning experience comparable to those students in larger practices. Attendance at training events has proved difficult for some of these tutors, but the extra input from the department, in order to address this deficit, has not been onerous. Indeed, single-handed practices have not been unique with regard to difficulties in attendance at training events. The study concludes that single-handed practices can make satisfactory provision for undergraduates in the new curriculum and there is no evidence from this study to suggest otherwise.

The association of some practice characteristics with antibiotic prescribing.

Antibiotic prescribing in general practice is often considered inappropriate, and its volume excessive. Considerable variation in antibiotic prescribing volume and costs exists among practices. To investigate some factors behind the variation in antibiotic prescribing among general practices, by examining the contribution to this variation of the level of deprivation in the practice population, training status, partnership status, and fundholding status. Analysis of prescribing data (PACT) from 351 practices in the Mersey region for the year ending March 1991 and the year ending March 1994; prescribing data standardized for variation in practice population demography. Use of multiple linear regressions to investigate the variation among practices in standardized prescribing volume and standardized prescribing costs, in both years. Level of deprivation, training status and partnership status contributed to the models explaining variation in prescribing volume. The same variables contributed to the model explaining variation in prescribing costs in the year ending March 1991. For the year ending March 1994, level of deprivation, training status, and fundholding status contributed to all models. Higher levels of antibiotic prescribing occur in practices serving more deprived communities, in single-handed practices, and in non-training practices. These higher levels of prescribing may be due to higher levels of morbidity, but may also reflect the organization and attitudes of these practices.