Nurses and nursing in primary medical care in England.
In 1974 we sent questionnaires on attachment and employment of nurses to 9214 general practices in England. There were 7863 replies (85%), of which 551 were excluded from the study. A total of 2654 nurses were directly employed by 24% (1774) of the practices, and 68% (4972) had attached nurses. Practices in health centres were larger and had greater nursing resources than those in other premises. We suggest that practices may employ nurses to compensate for ineffective nursing attachments, and we conclude that general-practice-employed nurses are becoming "professionalised". (+info
Randomised controlled trial of effect of feedback on general practitioners' prescribing in Australia.
OBJECTIVE: To evaluate the effect on general practitioners' prescribing of feedback on their levels of prescribing. DESIGN: Randomised controlled trial. SETTING: General practice in rural Australia. PARTICIPANTS: 2440 full time recognised general practitioners practising in non-urban areas. INTERVENTION: Two sets of graphical displays (6 months apart) of their prescribing rates for 2 years, relative to those of their peers, were posted to participants. Data were provided for five main drug groups and were accompanied by educational newsletters. The control group received no information on their prescribing. MAIN OUTCOME MEASURES: Prescribing rates in the intervention and control groups for the five main drug groups, total prescribing and potential substitute prescribing and ordering before and after the interventions. RESULTS: The intervention and control groups had similar baseline characteristics (age, sex, patient mix, practices). Median prescribing rates for the two groups were almost identical before and after the interventions. Any changes in prescribing observed in the intervention group were also seen in the control group. There was no evidence that feedback reduced the variability in prescribing nor did it differentially affect the very high or very low prescribers. CONCLUSIONS: The form of feedback evaluated here-mailed, unsolicited, centralised, government sponsored, and based on aggregate data-had no impact on the prescribing levels of general practitioners. (+info
Computer use by general practitioners in Scotland.
BACKGROUND: Despite the widespread adoption by general practitioners (GPs) of desktop computers, there has been very little evaluation of the way in which the computer is actually used during consultations and the way in which it affects patient satisfaction. AIM: To ascertain the extent to which the computer is used in the consultation and to investigate the possible relationship between computer use and patient satisfaction. METHOD: Six GPs completed a short questionnaire about the extent to which they use the computer during surgeries. Eighty-four consultations from the surgeries of these GPs were video recorded. Patient satisfaction data on these 84 patients were collected at the time of the surgery using the previously validated Consultation Satisfaction Questionnaire. RESULTS: All six GPs stated that they usually used the computer during consultations. However, video observation revealed that the computer was used in just 51% of surgeries. The proportion of time that the computer was used for varied from 0.03 to 0.4, with a mean value of 0.12. The commonest function for which the computer was used was prescribing. The consultations in which the computer was used (CU) were on average 148 seconds longer than the non-computerized consultations (NCU). There was no difference in patient satisfaction between the two groups. CONCLUSION: Despite this group of GPs having a self-declared interest in the use of computers, the extent to which the computer was used was much lower than expected from the GPs' self-reported use. This may be partly explained by the fact that using the computer takes up valuable time within the consultation and does not appear to contribute to patient satisfaction. If desktop computers are to be used to their full potential in general practice, more work is required to evaluate their impact on the consultation process itself. (+info
Relationship between practice counselling and referral to outpatient psychiatry and clinical psychology.
BACKGROUND: Although reduction in the use of secondary care mental health services is a suggested benefit of counselling in general practice, there has been little empirical investigation of this relationship. AIM: To investigate the relationship between the provision of counselling in general practice and the use of outpatient psychiatry and clinical psychology services across a geographical area. METHOD: Information on referrals to outpatient psychiatry and clinical psychology from all general practices in the London Borough of Islington over one year (October 1993 to September 1994) was collected from the routine information systems of the main hospital departments serving this area. Referral rates per 1000 practice population were compared for practices with and without a practice-based counsellor. RESULTS: Fifteen (35%) of the 43 practices had a counsellor based in the practice. The median referral rate to clinical psychology was higher in practices with a counsellor (4.1 per 1000) than in practices without a counsellor (0.8 per 1000). There was no relationship between the provision of practice counselling and median referral rates to outpatient psychiatry (1.8 per 1000 with a counsellor, 1.7 per 1000 without a counsellor). CONCLUSION: Provision of practice counselling in the study was associated with higher referral rates to clinical psychology and no difference in referral rates to outpatient psychiatry. This is in contrast to the hypothesis that counselling reduces the use of secondary care mental health services. (+info
Why do dyspeptic patients over the age of 50 consult their general practitioner? A qualitative investigation of health beliefs relating to dyspepsia.
BACKGROUND: The prognosis of late-diagnosed gastric cancer is poor, yet less than half of dyspeptic patients consult their general practitioner (GP). AIM: To construct an explanatory model of the decision to consult with dyspepsia in older patients. METHOD: A total of 75 patients over the age of 50 years who had consulted with dyspepsia at one of two inner city general practices were invited to an in-depth interview. The interviews were taped, transcribed, and analysed using the computer software NUD.IST, according to the principles of grounded theory. RESULTS: Altogether, 31 interviews were conducted. The perceived threat of cancer and the need for reassurance were key influences on the decision to consult. Cues such as a change in symptoms were important in prompting a re-evaluation of the likely cause. Personal vulnerability to serious illness was often mentioned in the context of family or friends' experience, but tempered by an individual's life expectations. CONCLUSION: Most patients who had delayed consultation put their symptoms down to 'old age' or 'spicy food'. However, a significant minority were fatalistic, suspecting the worst but fearing medical interventions. (+info
A single-blind, placebo-controlled trial of a simple acupuncture treatment in the cessation of smoking.
BACKGROUND: Tobacco smoking is a major cause of preventable disease and premature death. Physicians should play an active role in the control of smoking by encouraging cessation and helping the smoker to choose the most suitable aid to cessation. AIM: To evaluate a simple, ear acupuncture treatment for the cessation of smoking. METHOD: Randomized, single-blind, placebo-controlled trial of 78 currently smoking volunteers from the general public. Volunteers attended an acupuncture clinic in a general practice setting and were given a single treatment of electroacupuncture using two needles at either an active or a placebo site plus self-retained ear seeds for two weeks. The major outcome measure was biochemically validated total cessation of smoking at six months. RESULTS: A total of 12.5% of the active treatment group compared with 0% of the placebo group ceased smoking at six months (P = 0.055, 95% confidence interval -0.033 to 0.323). CONCLUSION: This simple ear electroacupuncture treatment was significantly more effective in helping volunteers to quit smoking than placebo treatment. (+info
Out-of-hours service in Denmark: the effect of a structural change.
BACKGROUND: In Denmark, the provision of out-of-hours care by general practitioners (GPs) was reformed at the start of 1992. Rota systems were replaced locally by county-based services. The new out-of-hours service resulted in a considerable reduction in the total number of GPs on call. AIM: To describe how the patients experienced the change from a satisfaction point of view, and how the pattern of patient contact and the fee for GPs changed with the new system. METHOD: The county of Funen was chosen as the geographical area where data were collected. A questionnaire measuring patient satisfaction was posted before the change, immediately after the change, and three years later to a random selection of patients who had been in contact with the out-of-hours service within two weeks before the mailing date. All primary care services for the Danish population are stored in a database (National Health Service Registry). From this continuously updated database, the contact pattern and the fee for GPs were extracted for 1991, 1992, and 1995. RESULTS: The total number of patient contacts was reduced by 16% in the first year, but by only 6% three years later. Three years after the change, there were more than twice as many telephone consultations as before the change, and there were only a third as many home visits. After three years, the GPs' fees were reduced by 20%. There was a significant decrease in patient satisfaction, although the overall level remained high. This decrease was lower three years after the change than immediately after the new system was introduced. CONCLUSION: The new service had a major cost-effectiveness benefit, but there was a price to pay in patient satisfaction. (+info
Health at work in the general practice.
BACKGROUND: Poor mental health and high stress levels have been reported in staff working in general practice. Little is known about how practices are tackling these and other issues of health at work in the absence of an established occupational healthcare service. AIM: To establish the extent of knowledge and good practice of health at work policies for staff working in general practice. METHOD: Practice managers in 450 randomly selected general practices in England were interviewed by telephone, and the general practitioner (GP) with lead responsibility for workplace health in the same practice was surveyed by postal questionnaire. We surveyed the existence and implementation of practice policies, causes and effects of stress on practice staff, and agreement between practice managers and GPs on these issues. RESULTS: Seventy-one per cent of GPs and 76% of practice managers responded, with at least one reply from 408 (91%) practices and responses from both the practice manager and GPs from 252 (56%) practices. Seventy-nine per cent of practices had a policy on monitoring risks and hazards. The proportion of practices with other workplace health policies ranged from 21% (policy to minimize stress) to 91% (policy on staff smoking). There was a tendency for practices to have policies but not to implement them. The three causes of stress for practice staff most commonly cites by both GP and practice manager responders were 'patient demands', 'too much work', and 'patient abuse/aggression'. Sixty-five per cent of GPs felt that stress had caused mistakes in their practices. Although there was general agreement between the two groups, there was a considerable lack of agreement between responders working in the same practices. CONCLUSIONS: The study revealed substantial neglect of workplace health issues with many practices falling foul of health and safety legislation. This report should help general practices identify issues to tackle to improve their workplace health, and the Health at Work in the NHS project to focus on areas where their targeted help will be most worthwhile. (+info