Bereavement care in general practice: a survey in South Thames Health Region

BACKGROUND: Studies have shown that bereaved individuals suffer increased rates of physical and mental ill health. Bereavement support has recently been advocated as an area of prevention in primary care, with suggestions that general practitioners (GPs) should adopt protocols for the active follow-up of their bereaved patients, which relies on the early notification of deaths by hospitals and hospices. Little is known about the routine care currently provided by GPs and primary health care teams (PHCTs) to support their bereaved patients. AIMS: To explore GPs' perceptions of patient death notifications by hospitals and hospices. To describe practice policies relating to patient deaths and the provision of bereavement support. METHOD: Postal questionnaires were sent to senior partners of a random sample of 500 general practices in South Thames Health Region. RESULTS: Three hundred and fifty-three practitioners responded (71%). Hospitals were perceived to be significantly slower than hospices in notifying deaths (P < 0.0001). One hundred and ninety-six practices (56%) kept death registers, 230 (65%) discussed deaths together, and 142 (40%) identified bereaved relatives. One hundred and thirty-seven practices (39%) routinely offered bereaved relatives contact with a PHCT member; while 133 (38%) supported only those who asked for help. Routine support was significantly more likely to be provided by practices that kept a death register, discussed deaths together, identified bereaved relatives, and had a special interest in palliative care. CONCLUSIONS: GPs perceive hospitals to be slower than hospices at notifying deaths, particularly in the first 24 hours. They are divided over whether bereavement support should be proactive or reactive. Keeping a practice death register, discussing deaths together, and identifying newly bereaved relatives are activities related to providing routine bereavement care.     

The role of the triage nurse practitioner in general medical practice: an analysis of the role

A 2-year pilot study was undertaken in a group general practice to evaluate the nurse practitioner triage role. The study was undertaken in several stages which included a patient satisfaction questionnaire survey, follow-up interviews with 30 patients from the questionnaire survey, and analysis of the nurse practitioner's work at different points over the 2-year study period. This paper describes the work of the nurse practitioner in comparison with that of seven general practitioners in a group general medical practice over a 5-day period in February 1996 and included patients' perceptions of their consultation. In this particular group medical practice, as in others throughout the country, many patients request same day appointments, often for self-limiting conditions, social advice and health education. This study demonstrates that the nurse practitioner can deal with such patients effectively and is undertaking an expanded and extended role in order to provide an holistic service to patients with which they are highly satisfied. It can be concluded that given the right kind of education and training and a supportive framework within the practice, the nurse practitioner undertaking a triage role can provide a highly effective service to patients and is a valuable member of the primary health care team.     

The general practitioner's role in breast cancer screening: a survey in Otago-Southland

AIMS: To study the experience of general practitioners in Otago and Southland with the existing breast cancer screening programme and the reviews on future programmes. METHODS: A questionnaire was sent to all 210 general practitioners in Otago and Southland in June 1996. RESULTS: The response rate was 71%. All the 141 respondents except one encouraged eligible women to take part in the programme; this was done mainly during individual doctor-patient consultations, by pamphlets and posters, and in the work of the practice nurse. Ten percent of practitioners had a practice-based recall system for breast cancer screening. Seventy-five percent of general practitioners currently provide a list of eligible women to the programme, and of these, 52% check the list to exclude ineligible women. Only 24% of practitioners supplying a patient list to the programme reported that a patient had ever requested that their name be excluded from the list. Twenty-five percent of general practitioners providing lists had a notice in the waiting room stating that. Of those who did not provide lists, concerns about logistics, ethical issues and cost were raised, although 40% of these general practitioners intended to provide lists in the future. In a future programme, 57% of general practitioners felt they should be paid for supplying lists defined by age only and 82% felt they should be paid for supplying a list of women eligible by both age and medical history. Most general practitioners felt that general practitioner lists were the preferred source for invitations to the breast screening programme and that general practitioners had an important part in any future programme. Screening at the ages 50-64 (as currently proposed) is supported by 95% of general practitioners; in addition, 64% supported screening at ages 65-69. Only a minority of general practitioners supported screening at ages 40-49 or ages 70-74. Most general practitioners would offer screening to women under age 50 with either a strong or a weak family history, or even with a past history of a fibroadenoma. CONCLUSIONS: These results show that almost all general practitioners support breast cancer screening programmes and feel that they have an important role in future programmes. The majority support extension of the programme to ages 65-69, but not to ages 40-49. The majority support screening women with individual risk factors at ages under 50, although their responses show that better information on the importance of different risk factors is required.     

Empowering GPs as purchasers

FHSAs have defined their role in purchasing primary care FHSAs have also found themselves intermediaries between district health authorities and general practitioners All of the purchasing authorities recognise the need to educate general practitioners on how to use their influence in the purchasing process General practitioners should be involved in the purchasing process as they purchase the bulk of health care; are the first point of contact for the users of the health service; need to have input on what is purchased; and need to be able to manage the changes resulting from the shift in the balance of power towards primary care The involvement of general practitioners in the purchasing process at present varies considerably among health authorities. Several district health authorities have developed models of purchasing that enable different levels of involvement     

Emphasizing terminal care as district nursing work: a helpful strategy in a purchasing environment?

This paper describes how within a study on the experiences of district nurses since the introduction of general practitioner purchasing, participants were encouraged to describe and define the district nursing service. The identification of terminal care by district nurses and others as a significant and defining example of district nursing work is explored and the possible reasons for its emphasis over other aspects of patient care. The extent to which terminal care was used within contract and purchasing discussions to aid general practitioner understanding of district nursing work and achieve extra funding is described. The paper concludes by questioning the extent to which terminal care is a helpful and accurate representation of what district nursing work entails, and the implications there may be in emphasizing one aspect of care within a purchasing environment.     

The impact on general practitioners of the changing balance of care for elderly people living in institutions

OBJECTIVES: To describe utilisation of general practitioners by elderly people resident in communal establishments; to examine variations in general practitioner utilisation and estimate the likely impact of the "downsizing" of long stay provision in NHS hospitals. DESIGN: Secondary analyses of the survey of disability among adults in communal establishments conducted by the Office of Population Censuses and Surveys in 1986, and projection to present day. SETTING: Nationally representative sample of communal establishments in Great Britain. SUBJECTS: Disabled residents aged 65 or more without mental handicap. RESULTS: Residents with higher levels of disability, disorders of the digestive system, resident in smaller local authority homes or larger voluntary residential homes were more likely to consult a general practitioner. For those who consulted, higher levels of disability and morbidity and residence in a private nursing home or a larger private residential home were all associated with greater general practitioner utilisation. Overall, when residents' characteristics and size of home was controlled for, residents in nursing homes had greater predicted utilisation than those in residential care homes. People who would previously have been cared for in NHS hospitals and are now cared for in nursing homes have high predicted utilisation due to their greater morbidity and disability. CONCLUSION: The "downsizing" of NHS provision for elderly people has increased demand on general practitioners by 160 whole time equivalents per year in Britain.     

General practitioners in partnership with management: an organisational model for debate

The role of general practitioners is changing and expanding. Doctors have more control over the treatment received by their patients but remain largely unaccountable to the public and management. This article proposes an organisational model for integrating primary and secondary care which retains the advantages of fund-holding while giving management control over overall strategy. It proposes that general practitioners control funds for all primary and secondary care. Secondary care will be contracted through a joint team of managers and an elected general practice executive committee. A new health care purchasing authority will contract for primary services with individual practices or primary care provider units. General practitioners will have local contracts reflecting their desire to provide an expanded range of services and the needs of the community.     

Teamwork in primary care: the views and experiences of nurses, midwives and health visitors

This paper reports on findings from a study of teamwork in primary care in one family health services authority in England. It is based on interviews using a semi-structured questionnaire with practice nurses, district nurses, health visitors and midwives in 20 practices. Six topics emerged as important in relation to the views of nurses, midwives and health visitors and their experiences of teamwork: team identity; leadership; access to general practitioners; philosophies of care; understanding of team members' roles and responsibilities; and, disagreement regarding roles and responsibilities. Differences in the various views and experiences of teamwork were identified. Midwives and health visitors emerged as the least integrated members of the primary health care team. Recent changes to the organization of primary health care services, as well as professional changes, are seen as accounting for the different experiences of the nursing groups. The potential for teamwork in the future is discussed.     

Does good practice organization improve the outcome of care for diabetic patients?

BACKGROUND: Audit of diabetic care is becoming common in general practice. Most of this audit is concerned with structure and process; outcome audit is much more difficult to achieve. AIM: To determine whether the structure of general practice diabetic care influenced the process or outcome and whether efficiency of process predicted improved outcome. METHOD: Cross-sectional survey, by questionnaire and review of notes, among general practices in the East Dorset district, involving diabetic patients identified from general practitioner (GP) disease registers or from a hospital diabetic register. The main outcome measures were the proportion of process and outcome measurements, related to selected structure criteria and the proportion of outcome measurements, related to appropriate process measurements. All associations were tested using the practice as the unit of analysis. RESULTS: Practices with a detailed diabetic register showed a positive association with a higher proportion of some process, but no outcome, measurements compared to those practices without such a registrar. A high proportion of process measurements did not correlate with improved outcome. CONCLUSION: Assessment of the follow-up of diabetic patients in general practice by measurement of the structure or process of care does not allow the prediction of an improved outcome for those patients when summarized on a practice basis. There is no shortcut to the collection of data on outcome as a measure of the benefit of follow-up for diabetic patients.     

Diagnosis and management of lead-poisoned children: the pediatric nurse practitioner in a specialty program

Lead poisoning, the leading environmental illness in this country, is a challenge to our health care and social systems. Because they provide routine health care in a variety of settings, including care to children from poor inner city families, who are most at risk for plumbism, nurse practitioners should be knowledgeable about this illness and prepared to care for children who have it. This article describes the role of a pediatric nurse practitioner in a specialty program who cares for children with lead poisoning and informs the general practitioner about prevention, education, treatment, coordination of care, and long-term follow-up for these children and their families.     

Continuing medical education in mental illness: a paradox for general practitioners

BACKGROUND: In 1992, the Royal College of General Practitioners instituted its fellowship in mental health education, which aimed to provide general practitioner tutors with the skills they need to help general practitioners manage mental illness in general practice. However, the emphasis of the fellowship on pedagogic education may discourage educators wishing to introduce andragogic teaching, a paradox which general practitioners must resolve if the aims are to be realized. AIM: This study set out to follow the difficulties encountered by the regional fellows in managing the fellowship and to understand how the scheme has evolved. METHOD: Data collected for interim evaluation of the fellowship was studied and interviews undertaken with the senior fellow and the regional fellows participating in the scheme. RESULTS: From its beginnings, the project encountered difficulties involving acceptance among general practitioner tutors. In response to the objections raised, the project metamorphosed through three stages, from a (perceived) pedagogic approach to a much more overtly learner-centered one. CONCLUSION: Learner-centred education requires trust and belief in the ability of general practitioners to teach general practitioners; over-protection of the audience from 'non-expert' educators merely perpetuates the status quo. If education in mental health care is to become truly learner-centred, general practitioners must address this paradox.     

GP documentation of obesity: what does it achieve?

BACKGROUND: Obesity is a major and increasing health problem in the United Kingdom, and, until recently, the government health promotion package for general practice reimbursed general practitioners for documenting obesity. Despite poor evidence for effectiveness of interventions in primary care, documentation of obesity could possibly improve patient awareness and knowledge, or provide public health information. AIM: To assess patient perception of obesity and its health risk, and the accuracy of estimating obesity using patient information. METHOD: Subjects were consecutive attenders to a general practitioner (GP) at a single urban practice in the South and West Region. Outcome measures were 'measured' body mass index (BMI) calculated from measured weight and height, 'estimated' BMI using patient information, and patient perception of obesity and the health risks of obesity. RESULTS: There is good correlation between 'estimated' and 'measured' BMI (intraclass correlation 0.91). Estimated BMI is lower than measured BMI (mean 0.77 lower), and the difference increases with age and level of BMI: for BMIs of < 20, 20-24.99, 25-29.99, and > or = 30 the mean differences (estimated-measured) were -0.06, -0.46, -0.98 and -1.72 respectively. Estimated obesity (BMI > 30) is reasonably sensitive (70%), specific (99%), and predictive (93% positive predictive value) of measured obesity (kappa 0.78). All obese subjects are aware that they are overweight, and most of them (78%, 95% confidence interval 66-88%) are aware that their weight is a health risk. CONCLUSION: Obese patients attending GPs' surgeries are likely to know if they are overweight, or could easily estimate from their knowledge of height and weight that they were overweight with reasonable accuracy. Obese subjects also know that their weight carries health risks. Thus, measurement of obesity in the general population is not likely to improve risk assessment or patient knowledge significantly. Without evidence for effective intervention or improved decision-making in primary care, reimbursement guidelines linked to the documentation of obesity in the population are probably an inefficient use of resources.     

Role of kinases and G-proteins on arachidonate release induced by zymosan in mouse peritoneal macrophages

Each of the 15 Health Boards in Scotland maintains a computer file of its residents who are registered with a general practitioner; this is known as the Community Health Index or CHI. The CHI allows a variety of demographic data and indicators of health to be analysed on either a geographic or general practice base, or both simultaneously. The considerable potential of the CHI as a public health tool may be of interest to health authorities outside Scotland which are developing wider uses for their own family practitioner registers.