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The purchaser/provider split and the introduction of GP fundholding has meant that GPs are now key players in determining the type of adult mental health services which are delivered. This paper describes the results of a recent survey of GPs' views and their use of adult mental health services. The survey was conducted in 100 fundholding practices and the same number of non-fundholding practices in 1994. Over one-quarter of the fundholding GPs had tried to make changes in out-patient provision and had used their purchasing power either to develop 'in house' psychiatric services or to reduce the number of consultants responsible for their patients. The results also indicate the large increase over the last few years in the number of mental health professionals based in general practice. This increase was particularly marked in fundholding practices. The implications for the delivery of mental health services are discussed. [ABSTRACT FROM AUTHOR]

Reproductive isolation can occur due to divergence in sexual selection for particular traits. For example, differences in mate preference associated with body size can play an important role in divergence between groups. The importance of mate preference for population divergence may be influenced by other aspects of a mating system, such as the requirement for parental care. In Nova Scotia, Canada, two ecotypes of marine Threespine Stickleback occur sympatrically: a "common" ecotype wherein males provide parental care, and a "white" ecotype that does not exhibit paternal care. The goal of our study was to examine differences in male mate preference between white and common stickleback males to test the prediction that males who invest more in parental care may be more selective about their mates. Because of the link between size and fecundity in this species, we predict that males that invest in parental care should prefer large females, while males that do not provide care will not exhibit preference for larger female size. We found that common male stickleback preferred larger-bodied females of both ecotypes, while white males showed a preference for larger-bodied common females. Secondarily, we assessed whether females differed in their willingness to mate with males of different sizes and ecotypes. Common female stickleback had a higher response rate toward smaller white males, which may be associated with their relatively high courtship rates. Counter to previous studies on these ecotypes that suggest that mating is completely assortative, interecotype matings occurred in half of the observed spawning events. This observation, coupled with the results that males may prefer females based mainly on size and females respond to males who court more rigorously regardless of their ecotype, may lend insight into recent genetic evidence for hybridization in the wild., Competing Interests: Both authors do not have a conflict of interest., (© 2023 The Authors. Ecology and Evolution published by John Wiley & Sons Ltd.)

Objective: A proportion of young women diagnosed with breast cancer are childless. Fertility can be impaired by treatment, and women may have to wait for a number of years before pregnancy is advised. The aim of this qualitative study was to investigate in detail the fertility-related experiences of young childless women with breast cancer, including the information they received, the fertility preservation options given, and the dilemmas they faced., Method: Interviews were conducted with 19 childless women aged below 45 with first episode breast cancer diagnosed at least 6 months before. They were recruited by contacting the breast cancer charities and were asked to tell their story, with an emphasis on fertility issues. Transcripts were analyzed using the thematic method developed by Braun and Clarke., Results: The amount of information given to women from health professionals varied considerably. Only half were given the opportunity to pursue assisted reproductive techniques prior to chemotherapy. Most women were worried about what the future might hold, including their fertility, the impact of pregnancy on recurrence, and the health of the child. They were generally given little information or support on these issues., Conclusions: Young women should be given more detailed information about fertility issues shortly after diagnosis, after chemotherapy, and during follow-up appointments. More holistic care should include emotional support to enable them to make decisions regarding their fertility options and planning for the future., (Copyright © 2013 John Wiley & Sons, Ltd.)

Background: The contributions of patients' opinions to the evaluation of health care is widely acknowledged. This study investigates whether the patients of a fundholding practice perceived any changes in the services offered., Aim: To examine the effect of general practice fundholding on patient satisfaction with both primary and secondary care services., Method: In April 1992, questionnaires were sent to 180 patients in each of four second-wave fundholding practices and four non-fundholding practices in the former South East Thames region. This took place before any changes were made in the practices as a result of fundholding. Repeat questionnaires were sent 30 months later., Results: The overall response rate was 70% in 1992 and 66% in 1994/1995. Satisfaction levels were generally high for primary care services and changed little over time. There was no evidence to suggest that fundholding GPs were less inclined to prescribe or refer to secondary care services. Waiting times for the first appointment with a consultant in secondary care had reduced between 1992 and 1994 for patients referred from the fundholding practices. However, there were no differences in the time patients had to wait for subsequent treatments or further investigations. One-fifth of the fundholding patients referred to secondary care were seen by the specialist in their doctor's surgery, and those seen in this setting preferred it., Conclusion: Patients perceived no major differences in primary care services over the period between the two surveys. There was some evidence of preferential treatment for patients of fundholding practices, but only in waiting times for the first appointment with the secondary care specialist.

Background: The general practice fundholding scheme is now at the forefront of the National Health Service (NHS) reforms and should lead to the more efficient use of services by making general practitioners more aware of the financial consequences of their clinical decisions. However, there is a concern that adverse effects may also occur., Aim: To monitor the changes occurring in a sample of fundholding and non-fundholding practices between 1992 and 1995, including providing care nearer to patients, the mixed economy of care, the efficiency and costs of fundholding, and the commitment of fundholders., Method: Fifteen first-wave practices, four second-wave practices, and four non-fundholding practices in the former South East Thames Region took part in the study. Information was collected using interviews, questionnaires, prescribing data, and annual fundholders' income and expenditure accounts., Results: Consultant clinics were set up in 10 different practices in 15 different specialties, and paramedical clinics in 12 different practices. Physiotherapy and mental health clinics constituted over 90% of the paramedical hours. Fundholders had private arrangements with an individual consultant or practitioner for approximately half of the contracted hours in both types of clinics. Fundholders had lower overall prescribing costs than non-fundholders, but the overall costs for prescribing for all groups had risen by about one third over three years., Conclusion: While outreach clinics may help to provide for the needs of patients with common conditions, they may lead to the fragmentation of services. The provision of primary care by those who are not NHS employees needs careful consideration. Recent policies for general practice have emphasized its role in disease prevention and in coordination of care for chronic illness. Fundholding also promotes two additional roles, the purchasing of care and the development of in-house facilities. Combining these different functions presents a considerable challenge.

Background: Fundholding general practitioners are able to determine the type of contracts they place with providers of mental health care, and are able to employ some categories of mental health care professionals directly. The impact of this on the care of the mental health of patients in non-fundholding practices is not yet fully known., Aim: A survey was undertaken of 100 fundholding general practices and 100 similarly sized non-fundholding practices in order to investigate the changes in mental health provision made by general practitioners., Methods: A sample of 100 fundholding general practices in England and Wales was randomly chosen from the list supplied by the Association of Fundholders and matched to a similarly randomly chosen sample of non-fundholding practices. Postal questionnaires were sent to the senior partner and to the practice manager in each practice., Results: The number of mental health care professionals who are either employed by or attached to general practices, or who visit the general practice on a regular basis appears to have increased substantially since 1991. This increase was particularly marked in fundholding practices. The results suggest that general practitioners with specific links to particular mental health care providers were more satisfied with the service provided by the mental health care team, and more likely to increase referrals to that service in the last 2 years, than general practitioners without such links. There was little evidence to suggest that increasing the number of mental health care professionals in primary care had brought about a major reduction in referrals to psychiatrists., Conclusion: General practitioners, particularly fundholders, are increasing their links with mental health professionals, and community psychiatric nurses, psychiatrists, psychologists and counsellors are spending more time either based in general practice or visiting regularly. While the shift of resources to primary care, particularly to fundholders, may increase the treatment options available to patients with less severe illnesses, this may have the effect of reducing the services available for the long-term and severely mentally ill.

Links between general practitioners and mental health professionals, such as counsellors, psychiatrists, community psychiatric nurses, clinical psychologists and social workers, are increasing in number and type. The aim of this survey was to elicit general practitioners' attitudes to these workers, comparing those with a link with a mental health worker and those without. General practitioners in two district health authorities were surveyed and a response rate of 70% was obtained. General practitioners linked to a mental health professional were more likely to have made a referral to that service in the previous three months and, on the whole, were more satisfied with that service. The commonest problem reported by respondents was the length of waiting lists. Regarding liaison with social workers, inadequate feedback and difficulty with contact were the problems mentioned most by doctors. A number of general practitioners expressed a desire for closer contact with all these mental health services. While caution is required in ascribing causality to these relationships, it is clear that a closer working relationship between general practitioners and mental health workers is productive and is valued by general practitioners. The challenge for policy makers is to structure mental health provision in such a way that more general practitioners are able to benefit than at present.

Objective: To assess the prevalence and severity of psychosexual dysfunction in women treated for cancer of the cervix and vulva by radical vulvectomy, Wertheim's hysterectomy and pelvic exenteration; and to identify the risk factors for sexual morbidity and ways in which it might be reduced., Design: Retrospective study of patients by questionnaire and semistructured interview, 6 months to 5 years following surgery., Setting: Gynaecology-Oncology Unit of a general hospital., Patients: 105 English speaking women with gynaecological cancer., Results: 90% of the women in relationships had been sexually active prior to surgery. Of this group, 24% had no sexual difficulties post-operatively; 66% of the latter still had problems more than 6 months later, and 15% of the latter never resumed intercourse (excluding those with a colpectomy). 82% of those aged less than 50 years who had had radiotherapy suffered sexual dysfunction. Lack of desire was the commonest problem, and half the women felt that their sexual relationship had deteriorated, yet only 16% felt that their marriage had worsened. Younger women were more likely to attribute personal and marital distress to their sexual problems. More information on sexual matters would have been liked by 28% of the women., Conclusions: Sexual dysfunction is common following radical pelvic surgery and tends to remain a chronic problem. As well as organic causes there is a strong psychogenic element brought about by loss of fertility, disfigurement, depression and anxiety about one's desirability as a sexual partner. The presence of a stable relationship before the diagnosis of cancer helps women cope better, and young single women are a very vulnerable group. Patients want more information on sexual matters and the provision of sexual counselling may improve outcome in the future.

One-hundred and five women had undergone major gynaecological surgery for carcinoma of the cervix and vulva were interviewed retrospectively to elicit post-operative psychosocial and psychosexual problems. This interview took place between 6 months and 5 yr after surgery. Responses to the Hospital Anxiety and Depression Scale indicated that 20% of the women were 'probable' cases of anxiety and 21% were 'definite' cases. On the depression scale, 18% were 'doubtful' cases and 14% were 'definite' cases. Scores on the scales were not associated with age of the woman, the type of operation or the time period between being interviewed and the operation. Two-thirds of the women who were sexually active prior to the operation indicated ongoing sexual problems when interviewed and the presence of these problems was found to be significantly associated with the woman's level of anxiety.

The aim of this study was to obtain an estimate of the extent to which collaborative schemes exist between general practice and mental health professionals and to assess the influence of practice size and district on these schemes. A questionnaire asking about such links was sent to each general practice in six randomly selected health districts in England. The response rate was 75%. Half of the 261 responding practices had a link with a community psychiatric nurse, 21% with a social worker, 17% with a counsellor, 15% with a clinical psychologist and 16% with a psychiatrist. Practices with more general practitioners were significantly more likely to have a link with a counsellor, after allowing for marked differences between the sizes of practices in the different districts. There was a tendency for some practices to have many links, while others had few. This poses questions about the efficiency and equity of collaborative schemes in primary care. Further research is required to investigate the quality of these links and the extent to which they serve the interests of the patient.

The irritable bowel syndrome is a highly prevalent condition whose underlying aetiology is not understood. While many patients respond to a combination of gastrointestinal antispasmodics, bulking agents and dietary manipulation, controlled clinical trials have suggested that the benefit is only marginal and is due mainly to the large placebo effect found in this condition, which has been calculated to range between 54 and 81%. Associations between the syndrome and psychological and social stresses suggest, however, that treatment involving a systematic approach to the management of symptoms may hold out real therapeutic possibilities. In the current study, 42 IBS patients were randomly allocated to either medical treatment or to behavioural psychotherapy with a nurse therapist. They were assessed initially and at 4 and 9 months. There was a general improvement over the 9 months on a number of physical and psychological symptoms measured. However, no differences were found between treatment groups except for changes in two avoidance scores. A significant correlation was found, however, between improvement in the bowel symptoms of IBS (stomach pain and diarrhoea) and improvement in the psychological symptoms measured by the Clinical Interview Schedule, suggesting a close interrelationship between the two.

A treatment trial was briefly mentioned in two British publications and women suffering from premenstrual syndrome were invited to write to us. After initial screening, postal questionnaires were sent to all eligible women. Six-hundred and ninety-nine questionnaires were returned and of these 658 were included in the analyses. Although the results of the study need to be considered cautiously because of the unrepresentative nature of the sample, the survey was helpful in ascertaining the views of women who report PMS symptoms and what they had found helpful. The majority of respondents were aged in their 30s and were married with children. Over 60% were chronic sufferers, having had symptoms for 5 years or more. High proportions of the women experienced both psychological and somatic symptoms but it was the psychological symptoms which were perceived as the most distressing. Over 60% of the sample were ascertained as suffering from some degree of psychological distress and the same proportion had one or more social problems. Overall 84% had visited their GP for this problem and many had also visited gynaecologists, family planning clinicians and psychiatrists. Agencies offering alternative medicine were also frequently contacted and often found more helpful. Most women had tried more than one type of medication but no one treatment was found to be particularly helpful.

A sample of patients aged 25-75 years was drawn from one general practice. The patients were sent a postal questionnaire to ascertain whether they had had a personal or emotional problem in the last 10 years and whom they had confided in. Of the 396 respondents 281 (71%) admitted to having had such a problem. It was found that significantly more women then men had had a problem. Of these 281 individuals, 94% had confided in someone, mainly friends and relatives, 47% had consulted one or more professionals or agencies and 37% had confided in their general practitioner. Although the majority had found the contact with the agency or professional helpful, those with depression/anxiety or problems following a bereavement were less likely to feel that they had been helped. The provision of practical advice, sympathy and support were most often mentioned as being helpful. This study demonstrates the important role of the general practitioner in the management and treatment of psychosocial problems.

Details of physical symptoms, psychological and social dysfunction of 42 outpatients diagnosed as having irritable bowel syndrome (IBS) were collected by interview and questionnaire. Social stresses and problems were also elicited as well as the impact of symptoms on their subjects' daily lives. High proportions of subjects were handicapped in their social, sexual and working lives by IBS symptoms and social stresses and problems were common. Forty-eight per cent were classified as having a 'minor psychiatric illness' using the Clinical Psychiatric Interview. Women were more severely affected by physical symptoms (with the exception of diarrhoea) and were more likely to be in pain longer and for more days in the month. They were also more likely than men to be diagnosed as having a psychiatric illness.

Women's rates of utilization of almost all health care services are higher than men's. General practice surveys endorse these findings with women attending more frequently, particularly in the child bearing years. The present study sought to explore the variables associated with consultation and help seeking behaviour for minor illnesses. Samples of male and female low and high attenders aged between 20 and 45 were drawn from one general practice to investigate which factors were important in explaining sex differences in consultation. Analysis of the results suggests that attendance and help seeking in men and women was closely linked to physical illness, the presence of physical symptoms was predictive of more frequent consultation in both men and women. The presence of psychosocial problems or distress, however, predicted consultation behaviour in women but not in men. The women had more confidants and contacted more social agencies than the men, also suggesting that they found it easier to divulge personal information to others than the men. There was no evidence from this study that such enabling factors as physical accessibility and time available were related to differential attendance rates.

Marital disharmony is a widespread phenomenon but it is largely hidden. Research, however, suggests that of the people with marital problems more approach the general practitioner than any other professional. This preliminary study reports on the help-seeking patterns of a sample of 60 patients in primary care identified as having marital problems, and a comparison is made with patients with housing problems. Men, it appeared, are less likely than women to confide in friends or relatives concerning marital problems and are less likely to find it helpful when they do; similarly, men are less likely to discuss their marital difficulties with their family doctor. Women were more satisfied with their doctor's help, which was mainly emotional support rather than more intensive counselling or referral. The implications of these preliminary findings are discussed.

Though numerous reports have strongly argued that there is a need for a closer collaboration between the health and social services, studies investigating the health of clients in contact with the personal social services have been few and limited. This study collected information regarding the physical and mental health of clients referred to social workers in the local authority intake team by means of questionnaires completed by the clients, and a selected sub-sample was also given an interview. Details were also taken regarding the social worker's assessment of health, reasons for referral and their intervention. The results indicated that the proportion of patients with physical or mental illness, or both, were very high and that social workers tended to under-report or under-estimate these illnesses. While there is some suggestion that the social workers were more likely to carry out more interviews with those clients who were ill, either physically or mentally, the contacts between social workers and medical personnel were very limited indeed.

This paper describes the preliminary testing and use of a short self-report instrument designed to identify psychosocial disorder. It combines a shortened version of the social problem questionnaire with the 12 item general health questionnaire. In a survey of 100 patients attending a health centre in inner London 46% recorded a psychiatric problem on the general health questionnaire compared with 35% identified by the general practitioner. For social problems 54% of patients assessed themselves as having one or more social problem compared with 23% detected by the general practitioner. The instrument normally takes five to 10 minutes for the patient to complete and thus can be filled out in busy situations such as a general practice surgery or a hospital outpatient department.

Although numerous reports have strongly argued that there is a need for a closer collaboration between the health and social services, studies investigating the health of clients in contact with the personal social services have been few and limited. This study collected information regarding the physical and mental health of clients referred to social workers in a local authority intake team and to a general practice attachment scheme by means of questionnaires completed by the client and at interview. The results indicated that the proportions of patients with physical or mental illness were very high. However, while social workers in the attachment scheme had many contacts with members of the primary care team regarding these clients, contacts between intake social workers and medical personnel were very limited.

Premenstrual syndrome is commonly found among GP female attenders of childbearing age. This article discusses the main types of drug therapies used to treat premenstrual syndrome. Guidelines are also given on the management of these patients incorporating nondrug treatments such as behavioural methods and supportive counselling for associated psychosocial difficulties.

We studied clients seen by social workers in two settings, one a conventional intake team in a social services department and another where clients were referred to social workers attached to a primary health care team.In both groups a high proportion of clients were either physically ill or disabled and the attachment group had a high proportion of clients with mental ill health. A large proportion of both groups were elderly and in general they had similar characteristics.However, clients referred to intake teams were more likely to be unemployed, to be living on benefits in council or rented accommodation, and to have had some contact with social services before. The attachment group consisted of more women who were either housewives or working, living on either their own earnings or their husbands', and were more likely to own their own homes and not to have had previous contact with social services.Clients referred to attached social workers were more likely to have an emotional or relationship problem, and many had practical problems as well. The implication is that attachment schemes will tap a wider section of the community and that the additional clients will have as many and as severe problems as clients referred to intake teams.

This paper discusses the results of a survey of all general practitioners and counsellors involved in attachments in the area covered by the London Marriage Guidance Council. The replies of both counsellors and doctors were generally enthusiastic and few problems with attachments were encountered. However, while subjective accounts are positive, it seems essential that more objective research into effectiveness should be conducted if counsellors are to argue their case for being paid.

This paper is based on interviews with everyone who attended the group at least once. It concentrates on the members' feelings about joining the group, their previous group experiences, whether or not they found it helpful, how it could have been improved and their impressions of the leaders. It discusses questions raised by members about the group composition and the necessity of having leaders.

Information regarding the physical and mental health of clients referred to social workers in a local authority intake team and to a general practice attachment scheme was collected over a 3-month period. Although returns to the Department of Health and Social Security during this period indicated that a very low proportion of clients were physically or mentally ill, it is clear that these figures greatly underestimate the extent of illness present. While social workers operating outside hospital and general practice attachments have been shown to have little contact with medical staff, in this study high proportions of their clients were ill and their social problems were often associated with their illness.

There is a pressing need to evaluate the different forms of treatment for depressive illness encountered in general practice. This study consists of a controlled, randomized, clinical trial designed to investigate the effectiveness of social work intervention with depressed women. Eighty women aged between 18 and 45 were included and assessed initially by means of a psychiatric and social interview. Those ascertained to be suffering from 'acute' or 'acute on chronic' depression were randomly allocated to an experimental group who were referred to a social worker attached to a general practice or to a control group for routine treatment by their doctor. They were re-assessed 6 months later. Over 60% of both groups were clinically improved at follow-up, with no statistically significant differences between the two groups in clinical, social or medical outcome. Further analyses suggested, however, that those women initially assessed as suffering from 'acute on chronic' depression with major marital difficulties were found to benefit from social work treatment. These patients could be distinguished from the others by their high degree of motivation, by the initial severity of their problems and by the amount of practical help provided by the social workers.

In a clinical trial investigating the effectiveness of social work intervention with depressed women patients in general practice, 80 women were randomly allocated to an experimental group for referral to attached social workers or to a control group for routine treatment by their GPs. They were reassessed at 6 and 12 months. The results indicated that women who had major marital problems were more likely to be depressed at follow-up than those with good relationships. However, patients with marital difficulties in the experimental group made more improvement than the controls. Women initially assessed as suffering from 'acute on chronic' depression and having major marital difficulties were found to benefit most from social work intervention.

A social work attachment scheme to several general practitioners was established. Data from the first 300 referrals to the scheme were compared with data from a previous study of referrals to the ;intake' teams of the social services department of the same London borough. In addition, data about the activities of the social workers in the ;attachment' were collected, and the work was found to be predominantly short-term.The populations referred to social workers in both settings were found to be similar in age and sex. Although general practitioners in the area referred only a few clients to social services departments, the clients in both groups were generally in poor health.The psychiatric morbidity of those referred to the attached social workers was significantly higher, however, than those referred to the intake team (p < 0.01), and their problems were also more likely to need psychological help rather than practical measures. These differences were considered to be due mostly to the different types of referral agencies operating in the two settings and to their perceptions of the social worker's role.THE FINDINGS SUPPORT THE ARGUMENT FOR CLOSER LIAISON BETWEEN MEDICAL AND SOCIAL SERVICES IN THE COMMUNITY: the attachment of social workers to general practices proved to be particularly valuable in the management and treatment of patients with emotional and mental illness.

The attachment of social workers to general practices has increased recently and this study reports some of the factors which affect the success of such arrangements.Access to a room in the surgery for interviewing and the use of a telephone is an important factor as the time spent by the social worker in the premises increases the chance of making good working relationships with members of the primary health care team.When the social worker handles all the cases personally there are advantages, especially for other members of the primary health care team, although in such a situation a social worker may become relatively isolated from her own profession. The organization of the practice itself is an important variable, especially the degree of commitment by members of the primary care team, and the attitudes of the doctors. It is helpful if the doctors meet together as a group or with other professionals. Equally, the social worker must be committed to the role. Social work attachments to health centres can be particularly effective. The lack of preliminary discussion with the social work agency can contribute to difficulties in such attachments, and preliminary meetings should include discussions about the type of cases to be referred and the quantity of social work time available.

A study day for general practitioners was arranged on the subject of managing the difficult patient. Participants were asked to supply written details of their most difficult patient and the problems they associated with him or her. The issues raised were addressed in a number of formal presentations and formed the basis for discussion in workshops. This paper focuses on the underlying similarities between the patients and discusses a practical approach to their management.

The construction and testing of a short self-report questionnaire identifying social problems, difficulties and dissatisfactions is described. The questionnaire covers housing, occupation, finance, social and leisure activities, child/parent and martial relationships, relationships with relatives, friends, neighbours and workmates, and legal problems. The results of the administration of the questionnaire in a number of settings are provided and discussed, and a final version is included in the Appendix.