Search

Objective: To study the feasibility of a practice nurse caring for patients with minor illnesses., Design: Nurse given training in dealing with patients with minor illnesses. Patients requesting a same day appointment were offered a nurse consultation., Setting: Group practice in Stockton on Tees., Main Outcome Measures: Number of consultations which required a doctor contact, treatment, and rate of reconsultation., Results: Of 696 consultations in six months, 602 (86%) required no doctor contact. 549 (79%) patients did not reconsult about the episode of illness, and 343 (50%) patients were given advice on self care only., Conclusion: Trained nurses could diagnose and treat a large proportion of patients currently consulting general practitioners about minor illness provided that the nurse has immediate access to a doctor.

The establishment of a well man clinic run entirely by a nurse in general practice showed an appreciable number of men to be hypertensive, smokers, or overweight; it also showed some previously undetected disease. Efforts were made either to treat or to counsel men in whom these findings were made. A well man clinic may have greater value than a well woman clinic.

A practice brochure describing the primary health care team was given to 262 new and established patients in a group practice. Most liked it, and thought it helpful, and improved their knowledge of team care. When asked how they would respond to certain hypothetical health problems and clinical situations, there was a significantly greater use of non-doctor members of the team than by a matched sample who had not read the brochure. Inappropriate use of members of the team was not engendered.

Two hundred and twenty eight deprived children were compared with a matched sample of more endowed children living in the same urban area. Both groups were served by the same experienced primary health care team. The deprived group had a significantly higher number of general practitioner consultations and admissions to hospital (aged under 5) and a significantly higher recorded prevalence of mental and psychological disturbance (aged 5-15). Accident and emergency attendances were significantly higher for the deprived group throughout childhood, as were non-attendances for medical care appointments. The deprived group had much worse rates of immunisation and significantly later immunisations; practical measures subsequently adopted to improve this uptake of immunisation are described.

When the FP5/6 record envelopes were converted to A4 folders in a busy practice a system of updating preventative health measures was begun and a disease index constructed. All the day-to-day work was delegated to lay staff, and the whole primary health care team participated in the updating procedures. The exercise, although expensive, was considered to be most worth while and has improved the quality of patient care.

A survey of the total care provided by a general practitioner and his paramedical team for 3,137 patients in Teesside in 1972 showed that even in this area of high morbidity and mortality the work load was very small. The doctor held an average of 2.3 consultations per patient per year, and the overall average for the team of doctor, nurse, and health visitor was only 3.1. By delegating work to a team of trained paramedical workers, by increasing the proportion of personal medicine, and by engaging the co-operation of his patients, the general practitioner reduced his work load considerably, without any apparent reduction in standard of care.

Of 260 follow-up medical outpatient consultations analysed by 12 general practitioners in the Northern Region, a large proportion appeared to be a complete waste of time. One follow-up consultation should be the normal for the great majority of cases and if more are necessary specific reasons should be given. Great economies could be made in the National Health Service by reducing medical outpatient follow-ups.

A method of collecting physician-patient encounter data is described and applied to the comparison of the clinical content of residents' experiences in the family practice office. Comparisons were made of over 1,000 consecutive unselected encounters in each of the three family practice residency programs. Considerable differences between the patients encountered by the three programs were observed and between program patients and patients attending family physicians in Iowa. It is important to monitor the demography and diagnostic status of patients attending family practice residency programs to ensure the authenticity of the residents' experience.

From a survey of 200 patients in two general practices it would appear that the patients' reaction to the use of a two-way mirror is on the whole not unfavourable. The results suggest, however, that in the very personal setting expected of general practice people suffering from psychiatric problems (especially depression) should be given every opportunity to decline consultation in front of the mirror and if any patient becomes upset, then the mirror should be 'turned off' immediately. Internal examinations should not take place when the mirror is in use.

The visiting habits of general practitioners in the north of England in 1969 and in 1980 have been compared. During this period overall visiting was reduced by 41%. The reduction was most pronounced in repeat visits, particularly to children. There was a greater reduction in visits to patients with respiratory disease than to those with other illness. The reduction was least in visits to patients over the age of 65. New visits requested by patients were reduced by 31%, but the general practitioner still considered that about the same percentage of patients could have attended the surgery as in 1969. The reasons for these differences include flexible appointment systems, improved efficiency, better organisation of the surgery, and more flexible arrangements for certification of absence from work. Though total workload (as measured by the number of consultations with patients) has diminished, general practice has changed, being more concerned with prevention, chronic disease, and vocational training.

A detailed comparison made in late 1984 of 587 matched pairs of patients from neighbouring deprived and more endowed urban communities, both served by the same experienced primary health care team, showed much worse morbidity, with almost three times as much mental illness, in the deprived group. This group also had 60% more hospital admissions and 75% more casualty attendances. In contrast, they had a much lower uptake of preventive health care, especially childhood immunisations and cervical cytology in older women. A much higher birthrate within the deprived group, contributing to ill health by worsening overcrowding and deprivation, indicates that family planning is ineffective where it is most needed. Practical measures have now been instituted to improve the preventive care of the deprived community.

More than half the general practitioners in the north of England, and all the health visitors, were sent questionnaires about the primary health care of children. Eighty per cent of general practitioners responded. Their qualifications and experience in paediatrics were poor, although this was less true for younger practitioners. The doctors differed widely in their management of hypothetical clinical problems, possibly owing to this lack of training. Health visitors were thought to have an important role in developmental screening within the primary health care team, but the teamwork itself seemed weak. Although 83% of general practitioners considered developmental screening should be primarily the responsibility of the primary health care team, 31% of practices did not do it and had no plans to start. Rather more than half of the doctors in these non-screening practices would accept a clinical medical officer to screen their patients on their premises. Suggestions are made for ways of encouraging general practitioners to carry out developmental screening.

In late 1983 a four page questionnaire on general practitioner obstetrics was sent to a 50% random sample of general practitioners in the Northern region of England; 84% responded. Half of them said that they had access to general practitioner facilities for delivery, and half of these used them. A quarter of all respondents had provided intranatal care previously but had given it up, most of them during the late 1970s. Younger general practitioners were more highly qualified in obstetrics than older ones but did not do more intranatal work. Isolated general practitioner maternity units were much more likely to be used than those that were alongside consultant units or integrated with them. Ninety per cent of respondents provided antenatal care, 77% of these at special clinics and 88% with midwives in attendance. Teamwork, however, was not well developed. Increasing general practitioner participation in obstetric care seems feasible but depends heavily on more appropriate training and intranatal facilities being provided for general practitioners in association with specialist units.

The conclusions from recent analyses of the clinical worth of routine antenatal attendances have been used in the setting of a modern primary health care team. As a result the number of times a low risk nulliparous woman is seen by her general practitioner has been reduced from 15 to eight and a low risk multiparous woman from 15 to six. The number of consultations with a midwife has also been considerably reduced. The time saved is used in longer, more structured consultations and for more intensive care of high risk, usually socially deprived, women. Despite these reductions in consultations organised, well recorded care of this type renders antenatal attendances at a hospital virtually unnecessary for low risk women.

This paper describes the work of a marriage guidance cousellor in a group-practice centre. The considerable advantages to patient, doctor, and counsellor of her close association with the primary medical care team are discussed.

The second part of a survey studying factors that affect a general practitioner's work load considers the effects of age, sex, social class and time on list. Women, the old, and the young created the most work for the doctor and his paramedical team. Patients in the lower social classes also generated more work, even though a larger proportion of the higher social classes used the resources of the general practice-and more fully. Newly-registered patients generated slightly more work than the more permanent residents. Not only the size of a doctor's list, therefore, but also the demographic features of the community should be taken into account in determining the size and structure of the general-practice team needed for an area.

A 15 month campaign by a primary health care team in Stockton on Tees raised the uptake of preventive care of its patients in a severely deprived area to a level generally exceeding that of a more endowed neighbouring community. This was achieved by opportunistic attention after unrelated consultations, writing twice to each household with a list of its outstanding items necessary for preventive care, using health visitors to encourage attendance, and occasionally undertaking preventive care in patients' homes. Extra clerical staff were needed to implement the new recording and monitoring procedures introduced. With rigorous monitoring and organisation general practitioners may improve the uptake of preventive health care by their more deprived patients.

In 1983 a quarter of general practitioners in the Northern region of England cared for obstetric deliveries and half of these for a minimum of 10 deliveries a year. Most expected their intranatal work to remain at the same level or increase in the next 10 years. Most participating general practitioners did their own forceps deliveries and initiated inductions. Most out of hours deliveries were attended by the mother's own general practitioner or a partner. A quarter of all respondents had cared for planned and unplanned home births. Few were happy about attending them, but most would provide planned home care if urged to do so.

Two doctors in a five-partner urban practice recorded details of their out-of-hours telephone calls for a year. No caller was refused a visit, but 474 of the 809 incoming calls (59%) were managed by telephone advice, an unexpectedly high proportion. Although these callers were instructed to telephone again if still worried, only 40 did so during the same duty period, and only 55% of a smaller sample of patients receiving telephone advice only consulted again within a week. No evident detriment to patients' health was observed. Thirty nine (5%) of the 809 incoming calls were managed by an out-of-hours surgery attendance and 296(37%) by a home visit. The urgency of the visits made was categorized retrospectively as high (34% of visits), medium (39%) and low (27%). It is hoped that this descriptive account will foster discussion of the value and implications of telephone advice in managing out-of-hours calls.

To assess the feasibility and quality of general practitioner obstetrics an audit of 1223 consecutive obstetric deliveries over 26 years was carried out with standard clinical records. The perinatal mortality of 9.0 per 1000 births was significantly better than the national average of about 19.0 per 1000 for the overall period. During the audit home deliveries virtually stopped. The proportion of consultant bookings and deliveries more than doubled because of more stringent booking arrangements despite relocation of the previously isolated general practitioner unit to beneath the consultant unit. Abnormal deliveries also rose significantly. A "steady state" was achieved during the final 11 years in which 73% of women booked to be delivered by their general practitioner, 64% were admitted to the general practitioner unit, and 54% were delivered by their general practitioner. Though this is enough to sustain obstetric experience, the proportion might safely be increased.

All the health visitors in the north of England, and more than half the general practitioners, were sent questionnaires about the primary health care of children. More than 90% of the health visitors responded. Most of them took part in developmental screening and considered it primarily their responsibility; some conducted developmental or well baby clinics with no other professionals present. Clinics run by health authorities often occupied several hours per week, and were more frequently attended by health visitors than clinics run by general practitioners. Almost all the health visitors' remaining time was spent in attached practices, despite the fact that more than half said they had neither office nor clinic space of their own on practice premises. A high proportion of time was spent on clerical work; more help with this could free the health visitor to provide better developmental care for all children.

A project of joint consultation between a paediatrician and several general practitioners serving a group practice of 15,000 patients has shown that outpatient clinics held at a group-practice centre (when 36 children were seen at 78 consultations over 18 months) reduced the overall work-load, eliminated dual care, and directly benefited the doctors, the children, and their families.