The academic triad in general practice.

Aim: This study was conducted to evaluate the knowledge, attitude, and practice of the general health practitioners toward diabetic retinopathy (DR), Kingdom of Saudi Arabia (KSA). Materials and Methods: This was a cross-sectional descriptive study. Responses were obtained using a structured multi-point questionnaire. It included closed-ended questions that were arranged in a Likert's scale. Informed consent and ethical approval were obtained. Data were analyzed using SPSS version 16 statistical software. Results: Of the 180 general practitioners (GPs) who participated in the study, 56.7% were males and 43.3% were females. Of those, 51.1% were practicing in rural areas, and 41.1% had postgraduate training. Participants had good knowledge about the prevalence of diabetes mellitus in KSA (97.2%). The majority (92.8%) agreed that early detection and treatment of DR plays a critical role in the prevention of permanent visual loss. However, participants had good attitude toward screening for DR. However, the practice of fundus examination was poorly mastered by 43.9% of the GPs. Conclusion: This study displays the need for hands-on training of GPs about detection of DR by direct use of ophthalmoscopes. Barriers for ophthalmoscope examination, as perceived, need to be further addressed and evaluated. Furthermore, It is of great importance to improve the screening facilities at the primary health care setting.

BackgroundSwitzerland, like many other countries, has a shortage of General Practitioners (GPs). Optional GP training modules in GP practices were offered during the at least 5-year GP training program to increase student and trainee interest in becoming a GP. The training modules had not yet been evaluated. We determined how many Swiss GP trainees became practicing GPs after they completed optional training modules, and if longer modules were associated with higher rates of GP specialization.MethodsIn this population-based cohort study, we included GP trainees who chose an optional GP training module in GP practice, provided by the Foundation to Promote Training in General Practice (WHM) between 2006 and 2015. GP trainees were invited to complete an online survey to assess the primary outcome (becoming a practicing GP by 2016). Data on non-responders was collected via an internet search. We calculated univariate time-to-event curves to become a practicing GP, stratified by trainee’s gender, length, part-time training, and number of years after graduation until training modules were completed. We used a multivariate model to adjust for characteristics of participants, training, and satisfaction with training modules.ResultsWe assessed primary outcome for 351 (92.1%) of 381 former GP trainees who participated in a WHM program between 2006 and 2015. Of these 218 (57%) were practicing GPs by 2016. When focusing on the trainees who had completed training between 2006 and 2010, the rate of practicing GPs was even 73%. Longer (p = 0.018) and part-time training modules (p = 0.003) were associated with higher rates of being a practicing GP. Most (81%) practicing GPs thought their optional GP training module was (very) important in their choice of specialty.ConclusionGP trainees who spent more time training in a GP practice, or who trained part-time were more likely to become practicing GPs. Most (80%) rated their training module as (very) important in their choice of career, highlighting that these modules effectively encourage the interests of those already inclined towards the GP specialty. Longer GP training modules and more opportunities for part-time training may attract and retain more interested trainees, and possibly increase the number of practicing GPs.

General practice services are under pressure due increased demand. Alongside substantial national recruitment challenges, there exists a shortage of general practitioners to meet current need. Resultingly, allied healthcare professionals, including paramedics, are being utilised in general practice. To determine the models of paramedics in general practice settings; the mechanisms that underpin effective paramedics in general practice; and the impact of paramedics in general practice on safety, costs and clinical and patient-reported outcomes and experience. A mixed-methods realist evaluation comprised a rapid realist review followed by an evaluation of paramedics in general practice in general practice case study sites. Patient and public involvement and input was integral, ensuring validity from a patient and carer perspective. General practices in England. A total of 34 general practices participated as case study sites, of which 25 were 'paramedics in general practice' sites. Data from qualitative realist interviews (n = 69), quantitative questionnaires (n = 489) and electronic records (n = 22,509 consultations) were collected. Paramedics in general practice models were classified according to: (1) level of integration of the paramedic to the general practice team; and (2) complexity of patients seen by paramedics. Qualitative interviews investigated initial programme theories with staff and patient participants. Patient participant questionnaires utilised validated measures: the Patient-Reported Experiences and Outcomes of Safety in Primary Care (safety); EuroQol-5 Dimensions, five-level version (health-related quality of life); Primary Care Outcomes Questionnaire; the Modular Resource Use Measure (health and care resource utilisation). Electronic health records provided data on primary care use. A rapid realist review of the published and grey literature, supplemented with direct enquiry with system leaders and key stakeholders. The rapid realist review highlighted significant variation in paramedics' roles in general practice. Qualitative interviews identified domains related to access, safety, workforce reconfiguration, infrastructure, patient experience, and outcomes. Lower Patient-Reported Experiences and Outcomes of Safety in Primary Care practice activation scores were found at paramedics in general practice sites (perceived less engaged in promoting safety), in particular those with medium and low levels of paramedics in general practice integration and complexity. There was a small statistically significant difference in the Primary Care Outcomes Questionnaire 'Confidence in Health Plan' by paramedics in general practice complexity, such that confidence had deteriorated slightly more in the high-complexity group compared to non-paramedics in general practice. Paramedics in general practice sites had lower scores at initial visit and 30 days for the Primary Care Outcomes Questionnaire 'Confidence in Health Provision'. We found little evidence that paramedics in general practice care led to substantial spillover effects via increased reconsultations, prescriptions, secondary care referrals or unplanned hospital admission costs. The study faced challenges in recruitment. Self-selected participating sites may not be representative of all general practitioners in England, and categorising paramedics in general practice models for analysis was more complex than anticipated. The comparison of costs and outcomes between paramedics in general practice and non-paramedics in general practice sites was based on an observational study design. Paramedics in general practice care improves access to general practice. Safety and acceptability require resources for induction, supervision, training and education. Paramedics in general practice integration affects staff satisfaction and role longevity. Paramedics in general practice allows paramedics to develop and evolve. Larger studies utilising different study designs with longer follow-up are needed to fully understand the impact of paramedics in general practice on clinical outcomes and episode of care costs. This study is registered as ISRCTN56909665 https://doi.org/10.1186/ISRCTN56909665. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR132736) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 6. See the NIHR Funding and Awards website for further award information.

Teamwork in primary healthcare is associated with patient care processes and staff outcomes. The ability of teams to be innovative is a hypothesized mechanism. We examined the characteristics of general practices with good team climate for innovation, and assessed the impact of climate on chronically ill patients' assessment of their care and on the job satisfaction of the staff. Large cross-sectional study. Australian general practices. A total of 654 general practitioners and staff and 7505 chronically ill patients from 93 general practices in 6 Australian states and territories. The Team Climate Inventory and the Overall Job Satisfaction Scale, customized for use with general practices, were administered to general practitioners and practice staff, and the General Practice Assessment Survey was administered to patients. Practice characteristics were collected by survey from the principal doctor or practice manager. Mean scores of team climate in Australian general practices were similar to those reported in the UK, except that in our study there was no association between the number of doctors in a practice and their team climate. Better team climate was found in practices with fewer non-clinical staff. Team climate predicted the job satisfaction of the general practitioners and staff, irrespective of the number of practice staff. Better team climate was associated with greater satisfaction by patients with their care. Team climate is important for patient and staff satisfaction. In large general practices, separate sub-cultures may exist between administrative and clinical staff, which has implications for designing effective team interventions.

Objective To examine associations between the contract and ownership type of general practices and patient experience in England. Design Multilevel linear regression analysis of a national cross-sectional patient survey (General Practice Patient Survey). Setting All general practices in England in 2013-2014 ( n = 8017). Participants 903,357 survey respondents aged 18 years or over and registered with a general practice for six months or more (34.3% of 2,631,209 questionnaires sent). Main outcome measures Patient reports of experience across five measures: frequency of consulting a preferred doctor; ability to get a convenient appointment; rating of doctor communication skills; ease of contacting the practice by telephone; and overall experience (measured on four- or five-level interval scales from 0 to 100). Models adjusted for demographic and socioeconomic characteristics of respondents and general practice populations and a random intercept for each general practice. Results Most practices had a centrally negotiated contract with the UK government ('General Medical Services' 54.6%; 4337/7949). Few practices were limited companies with locally negotiated 'Alternative Provider Medical Services' contracts (1.2%; 98/7949); these practices provided worse overall experiences than General Medical Services practices (adjusted mean difference -3.04, 95% CI -4.15 to -1.94). Associations were consistent in direction across outcomes and largest in magnitude for frequency of consulting a preferred doctor (-12.78, 95% CI -15.17 to -10.39). Results were similar for practices owned by large organisations (defined as having ≥20 practices) which were uncommon (2.2%; 176/7949). Conclusions Patients registered to general practices owned by limited companies, including large organisations, reported worse experiences of their care than other patients in 2013-2014.

General Medical Practitioners play a crucial role in the detection and referral of mental health problems in primary care. This study describes the referral patterns of Irish General Practitioners (GPs) to psychological therapies and profiles the range of psychological therapies available. A 21-item study-specific questionnaire exploring referral processes to psychological therapies was sent to all GPs listed by the Irish College of General Practitioners in one county in Ireland. A 19-item questionnaire exploring details of psychological therapies offered and referral pathways was sent to members of psychological therapy accrediting bodies in the same county. Of 97 GP respondents (33% response rate), their estimation of the percentage of their patients who have presenting or underlying mental health issues averaged 22%. When asked to indicate which psychological therapies they consider for referrals, psychiatric referrals was the most frequent referral option (94%), followed by Counsellors (69%), Clinical psychologist (60%) and Psychotherapists (30%). GPs indicated they had some or very little knowledge of specific psychological therapies. Of 129 psychological therapists (45% response rate), self-referral and GP referral were their main referral pathways; 80% worked in private practice; highest qualification level was Undergraduate/Higher Diploma (66%), Master Level (39%) and Doctoral Level (5%). GPs refer patients presenting with mental health problems to psychiatrists with significantly lower percentages referring to other types of psychological therapists. Findings demonstrate that there is a need for greater education and information-sharing between GPs and providers of accredited psychological therapies to increase knowledge on specific therapies and their evidence base.

In the early 1970s general practitioners were well aware that they were being asked to deal not only with physical illness in their patients but also with the stresses relating to social and emotional problems. Increasingly often they were working together with health visitors and social workers in attempting to respond more effectively to these demands. Originally published in 1972, this study describes the attachment of a social worker to a group general medical practice in London, indicating why, for all social groups, the general practice is an appropriate point at which psychosocial problems may be identified and treated. The authors describe the nature and range of patients' problems that come to light in the consulting room; how patients present their problems to the social worker; and the kind of help the social worker is able to offer. They explore the extent to which the general practice setting provides opportunities for preventive therapy and further describe how social work in general practice can most effectively be related to existing social services in the community, particularly to the reorganised personal social services. Their findings are supported throughout by illuminating case studies. The book also discusses the integration of the social worker into the general practice team, the problems that have to be solved and the mutual enlightenment that results. This emerges as an extremely encouraging and instructive experiment, which will immediately interest social service departments and social workers, doctors and nurses, both students and those in practice. The wide spectrum of social problems encountered and dealt with by the social worker in a general practice make it a particularly stimulating account.

Brief intervention content mattersFor more than 30 years, there have been concerted efforts internationally to develop the evidence base for brief interventions in general practice [1].The choice of this setting reflected strategic judgements about where in health systems heavy drinking and alcohol problems were likely to be most encountered and thus where these interventions may be optimally delivered.This literature is usually interpreted along the lines that efficacy is now well established in general practice and that there is a need to extend study to new settings [2,3].This year has seen the publication of two large general practice cluster randomised effectiveness trials that in different ways draw attention to a crucial limitation of the evidence base in this setting; the lack of welldeveloped study of intervention content.Although both undertaken in the UK, they are likely to be seen internationally as important studies.The three-arm Screening and Intervention Programme for Sensible drinking (SIPS) trial compared a leaflet control condition against the same leaflet plus five minutes advice and the addition subsequently of 20 minutes counselling [4].Preventing disease through opportunistic, rapid engagement by primary care teams using behaviour change counselling (PRE-EMPT) compared training practitioners to address behaviour change for the big four key lifestyle risk factors (diet, exercise, smoking and alcohol) versus delayed training, thus entailing a non-intervention control condition [5].Both trials found no differences in alcohol outcomes for hazardous and harmful drinkers over a 12-month study period following interventions delivery by general practitioners and practice nurses.The authors of these studies identify contrary implications for practice from these null findings.The SIPS authors conclude that the control condition: 'screening followed by simple feedback and written information may be the most appropriate strategy to reduce hazardous and harmful drinking in primary care ' [4].One commentator, however, is concerned that this provides: 'false reassurance that we have taken care of unhealthy alcohol use and will waste time and money' [6] by delivering more time consuming interventions.In contrast, the PRE-EMPT authors, including myself, conclude that: 'enduring behaviour change and improvements on biochemical and biometric measures are unlikely after a single routine consultation with a bs_bs_banner

ObjectivesFailure to recruit sufficient applicants to general practice (GP) training has been a problem both nationally and internationally for many years and undermining of GP is one possible contributing factor....

The practice of general practice emphasizes that the general practitioner is the backbone, and the primary health institution is the main body, which solves the main health problems of the community and meets the basic health service needs of the residents. Rehabilitation medicine occupies a prominent position in the community health service, and its related knowledge and skills are the important part of the whole medical education. However, rehabilitation medicine has more teaching contents, less training time and out-of-date teaching model, which have made the effect of rehabilitation medicine teaching not good. In the rehabilitation medicine teaching for training general practitioners, by strengthening the concept of rehabilitation, elaborating teaching content, optimizing teaching ward-round, and outstanding ability as well as reforming evaluation way, we try to exercise the students' clinical thinking and improve clinical skills, to cultivate outstanding qualified general medical practitioners for community rehabilitation ultimately. Key words: General practice; Rehabilitation medicine; General medical practitioner; Community rehabilitation

Objective With increasing cancer incidence and survival rates, follow-up care becomes a major healthcare concern, placing increased demands on general practitioners (GPs). We explored GPs’ awareness of late effects (LEs) after cancer treatment. Their degree of involvement and attitudes towards follow-up care was studied separately for solid cancers and Hodgkin’s lymphoma (HL). Design and setting Mailed questionnaire study in Norwegian general practice. Subjects 185 responding GPs with responsibility for HL survivors, more than 10 years since diagnosis. Main outcome measures and results All GPs reported some awareness of LEs. Increasing awareness of LEs was associated with female sex, being a specialist, having experience from hospital-based cancer care and familiarity with official guidelines on LEs after treatment. The majority of GPs were involved in follow-up care, which increased with patients’ time since treatment and was associated with higher awareness of LEs. GPs with work experience in hospital-based cancer care were more likely to be engaged in HL follow-up. Most GPs were willing to provide follow-up care at some point after treatment. Older and more experienced GPs, and those satisfied with the collaboration with hospital specialists, were more likely to provide follow-up earlier. Conclusion GPs’ awareness of LEs and their willingness to provide follow-up care were related to familiarity with guidelines and experience. GPs more involved in follow-up care also had higher knowledge of LEs. Distribution of guidelines on LEs and follow-up care, and improving collaboration with hospital specialists, might increase GPs’ knowledge and willingness to become involved in follow-up care, especially early in their careers. GPs’ involvement and attitude towards follow-up of survivors of common solid cancers and HL, a rare malignant disease, were similar. KEY POINTS Norwegian general practitioners (GPs) are involved in survivorship care after cancer treatment. We investigated their awareness of late effects (LEs), their involvement and their attitude towards follow-up care of solid cancers and Hodgkin’s lymphoma. • GPs registered as specialists, aware of guidelines and with experience from hospital-based cancer care reported higher awareness of LEs. • GPs with higher awareness of LEs were more frequently involved in follow-up care. • GPs with longer experience in general practice were comfortable with follow-up care at an earlier stage after treatment. • Results were similar for follow-up care of survivors of solid cancers and Hodgkin’s lymphoma.

To assess the knowledge, attitudes and practices of general practitioners in New South Wales regarding the provision of emergency contraception. Randomised group comparison of 100 rural and 100 urban general practitioners (GPs) by questionnaire. Eighty-four rural and 76 urban GPs responded. More rural GPs were knowledgeable about emergency contraception than urban GPs (95% v. 78%), and more women knew about it than men. More urban GPs frequently prescribed emergency contraception than rural GPs (26% v. 6%) and female GPs prescribed it more readily than male GPs (22% v. 12%). There was great variation in the regimens prescribed, especially among rural GPs. Twenty-five per cent of urban GPs and 31% of rural GPs did not offer women information about emergency contraception, while 16% of both groups included such information in any discussion about contraceptive options, and 18% gave information only if requested by the woman. More than 60% of the GPs would provide information about emergency contraception as a back-up to use of barrier methods. The sex, attitude and knowledge of the GPs influence the likelihood of women being made aware of or being given emergency contraception in NSW. There is a need to further educate both the public and practitioners about emergency contraception.

An accurate diabetes register enables a general practice to effectively monitor and manage the services for their patients with diabetes. This pilot project builds on the National Primary Care Collaboratives Program (a quality improvement programme for general practice) as the first change principle for managing chronic diseases. The main aim of the project was to improve the systems management of electronic registers of people with diabetes in the general practice setting. The pilot project assessed the uptake, awareness and confidence levels amongst practice staff in improving the diabetes register. This was completed by conducting a survey of general practitioners and practice nurses within one general practice in Perth, Western Australia. In addition, focus groups per and post intervention were facilitated to obtain practice staff's views upon the issues around maintaining an efficient and updated patient register within a busy practice setting. By the end of the project the general practice had an established diabetes register with defined and agreed practice systems.

BackgroundPhysical inactivity is a significant contributor to preventable chronic health conditions worldwide. General practice has been identified as a setting to improve physical activity levels through exercise promotion during consultations. However, physical activity promotion in general practice is unstructured and suboptimal.AimsThe aim of this study is to review the literature pertaining to factors that influence physical activity promotion in general practice and to answer the research question: what are the experiences of patients and GPs with physical activity promotion in consultations?MethodsOnline databases were searched for relevant papers using predetermined inclusion and exclusion criteria. Papers retrieved were original research only, involving patients, general practitioners or practice nurses. A PRISMA approach to study selection was followed.ResultsOf 464 papers retrieved, 20 were included in the review. Physical activity promotion is acceptable to patients but some do not appreciate its health benefits. A personalised approach is important to patients, including tailored advice and setting meaningful goals. Studies involving general practitioners and practice nurses report that they are aware of the importance of physical activity and their role in its promotion, but time is the primary barrier. Strategies identified include demedicalisation of physical activity, resources such as patient handouts as well as signposting to community initiatives, social prescribers and collaboration with exercise professionals.ConclusionGeneral practice has the potential to effectively promote physical activity but system- and practitioner-level changes are necessary to achieve meaningful change.

BackgroundThe Health Improvement and Prevention Study (HIPS) study aims to evaluate the capacity of general practice to identify patients at high risk for developing vascular disease and to reduce their risk of vascular disease and diabetes through behavioural interventions delivered in general practice and by the local primary care organization.Methods/DesignHIPS is a stratified randomized controlled trial involving 30 general practices in NSW, Australia. Practices are randomly allocated to an 'intervention' or 'control' group. General practitioners (GPs) and practice nurses (PNs) are offered training in lifestyle counselling and motivational interviewing as well as practice visits and patient educational resources. Patients enrolled in the trial present for a health check in which the GP and PN provide brief lifestyle counselling based on the 5As model (ask, assess, advise, assist, and arrange) and refer high risk patients to a diet education and physical activity program. The program consists of two individual visits with a dietician or exercise physiologist and four group sessions, after which patients are followed up by the GP or PN. In each practice 160 eligible patients aged between 40 and 64 years are invited to participate in the study, with the expectation that 40 will be eligible and willing to participate. Evaluation data collection consists of (1) a practice questionnaire, (2) GP and PN questionnaires to assess preventive care attitudes and practices, (3) patient questionnaire to assess self-reported lifestyle behaviours and readiness to change, (4) physical assessment including weight, height, body mass index (BMI), waist circumference and blood pressure, (5) a fasting blood test for glucose and lipids, (6) a clinical record audit, and (7) qualitative data collection. All measures are collected at baseline and 12 months except the patient questionnaire which is also collected at 6 months. Study outcomes before and after the intervention is compared between intervention and control groups after adjusting for baseline differences and clustering at the level of the practice.DiscussionThis study will provide evidence of the effectiveness of a primary care intervention to reduce the risk of cardiovascular disease and diabetes in general practice patients. It will inform current policies and programs designed to prevent these conditions in Australian primary health care.Trial RegistrationACTRN12607000423415