Showing papers in "British Journal of General Practice in 2004"

The 9/11 Commission Report: Final Report of the National Commission on Terrorist attacks upon the United States.

Abstract: Twenty-five years ago, as an American GP living and practising in Wales, I would watch BBC sports programmes, such as darts and bowls and snooker, all unknown to me and, therefore, fascinating. I always found it odd — pairings such as Scotland (or Wales) versus The Rest of the World. It either seemed overly ambitious for Scotland or slim pickings for the rest of the world. After the recent US presidential election, it appears as if it will continue to be the US versus The Rest of the World. Three books might help you, who are of ‘the rest of the world’, begin to grapple with what is going on in the US. Written from the short, medium, and long view, each has a somewhat parochial twist. Each also, however, contains a great deal of useful history. The 9/11 Commission Report refutes the old saw that nothing good can be written by a committee. The report is a remarkable book and its recent nomination as a finalist for the National Book Award is a first for a government document, and well deserved. What is contained in this report is well known by most of us — the cast of characters has been in the news for over 3 years. And the sequence of events and many of the details that were gleaned from the ongoing hearings have been contained in news stories, long and short. However, to have published what is known until this point in a single narrative, which is at once accessible and clearly written, is a truly historical achievement. Reading the events of the day — regarding the planes that crashed in the city of New York, as the rescue squads from police and fire departments move into place and act — is both familiar and detailed in a way that helps us understand better than I would ever have imagined the why and how of all the death and destruction. So much about those days have been parsed into documentaries — long analyses of causation of issues, like why the towers fell — that one would think that everything that could be written had been. But the Commission's report really does add enormous amounts of history to the sound bites and 30-second visuals that have pervaded politics and the world assessment of the US since that time. The report deals extensively and thoughtfully with the history of Islam, both ancient and recent, and describes the history of terrorism as it evolved from highjackings of the 1970s to the use of bombs and targeted destruction of military targets in the late 1980s and 1990s. Events that occurred in the time that preceded the attacks of 9/11 are written in a way that shows the convergence of intelligence reports, a long history of threats from Bin Laden, and many alerts and warnings (‘the system was blinking red’ in the words of Tenet, CIA director). The information about the movements of the terrorists in their planning and the worldwide involvement of cells, support systems, and finances makes it clear that these events were truly the result of a network that reaches virtually everywhere. After the attacks, reading of the efforts of the fire, police, and other rescue squads in New York adds specifics that are terrible and remarkable. On 9/11, I ran up and down the stairs between patients to watch on television as it was all happening. All of us who watched that day wondered what those people who were clearly doomed were thinking, feeling, and seeing. Their actual words in this report are not fiction, they are the words, for most the last words, of people who died as we watched. Their words are the hardest part of this long, detailed report to deal with. Much of the final third of the report is devoted to what a fire captain friend of mine once called a PFE — a post-fire evaluation — which he mandated for his squad after every fire. In a PFE, the entire squad reconstructed, relived, and discussed the events to see what could be improved next time. The 9/11 Commission engaged in a world-scale PFE. Although all US politicians state that they intend to follow the recommendations of The 9/11 Commission Report, the backing and filling is already well underway. What politician, for example, is going to agree that major conurbations, and political and tactical targets should receive preference over their hometown fire departments and that homeland security money should ‘not be used as a pork barrel’? Rather than bringing a grieving country together in a way that will make such events unlikely to happen again, the reactions from the report have begun to cleave along party lines once again. The 9/11 Commission was almost unique in its thoroughness, transparency, and its ability to focus on the real issue of terror and lawlessness. However, the extent to which a violent stateless ideology has negatively affected the tolerance of differences, the sense of community, and the level of civic discourse in the US means that terrorism has affected our neighborhoods as much as it has affected our country. And fear rather than determination, despite the President's stump speech, has become the dominant emotion. Robert Byrd, from his 45-year perspective in the US Senate, understands that cheques and balances are essential to avoid tragedy, even if they, at times, impede progress. His book, Losing America, contains several ‘under-the-table’ looks at Congress and the manipulations and arrogance of the coterie of ideologues who surround George W. Bush. Byrd, from the Southern tradition of politeness and respect, which often cloaks bar-room politics, is steeped in the history of the institution of the Senate. He is personally offended by Bush's lack of interest or curiosity in the legislative process prior to 9/11, and his dishonesty and deception afterwards. Byrd's address to the Senate on the eve of the war on Iraq was widely quoted and is contained in this book. While people marching in the streets made headlines, it was an 85-year-old senator, not previously known as an outraged progressive, who took on both the Administration for its hypocrisy and many of his colleagues for their lack of courage and principle. He voted against the war and continues to point out the dishonesty of the people who guide it. The book reads with a sensibility from another age. Although his own history is certainly not without problems, Senator Byrd's belief in the true democratic process, rather than the gun-barrel approach of George W. Bush, should be given the respect that he, and it, deserve. Arthur Schlesinger Jr has been writing history since 1946 and has Pulitzer prizes to prove he does it well. His voice is considered, thoughtful, and scholarly — as one might expect from a historian and distinguished teacher. Toward the end of his book War and the American Presidency, however, Schlesinger's voice rises with outrage at those who surround and influence George W. Bush, the ‘small group of Messianic statesman whose self righteousness bids fair to wreck our age’. He writes of the imperial presidencies of the early years of the country, which repressed dissent during wartime, and how the US moved from wars based on pique to engaging international diplomacy and internationalism. Schlesinger reminds us that all presidents since Wilson, with George W. Bush being the glaring exception, believed in statesmanship, diplomacy, alliances to guard against capricious choices and, when necessary, taking on common enemies. Much of Schlesinger's book, however, also chronicles the record of the current Administration which, by being ‘judge, jury, and executioner resurrects the imperial presidency’. An imperial presidency in the age of frigates and single-shot rifles cannot be compared with one that possesses weapons of mass destruction and a wooly-headed sense of divine guidance. We used to think of Henry Kissinger as the prototype for Dr Strangelove, but I wish Kubrick were still alive to do the remake with Dick Cheney and Donald Rumsfeld in mind. Needless to say, the recent election, instead of relegating George W. Bush and his hangers-on to the historical trashbin, has pushed them to the front of the international agenda. A secretive, defensive, unreflective president will now shape the world for our grandchildren. Each of these books elaborates on the ineffectiveness of Bush dealing with the real enemy while he digs deeper into a country where he is creating more enemies by the day. One has to ask why, instead of quietly writing their memoirs, two distinguished 87-year-old statesmen are raising the alarm and shaking us by the throat — like the aging Thomas Jefferson who, in his famous letter of 1820, said of the first compromise to try to divide the country between slave and free states: ‘this momentous question, like a firebell in the night, awakened and filled me with terror’. Byrd and Schlesinger hear the firebell and are ringing it to wake us up. Another quote that might better capture Bush and his legacy would be from the Bible he uses as justification for his policies: ‘He that troubleth his own house shall inherit the wind’ (Proverbs 11, 29).

Risk factors of influenza transmission in households

Abstract: Background: Influenza transmission in households is a subject of renewed interest, as the vaccination of children is currently under debate and antiviral treatments have been approved for prophylactic use. Aims: To quantify the risk factors of influenza transmission in households. Design of study: A prospective study conducted during the 1999 to 2000 winter season in France. Setting: Nine hundred and forty-six households where a member, the index patient, had visited their general practitioner (GP) because of an influenza-like illness were enrolled in the study. Five hundred and ten of the index patients tested positive for influenza A (subtype H3N2). A standardised daily questionnaire allowed for identification of secondary cases of influenza among their household contacts, who were followed-up for 15 days. Of the 395 (77%) households that completed the questionnaire, we selected 279 where no additional cases had occurred on the day of the index patient's visit to the GP. Methods: Secondary cases of influenza were those household contacts who had developed clinical influenza within 5 days of the disease onset in the index patient. Hazard ratios for individual clinical and demographic characteristics of the contact and their index patient were derived from a Cox regression model. Results: Overall in the 279 households, 131 (24.1%) secondary cases occurred among the 543 household contacts. There was an increased risk of influenza transmission in preschool contacts (hazard ratio [HR] = 1.85, 95% confidence interval [CI] = 1.09 to 3.26) as compared with school-age and adult contacts. There was also an increased risk in contacts exposed to preschool index patients (HR = 1.93, 95% CI = 1.09 to 3.42) and school-age index patients (HR = 1.68, 95% CI = 1.07 to 2.65), compared with those exposed to adult index cases. No other factor was associated with transmission of the disease. Conclusion: Our results support the major role of children in the dissemination of influenza in households. Vaccination of children or prophylaxis with neuraminidase inhibitors would prevent, respectively, 32–38% and 21–41% of secondary cases caused by exposure to a sick child in the household.

Prevalence of irritable bowel syndrome: a community survey

Abstract: Background: Irritable bowel syndrome (IBS) is a common health problem affecting a substantial proportion of the population. Many individuals with symptoms of IBS do not seek medical attention or have stopped consulting because of disillusionment with current treatment options. Such patients may choose to re-consult with the advent of new therapies with a resulting impact on health services. Aim: To generate reliable estimates of the prevalence of IBS by age, sex and symptom group. Design of study: Postal survey. Setting: Patients selected from registers of eight general practices in north and west Birmingham. Method: Eight thousand six hundred and forty-six patients aged ≥18 years were randomly selected from practice lists. Selected patients received a questionnaire, which included diagnostic criteria for IBS. A second questionnaire, seeking more detailed information, was sent to those whose responses indicated the presence of IBS symptoms. Results: Of the 8386 patients surveyed 4807 (57.3%) useable replies were received. The community-based prevalence of IBS was 10.5% (6.6% of men and 14.0% of women). Overall the symptom profiles were characterised by diarrhoea (25.4%), constipation (24.1%) and alternating symptoms (46.7%). Over half (56%) of all patients had consulted their general practitioner within the past 6 months and 16% had seen a hospital specialist. A quarter of patients consulted more than twice and 16% were referred to secondary care; almost half were on prescribed medication. However, the majority of patients were self-treated. Less than half of those currently reporting symptoms of IBS according to the Rome II criteria had received a diagnosis of IBS. Reduced quality of life and a previous diagnosis of a stomach ulcer were identified as predictors of consultation. Conclusion: Quality of life was significantly reduced in patients with IBS. There is a substantial burden on primary healthcare services despite over half of those with symptoms also self-medicating. The Rome II diagnostic criteria identified those most affected by their symptoms and are a valid clinical tool. Population-based health surveys will need to supplement the Rome criteria with questions aiming to identify patients formally diagnosed but whose symptoms are currently under control if prevalence is to be reliably estimated.

Factors influencing help seeking in mentally distressed young adults: a cross-sectional survey.

Abstract: BACKGROUND: Young adults, especially men, are among those least likely to consult healthcare professionals when mentally distressed or suicidal. AIMS: To investigate the help-seeking behaviours of mentally distressed young adults. Design of study: Cross-sectional survey. SETTING: Bristol and surrounding areas, including inner-city, suburban and urban locations. METHOD: A questionnaire was sent to a sample of 3004 young adults aged 16-24 years. This assessed probable mental disorder (using the 12-item general health questionnaire [GHQ-12]), suicidal thoughts (GHQ-28 suicide subscale), and help-seeking behaviours. RESULTS: Most responders who were assessed as having probable mental disorders (GHQ "cases") had not sought help. Help seeking was more common in female GHQ cases than male cases (34.8% and 21.8%,respectively; P = 0.003) and women with suicidal thoughts more commonly sought help than men with suicidal thoughts (41.6% and 30.9%, respectively; P = 0.15). Small proportions of male and female GHQ cases (7.5% and 8.9%, respectively; P = 0.6), and less than one in five responders with suicidal thoughts, had consulted a general practitioner. In more female than male cases, help was sought from family and friends (30.7% and 18.4%, respectively; P = 0.004). GHQ score was the strongest predictor of help seeking. Men had a higher threshold of severity at which they would seek help than women. Recent experience of suicidal thoughts appeared to be a stronger predictor of formal help seeking in mentally distressed women than mentally distressed men. CONCLUSION: Distressed young adults are reluctant to seek help. Men are particularly unlikely to do so unless severely distressed and tend not to seek lay support. Sex differences in help seeking may be important in understanding the high suicide rate for men.

Voiced but unheard agendas: qualitative analysis of the psychosocial cues that patients with unexplained symptoms present to general practitioners

Abstract: BACKGROUND: Symptomatic investigation and treatment of unexplained physical symptoms is often attributed to patients' beliefs and demands for physical treatments. AIM: To test the influential assumption that patients who present symptoms that the general practitioner (GP) considers to be medically unexplained do not generally provide the opportunity for discussion of psychological issues. DESIGN OF STUDY: Qualitative analysis of audiotaped consultations between patients and GPs. SETTING: Seven general practices in Merseyside, United Kingdom. METHODS: Transcripts of audiotaped consultations between 21 GPs and 36 patients with medically unexplained symptoms were analysed inductively to identify opportunities that patients presented for their doctors to address emotional problems or their need for explanation. RESULTS: All but two patients provided psychological opportunities. They described social or emotional difficulties as problems of stress or mood. They presented their need for explanation by: explicit questions; statements of concern about symptoms; suggestions that disease might be absent; or tentative references to serious disease. In general, GPs did not engage with these cues. CONCLUSIONS: Patients with unexplained symptoms present opportunities for GPs to address psychological needs. By taking these opportunities, GPs might be able to avoid unnecessary symptomatic intervention.

Patients' experiences when accessing their on-line electronic patient records in primary care.

Abstract: BACKGROUND: Patient access to on-line primary care electronic patient records is being developed nationally. Knowledge of what happens when patients access their electronic records is poor. AIM: To enable 100 patients to access their electronic records for the first time to elicit patients' views and to understand their requirements. DESIGN OF STUDY: In-depth interviews using semi-structured questionnaires as patients accessed their electronic records, plus a series of focus groups. SETTING: Secure facilities for patients to view their primary care records privately. METHOD: One hundred patients from a randomised group viewed their on-line electronic records for the first time. The questionnaire and focus groups addressed patients' views on the following topics: ease of use; confidentiality and security; consent to access; accuracy; printing records; expectations regarding content; exploitation of electronic records; receiving new information and bad news. RESULTS: Most patients found the computer technology used acceptable. The majority found viewing their record useful and understood most of the content, although medical terms and abbreviations required explanation. Patients were concerned about security and confidentiality, including potential exploitation of records. They wanted the facility to give informed consent regarding access and use of data. Many found errors, although most were not medically significant. Many expected more detail and more information. Patients wanted to add personal information. CONCLUSION: Patients have strong views on what they find acceptable regarding access to electronic records. Working in partnership with patients to develop systems is essential to their success. Further work is required to address legal and ethical issues of electronic records and to evaluate their impact on patients, health professionals and service provision.

Normalisation of unexplained symptoms by general practitioners: a functional typology.

Abstract: BACKGROUND: Patients often present in primary care with physical symptoms that doctors cannot readily explain. The process of reassuring these patients is challenging, complex and poorly understood. AIM: To construct a typology of general practitioners' (GPs') normalising explanations, based on their effect on the process and outcome of consultations involving patients with medically unexplained symptoms. DESIGN OF STUDY: Qualitative analysis of audiotaped consultations between patients and GPs. SETTING: Seven general practices in Merseyside, United Kingdom. METHODS: Transcripts of audiotaped consultations between 21 GPs and 36 patients with medically unexplained symptoms were analysed inductively, to identify types of normalising speech used by GPs. RESULTS: Normalisation without explanation included rudimentary reassurance and the authority of a negative test result. Patients persisted in requesting explanation and elaborated or extended their symptoms, rendering somatic management more likely. Normalisation with ineffective explanation provided a tangible physical explanation for symptoms, unrelated to patient's expressed concerns. This was also counterproductive. Normalisation with effective explanation provided tangible mechanisms grounded in patients' concerns, often linking physical and psychological factors. These explanations were accepted by patients; those linking physical and psychological factors contributed to psychosocial management outcomes. CONCLUSIONS: The routine exercise of normalisation by GPs contains approaches that are ineffective and may exacerbate patients' presentation. However, it also contains types of explanation that may reduce the need for symptomatic investigation or treatment. These findings can inform the development of well-grounded educational interventions for GPs.

An epidemiological survey of symptoms of menstrual loss in the community.

Abstract: Background: For the early detection of gynaecological malignancy, guidance based on presenting symptoms exists to aid a general practitioner (GP) in determining who to investigate or refer. The evidence for this advice is based on the prevalence of symptoms in women with gynaecological malignancy or within specialist clinics. There are no studies on the incidence of symptoms within the community. Aim: To provide an estimate of the incidence of self-reported symptoms of menstrual loss in the community population of a single general practice. Design of study: A prospective population-based cohort study of women identified through a baseline postal survey and followed 6 and 12 months later. Setting: An urban general practice with four partners and 10 000 registered patients. Method: A postal baseline survey was undertaken on all women aged 18–54 years on the practice age–sex register. Responders who consented to follow-up were sent further questionnaires at 6 and 12 months. All questionnaires enquired about the presence or absence of symptoms related to vaginal bleeding. Twelve-month cumulative incidence rates were calculated using responders to the baseline, 6-month and 12-month questionnaires. Results: A total of 2435 questionnaires were initially sent out at baseline and 1513 (62%) women replied to all three questionnaires. The 12–month cumulative incidence of symptoms in menstruating women was: menorrhagia 25% (95% confidence interval [CI] = 22 to 29); periods heavier than usual, 21% (95% CI = 18 to 23); change in pattern of cycle, 29% (95% CI = 26 to 32); short cycle 21% (95% CI = 19 to 24); long cycle 15% (95% CI = 13 to 18); intermenstrual bleeding 17% (95% CI = 14 to 19); postcoital bleeding 6% (95% CI = 5 to 8); prolonged period 9% (95% CI = 7 to 11). Conclusion: The development of symptoms of menstrual loss among women in the community is common, in contrast to the rarity of gynaecological malignancy. This raises concern about the usefulness of current guidelines, based on symptoms, advising women when to consult, and for the early detection of gynaecological malignancy in the community and primary care.

Patient factors associated with duration of certified sickness absence and transition to long-term incapacity.

Abstract: BACKGROUND: Despite a considerable increase in claims for long-term sickness benefits, and the impact of certifying sickness upon general practitioner (GP) workload, little is known about transition to long-term incapacity for work. AIM: To explore the relationship between patient factors and the transition from short-term to long-term work incapacity, in particular focusing on mild mental health and musculoskeletal problems. SETTING: Nine practices comprising the Mersey Primary Care R&D Consortium. DESIGN: Prospective data collection and audit of sickness certificate details. METHOD: GPs issued carbonised sickness certificates for a period of 12 months. The resulting baseline dataset included claimant diagnosis, age, sex, postcode-derived deprivation score, and sickness episode duration. Associations of patient factors with sickness duration outcomes were tested. RESULTS: Mild mental disorder accounted for nearly 40% of certified sickness. Relatively few claimants had their diagnosis changed during a sickness episode. Risk factors for longer-term incapacity included increasing age, social deprivation, mild and severe mental disorder, neoplasm, and congenital illness. For mild mental disorder claimants, age, addiction, and deprivation were risk factors for relatively longer incapacity. For musculoskeletal problems, the development of chronic incapacity was significantly related to the nature of the problem. Back pain claimants were likely to return to work sooner than those with other musculoskeletal problems. CONCLUSIONS: In addition to the presenting diagnosis, a range of factors is associated with the development of chronic incapacity for work, including age and social deprivation. GPs should consider these when negotiating sickness certification with patients.

Blood glucose self-monitoring in non-insulin-treated type 2 diabetes: a qualitative study of patients' perspectives.

Abstract: BACKGROUND: Self-monitoring of blood glucose is controversial in the management of type 2 diabetes. Some research suggests that self-monitoring improves glycaemic control, whereas other research is sceptical about its value for people with type 2 diabetes who are not on insulin. Although blood glucose meters are widely available and used by this group, patients' own views are absent from the debate. AIM: To explore the pros and cons of glucose monitoring from the patients' perspectives. DESIGN OF STUDY: Qualitative repeat-interview study. SETTING: Patients were recruited from 16 general practices and three hospital clinics within four local healthcare cooperatives in Lothian, Scotland. METHOD: Interview data from 40 patients diagnosed with type 2 diabetes within the previous 6 months were analysed using thematic analysis informed by grounded theory. We report findings from round 1 and round 2 interviews. RESULTS: Glucose monitoring can heighten patients' awareness of the impact of lifestyle; for example, dietary choices, on blood glucose levels. Glucose monitoring amplifies a sense of 'success' or 'failure' about self-management, often resulting in anxiety and self-blame if glucose readings remain consistently high. Moreover, monitoring can negatively effect patients' self-management when readings are counter-intuitive. CONCLUSION: Our analysis highlights the importance of understanding the meanings that newly diagnosed patients attach to glucose self-monitoring. To maximise the positive effects of self-monitoring, health professionals should ensure that patients understand the purpose of monitoring and should clarify with patients how readings should be interpreted.

The Shipman Inquiry

Abstract: The proposals of the independent public inquiry into the issues arising from the case of Harold Shipman, as currently listed on The Shipman Inquiry website, include the recommendation that coroner's investigators should be trained to ‘think dirty’.1 Doctors will soon learn that medical coroners are keen to discover medical error and that such …

Systematic review of recent innovations in service provision to improve access to primary care

Abstract: Background: In England, there are particularly pressing problems concerning access to adequate primary care services. Consequently, innovative ways of delivering primary care have been introduced to facilitate and broaden access. Aims: The aim of this study was to review the evidence of seven recent innovations in service provision to improve access or equity in access to primary care, by performing a systematic review of the literature. Design of study: Systematic review. Setting: Primary care in the United Kingdom (UK). Method: Seven electronic databases were searched and key journals were hand-searched. Unpublished and ‘grey’ literature were sought via the Internet and through professional contacts. Intervention studies addressing one of seven recent innovations and conducted in the UK during the last 20 years were included. Two researchers independently assessed the quality of papers. Results: Thirty studies (32 papers and two reports) were identified overall. Variation in study design and outcome measures made comparisons difficult. However, there was some evidence to suggest that access is improved by changing the ways in which primary care is delivered. First-wave personal medical services pilots facilitated improvements in access to primary care in previously under-served areas and/or populations. Walk-in centres and NHS Direct have provided additional access to primary care for white middle-class patients; there is some evidence suggesting that these innovations have increased access inequalities. There is some evidence that telephone consultations with GPs or nurses can safely substitute face-to-face consultations, although it is not clear that this reduces the number of face-to-face consultations over time. Nurse practitioners and community pharmacists can manage common conditions without the patient consulting a general practitioner. Conclusion: The evidence is insufficient to make clear recommendations regarding ways to improve access to primary care. In the future, it is important that, as new initiatives are planned, well-designed evaluations are commissioned simultaneously.

The health-related quality of life of people with peripheral arterial disease in the community: the Edinburgh Artery Study.

Abstract: Background: Previous studies investigating the health-related quality of life of those with peripheral arterial disease have focused on patients recruited from hospital clinics. The health-related quality of life of people with peripheral arterial disease in the general population is unknown. Aims: We aimed to determine the health-related quality of life of people with intermittent claudication and asymptomatic peripheral arterial disease in the general population and to compare it with those with angina and those with no peripheral arterial disease or angina. Design of study: Analysis of cross-sectional data from the 12-year follow-up of a population-based cohort. Setting: Edinburgh, Scotland. Method: Data from the Edinburgh Artery Study cohort's 12-year follow-up was analysed. Participants' peripheral arterial disease status was measured using the World Health Organisation intermittent claudication questionnaire and the ankle brachial pressure index. Self-assessed health-related quality of life data was collected using the SF-36 generic questionnaire. Health-related quality of life scores were calculated and their associations with peripheral arterial disease status groups were tested. Results: Subjects with intermittent claudication had significantly worse median health-related quality of life scores than patients without claudication in all domains except social functioning and mental health. Patients with claudication had a significantly lower physical component summary score than those without claudication (P≤0.001). This association remained after adjustment for age, sex, social class, body mass index, smoking, and angina. Those with angina and claudication had significantly worse physical component summary scores than those with no peripheral arterial disease or angina (P≤0.001). No significant difference was found in health-related quality of life scores between those with asymptomatic peripheral arterial disease and those with no peripheral arterial disease even after multiple adjustment for confounding factors. Conclusion: People with intermittent claudication in the community had impaired health-related quality of life related to reduced physical health, but asymptomatic peripheral arterial disease did not significantly affect health-related quality of life.

Positive experiences of teenage motherhood: a qualitative study.

Abstract: Background: Teenage pregnancy is seen as a cause for concern in the United Kingdom (UK). However, there has been little research from primary care looking at teenage motherhood and its implications. Aim: To investigate the experiences of teenage mothers in relation to their role as mothers and their expectations of their futures. Design of study: Qualitative study. Setting: East Devon, England. Methods: Nine women who had conceived their first child while still a teenager agreed to participate. Semi-structured interviews were undertaken, audiotaped, transcribed, and analysed using interpretative phenomenological analysis. Results: The women expressed positive attitudes to being mothers and described how it had affected their lives. For some, motherhood had been the impetus to change direction and consider a career, because they had someone else for whom they were responsible. They recognised that they were still young enough to enter further education or other aspects of employment as their children grew up. Conclusions: For the women in this study, having been a teenage mother did not mean that their life and future were all over. Motherhood and bringing up children were valued in their own right. The women were realistic about their futures, often making plans to develop their careers.

Early detection of COPD in primary care: screening by invitation of smokers aged 40 to 55 years.

Abstract: BACKGROUND: The incidence of chronic obstructive pulmonary disease (COPD) is increasing in developed countries, as is the mortality rate. The main cause of COPD is smoking, and COPD is usually diagnosed at a late stage. AIM: To evaluate a method to detect COPD at an early stage in smokers in a young age group (40-55 years). DESIGN OF STUDY: Prospective descriptive study. SETTING: The city of Motala (45,000 inhabitants) and its surrounding rural areas (43,000 inhabitants) in south-east Sweden. Nineteen thousand, seven hundred and fifty subjects were between 40 and 55 years of age. According to Swedish statistics, approximately 27% of this population are smokers. METHOD: Smokers aged between 40 and 55 years were invited to have free spirometry testing in primary healthcare centres. Placards were placed in pharmacies and health centres and advertising was carried out locally twice a year. RESULTS: A total of 512 smokers responded. The prevalence of COPD was 27% (n = 141). The COPD was classified as mild obstruction in 85% (n = 120), moderate in 13% (n = 18) and severe in 2% (n = 3) according to the European Respiratory Society classification. Knowledge of the disease COPD was acknowledged by 39% of the responders to the questionnaire. Logistic regression analysis showed that age, male sex, number of pack years, dyspnoea and symptoms of chronic bronchitis significantly increased the odds of having COPD. The adjusted odds ratio was significant for having > 30 pack years. CONCLUSIONS: This method of inviting relatively young smokers selected a population of smokers with a high incidence of COPD, and may be one way of identifying smokers with COPD in the early stages.

The maldistribution of general practitioners in England and Wales: 1974-2003

Abstract: Background: The geographical distribution of general practitioners (GPs) is a persistent policy concern within the National Health Service. Maldistribution across family health service authorities in England and Wales fell between 1974 and the mid-1980s but then remained, at best, constant until the mid-1990s. Aim: To estimate levels of maldistribution over the period 1994–2003 and to examine the long-term trend in maldistribution from 1974–2003. Design: Annual snapshots from the GP census. Setting: One hundred 2001 ‘frozen’ health authorities in England and Wales for 1994–2003 and 98 family health service authorities for 1974–1995. Method: Ratios of GPs to raw and need-adjusted populations were calculated for each health authority for each year using four methods of need adjustment: age-related capitation payments, national age- and sex-specific consultation rates, national age- and sex-specific limiting long-term illness rates, and health authority-specific mortality. Three summary measures of maldistribution across health authorities in the GP to population ratio — the decile ratio, the Gini coefficient, and the Atkinson index — were calculated for each year. Results: Maldistribution of GPs as measured by the Gini coefficient and Atkinson index increased from the mid-1980s to 2003, but the decile ratio showed little change over the entire 1974–2003 period. Unrestricted GP principals and equivalents were more equitably distributed than other types of GP. Conclusion: The 20% increase in the number of unrestricted GPs between 1985 and 2003 did not lead to a more equal distribution.

Managing controversy through consultation: a qualitative study of communication and trust around MMR vaccination decisions

Abstract: Background: Controversy over the measles, mumps, and rubella (MMR) vaccine has reduced uptake, raising concerns of a future disease epidemic. Aims: To explore parents' accounts of decision making relating to the MMR vaccine controversy, identifying uptake determinants and education needs. Design of study: Qualitative interviews analysed using the ‘framework’ approach. Setting: Five general practices in the Leeds area, 2002–2003. Method: Sixty-nine interviews conducted with parents of children aged between 4 and 5 years, and 12 interviews with primary care practitioners, managers and immunisation coordinators serving participating sites. Participants were interviewed one-to-one in a place of their choice. Results: The vaccination decision is primarily a function of parental assessments of the relative acceptability and likelihood of possible outcomes. For most parents the evidence of science and medicine plays little role in the decision. Although local general practitioners and health visitors are trusted information sources, the influence of primary care providers on the vaccination decision is limited by concerns over consultation legitimacy, discussion opportunity, and perceptions of financial and political partiality. Parents and practitioners identify a need for new approaches to support decisions and learning when faced with this and similar healthcare controversies. These include new collaborative approaches to information exchange designed to transform rather than supplant existing parent knowledge as part of an ongoing learning process. Conclusion: The study identified new ways in which parents and practitioners need to be supported in order to increase understanding of medical science and secure more informed decisions in the face of health controversy.

Qualitative study of men's perceptions of why treatment delays occur in the UK for those with testicular cancer.

Abstract: BACKGROUND: Many studies (but not all) have shown that for men with testicular cancer a longer treatment delay is associated with additional treatments, greater morbidity, and shorter survival. AIM: This paper explores patients' perspectives on why treatment delays occur. DESIGN: Qualitative study using narrative interviews SETTING: Interviews in patient's homes throughout the United Kingdom (UK). METHOD: Interviews with a maximum variation sample of 45 men with testicular cancer, recruited through general practitioners (GPs), urologists, support groups, and charities. RESULTS: Those who sought help relatively quickly responded to symptoms, had heard about testicular cancer in the media, had seen leaflets in GPs' surgeries, or knew others with this disease. Men delayed because they did not recognise signs and symptoms; feared appearing weak, a hypochondriac, or lacking in masculinity; recalled past illness or painful examinations; were embarrassed; feared the consequences of treatment; or lacked time to consult their doctors. Beliefs about symptoms and pessimistic associations with cancer also led to delay. Treatment delays also resulted from misdiagnosis or waiting lists. CONCLUSION: Whether or not men should be taught to examine themselves routinely to check for testicular cancer is much debated. This study suggests that it is important that men are aware of the normal shape and feel of their testicles, and may benefit from information about signs and symptoms of testicular cancer and the excellent cure rate. Information, provided in surgeries where men feel welcome, might encourage men to seek help promptly when a problem arises. Our study also suggests that GPs may need to accept a low threshold for ultrasound investigation of testicular symptoms and that the ultrasound service needs to be improved. These measures may further reduce mortality and morbidity.

Missed appointments in primary care: questionnaire and focus group study of health professionals

Abstract: BACKGROUND: The issue of missed appointments in primary care is important for patients and staff. Little is known about how missed appointments, and the people who miss them, are managed in primary care, or about effective strategies for managing missed appointments. AIMS: To understand the perceptions of primary care staff as to why patients miss appointments, to determine how these perceptions influence their management, and to explore the merit of different management strategies. Design of study: A postal questionnaire survey and focus group interviews. SETTING: General practices in Yorkshire. RESULTS: Missed appointments were regarded as an important problem. Patient factors rather than practice factors were perceived as most important in causing missed appointments. Intervention strategies appeared to be driven by perceptions of why patients miss appointments. Negative attitudes, embodied in terms such as "offenders" to refer to those who missed appointments were prevalent, and favoured intervention strategies included punishing the patient in some way. Receptionists believed that general practitioners should address the issue of the missed appointment with the patient. General practitioners felt guarded about addressing missed appointments with their patients in case it affected the doctor-patient relationship. CONCLUSION: People who miss appointments were viewed negatively by primary care staff, and most of the reasons for missed appointments were focused on patients. These beliefs underpinned intervention strategies aimed mainly at punishment. Since there is no evidence base concerning interventions that are effective in reducing missed appointments, these negative attitudes may not be beneficial to staff or their patients.

Cognitive status and analgesic provision in nursing home residents

Abstract: SUMMARY Background: Although it is becoming acknowledged that pain management is generally poor for older people, little is known about pain management for nursing home residents in the United Kingdom, and the specific problems for those with cognitive impairments. Aims: This section of a larger study of pain aimed to explore analgesic prescription and administration according to nursing home residents’ cognitive status. Design of study: A survey of nursing home residents and their medication documentation. Setting: The sample included 113 nursing home residents from 15 nursing homes in large city in the north of England. Method: Residents’ cognitive status was assessed using the mini-mental state examination (MMSE). Pain was measured with a four-point verbal rating scale and a 10-point horizontal numeric rating scale. Residents’ medications — including name, dose, and frequency of administration — were noted, as well as provision within the previous 24 hours. Results: There were no statistically significant differences in pain scores according to level of cognitive impairment. The prescription and administration of opioid and non-opioid analgesics were highest for residents with low cognitive impairment; these decreased as impairment increased. Those who were prescribed neither opioid nor non-opioid analgesics had significantly lower MMSE scores than those who were. A low MMSE score indicates a high level of cognitive impairment. Conclusion: It is not clear why those with greater cognitive impairment received fewer analgesics than others. More research is needed into the relationships between pain assessment, pain experience, cognitive impairment, and analgesic provision. It is likely that improvements in carers’ knowledge of pain assessment and the risks and benefits of commonly used analgesics could improve analgesic provision.

C-reactive protein measurement in general practice may lead to lower antibiotic prescribing for sinusitis.

Abstract: Background: Symptoms of bacterial sinusitis overlap with viral sinusitis, and it is difficult to distinguish between the two conditions based only on a clinical examination. Uncertain diagnosis results in the significant overuse of antibiotics, which is considered to be one of the most important reasons for development of bacterial resistance to antibiotics. A raised C-reactive protein (CRP) level is an indicator of bacterial infection and the CRP rapid test has been shown to be useful for the diagnosis of bacterial sinusitis in general practice. Aims: To examine whether general practitioners (GPs) who use the CRP rapid test in their practice have a lower antibiotic prescribing rate for sinusitis than GPs who do not use the test. Design of study: Observational design. Setting: General practice in Denmark. Method: A group of GPs registered all contacts (n = 17 792) with patients who had respiratory tract infections during a 3-week period between 1 November 2001 and 31 January 2002. GPs who used a CRP rapid test were compared with GPs who did not, and the treatment of their patients (n = 1444) with suspected sinusitis was compared. Results: A CRP rapid test was used by 77% (n = 281) of the GPs. In the group of GPs using a CRP rapid test, the rate of antibiotic prescribing was 59% (95% confidence interval [CI] = 56 to 62) compared with 78% (95% CI = 73 to 82) in the group of GPs who did not use a CRP test. Performing a CRP rapid test was the factor that exerted the greatest influence on whether the patients were prescribed antibiotics, and the level of CRP had a strong influence on the prescribing rate. Conclusion: The CRP rapid test has a substantial influence on the treatment of sinusitis, and implementing the test in general practice may lead to a reduction in antibiotic prescribing to patients with sinusitis.

Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial.

Abstract: BACKGROUND: The Royal College of General Practitioners (RCGP) has produced guidelines for the management of acute low back pain in primary care. AIM: To investigate the impact on patient management of an educational strategy to promote these guidelines among general practitioners (GPs). DESIGN OF STUDY: Group randomised controlled trial, using the health centre as the unit of randomisation. SETTING: Primary care teams in north-west England. METHOD: Twenty-four health centres were randomly allocated to an intervention or control arm. Practices in the intervention arm were offered outreach visits to promote national guidelines on acute low back pain, as well as access to fast-track physiotherapy and to a triage service for patients with persistent symptoms. RESULTS: Twenty-four centres were randomised. Two thousand, one hundred and eighty-seven eligible patients presented with acute low back pain during the study period: 1049 in the intervention group and 1138 in the control group. There were no significant differences between study groups in the proportion of patients who were referred for X-ray, issued with a sickness certificate, prescribed opioids or muscle relaxants, or who were referred to secondary care, but significantly more patients in the intervention group were referred to physiotherapy or the back pain unit (difference in proportion = 12.2%, 95% confidence interval [CI] = 2.8% to 21.6%). CONCLUSION: The management of patients presenting with low back pain to primary care was mostly unchanged by an outreach educational strategy to promote greater adherence to RCGP guidelines among GPs. An increase in referral to physiotherapy or educational programmes followed the provision of a triage service.

The course of C-reactive protein response in untreated upper respiratory tract infection

Abstract: SUMMARY Background: High C-reactive protein (CRP) values are frequently found in patients with bacterial respiratory infection, and CRP testing has been shown to be useful in differentiating pneumonia from other respiratory infections. Raised CRP values may also be found in viral respiratory infection, and as a result there is a risk that antibiotics may be wrongly prescribed. Aims: To describe the course of the CRP response during untreated upper respiratory tract infections and associations between the development of CRP values, erythrocyte sedimentation rate (ESR) and respiratory symptoms. Design of study: Prospective study. Setting: Seven general practices in northern Norway. Method: Patients with upper respiratory tract infection aged 16 years or over, who were not treated with antibiotics and who had been ill for no more than 3 days, were recruited. Microbiological examinations were undertaken, together with measurements of CRP, ESR and recording of symptoms daily during the first week of illness and on days 10, 14 and 21. Results: An aetiological agent was established in 23 of the 41 included subjects. These were: influenza A, influenza B, rhinovirus, and other agents. Among the 15 patients examined on both the second and the third day of illness, the median CRP value increased from 7–10 mg/l, and the mean value was from 19–24 mg/l between day 2 and day 3. Peak CRP values were reached on days 2 to 4. Higher CRP values were found in those infected with influenza A and B than in the other subjects (P 10 mg/l was found in 26 subjects during the first 7 days, compared to five subjects after 1 week. Evidence of a secondary infection with group A streptococci was found in two of these five subjects. The development of the symptoms of sore throat, fatigue, clamminess, and pain from muscles and joints followed a similar course as the CRP response, while stuffy nose, cough, sputum production, and dyspnoea tended to persist after the CRP values had approached the normal range. Conclusion: A moderately elevated CRP value (10–60 mg/l) is a common finding in viral upper respiratory tract infection, with a peak during days 2–4 of illness. Moderately elevated CRP values cannot support a diagnosis of bacterial infection when the illness has lasted less than 7 days, but may indicate a complication of viral infection after a week.

Randomised controlled trial of pelvic floor muscle exercises and manometric biofeedback for erectile dysfunction.

Abstract: The paper presents the results of an RCT which established the effectiveness of pelvic floor muscle exercises for erectile dysfunction. A paper reporting the findings won the best scientific presentation award at the 2004 International Continence Society (UK division) conference. Whurr has published a full report of the study.

Self-reported experiences of health services among female street-based prostitutes: a cross-sectional survey

Abstract: Background: Previous studies show that women working in prostitution do not use routine health services appropriately. Little is known about the nature and frequency of service contacts or barriers to access. This information is needed if use of current services by this group is to improve. Aim: To identify barriers reducing access to health services by street prostitutes, and to identify current patterns of use. Design of study: Cross-sectional survey. Setting: Inner-city Bristol. Method: Seventy-one female street-based prostitutes were interviewed about their experiences of health services. Results: The women had frequent contacts with healthcare providers. The general practitioner (GP) was the main source of all types of care. Although 83% (59/71) were registered with a GP, 62% (36/59) had not disclosed their work. Only 46% (33/71) had been screened for sexually transmitted infection in the previous year and 24% (17/71) were vaccinated against hepatitis B, a national recommendation for sex workers. Only 38% (25/65) had had cervical smears according to screening guidelines. Opportunistic screening and care was important. While pregnant with their last child, only 30% (14/47) booked in the first trimester and attended all antenatal appointments, with 13% (6/47) receiving no antenatal care until admitted in labour. Appointments, waiting times, and fear of judgement and other patients staring, were considered significant barriers to service use. The model suggested by the women was an integrated service providing basic living needs alongside health care. Conclusion: Non-disclosure and poor attendance for follow-up make appropriate care difficult, and may contribute to poor health. Despite frequent service contacts, opportunities for care are being missed.

Detection of child mental health disorders by general practitioners.

Abstract: Background: Few children with mental disorders access specialist services. Although previous studies suggest that general practitioner (GP) recognition is limited, parents may not be presenting these problems. Aim: To compare GP recognition of disorders with child mental health data and to examine factors affecting recognition, in particular whether recognition is enhanced if the parent expresses concern during the consultation. Design of study: A two-phase design involving an initial community survey of children between the ages of 5 and 11 years. In the second phase, primary care attenders who were regarded by their GP as having a mental health disorder were compared with those who were not. Setting: Five general practices in Croydon, outer London. Method: For 186 children attending primary care, GP recognition of disorders was compared with the results of a child mental health questionnaire completed by parents. Accuracy and predictors of GP recognition were examined. Results: Seventy-four per cent of children meeting criteria for caseness were not recognised by GPs as having a mental health disorder. The expression of parental concern in the consultation about a mental health problem increased the sensitivity of recognition from 26% to 88%. Expression of concern also increased GP recognition of non-cases; this reflected GP identification of other mental health and learning problems. Only a third of parents who had concerns expressed these during the consultation. Conclusions: GPs are responsive to concern and take parental views into account. As well as detecting disorders, GPs are also sensitive to other psychosocial and educational problems that may present in primary care. There is a need for parental education about child mental health disorders.

New concepts in screening

Abstract: ALTHOUGH screening is often delivered by clinicians, screening programmes are public health services that need to be managed at the level of a large population to monitor quality effectively. In the United Kingdom (UK) this is carried out by the National Screening Committee. The first task of the National Screening Committee is to use research evidence to identify programmes that do more good than harm. The second is to make policy recommendations about those programmes that will do more good than harm at reasonable cost, focusing on opportunity cost; that is, the professional time involved, as well as the financial cost. When it has been decided to introduce screening, using criteria based on the Wilson and Jungner WHO criteria, 1 care has to be taken to ensure that the programme is set up in a way that will minimise harm and maximise benefit. In policy making the evidence for screening is often limited because of the rarity of the conditions being screened for, which minimises the contribution that the randomised controlled trial can make, but emphasises the need for a systematic review of the evidence.

Preferences for general practice jobs: a survey of principals and sessional GPs

Abstract: Background: Many countries are experiencing recruitment and retention problems in general practice, particularly in rural areas. In the United Kingdom (UK), recent contractual changes aim to address general practitioner (GP) recruitment and retention difficulties. However, the evidence base for their impact is limited, and preference differences between principals and sessional GPs (previously called non-principals) are insufficiently explored. Aim: To elicit GP principals' and sessional GPs' preferences for alternative jobs in general practice, and to identify the most important work attributes. Design of study: A discrete choice experiment. Setting: National Health Service (NHS) general practices throughout Scotland. Method: A postal questionnaire was sent to 1862 principals and 712 sessional GPs. The questionnaire contained a discrete choice experiment to quantify GPs' preferences for different job attributes. Results: A response rate of 49% (904/1862) was achieved for principals and 54% (388/712) for sessional GPs. Of responders, most principals were male (60%), and sessional GPs female (75%), with the average age being 42 years. All GPs preferred a job with longer consultations, no increase in working hours, but an increase in earnings. A job with outside commitments (for example, a health board or hospital) was preferable; one with additional out-of-hours work was less preferable. Sessional GPs placed a lower value on consultation length, were less worried about hours of work, and a job offering sufficient continuing professional development was less important. Conclusion: The differences in preferences between principals and sessional GPs, and also between different personal characteristics, suggests that a general contract could fail to cater for all GPs. Recruitment and retention of GPs may improve if the least preferred aspects of their jobs are changed. However, the long-term success of contractual reform will require enhancement of the positive aspects of working, such as patient contact.

Valued aspects of primary palliative care: content analysis of bereaved carers' descriptions.

Abstract: Background: Informal carers provide the bulk of palliative home care. They largely rely on general practitioners (GPs) and district nurses to support them in this role, yet little is known about what carers themselves consider important in this support. Aim: To identify what informal carers valued in the palliative support provided by GPs and district nurses by using carers' own descriptions of such support. Design of study: Retrospective interviews. Setting: Primary care in Cambridgeshire. Method: Semi-structured interviews with bereaved carers of 48 patients with cancer and 12 patients with non-cancer diagnoses. Content analysis of carers' evaluative descriptions of GP and district nurse support. Results: The accessibility of the GP and district nurse emerged as the most important aspect of support. Enlistment of help from other agencies was also extensively mentioned, together with provision of equipment. Attitude or approach during interactions, and relationship with the professional were important, particularly regarding GP support, whereas support for the carer, information, and symptom control were mentioned less often. Data suggested that support was not as good for older patients (≥75 years), but this finding requires further investigation. Conclusion: Results largely confirmed findings of previous, quantitative research and the importance of a patient-centred approach. What emerged most strongly, however, was the central importance of accessibility of support services for lay carers responsible for end-of-life home care. This mainly concerned GP and district nurse support, but accessibility of additional care and equipment were also important. In short, carers' main focus was the basic support that enabled them to sustain care in the home.

Evaluation of Advanced Access in the National Primary Care Collaborative

Abstract: Background: An aim of the National Primary Care Collaborative is to improve quality and access for patients in primary care using principles of Advanced Access. Aims: To determine whether Advanced Access led to improved availability of appointments with general practitioners (GPs) and to examine GPs' views of the process. Design: Observational study. Setting: Four hundred and sixty-two general practices in England participating in four waves of the collaborative during 2000 and 2001. Method: Regression analysis of the collaborative's monthly data on the availability of GP appointments for the 352 practices in waves 1–3, and a postal survey of lead GPs in all four waves. The main outcome measures were the change in mean time to the third available appointment with GPs, and the proportion of GPs thinking it worthwhile participating in the collaborative. Results: The time to the third available appointment improved from a mean of 3.6 to 1.9 days, difference = 1.7 days, 95% confidence interval (CI) = 1.4 to 2.0 days. It improved in two-thirds of practices (66% [219/331]), remained the same in 16% (53/331), and worsened in 18% (59/331). The majority of GPs in all four waves, 83% (308/371, 95% CI = 79 to 87), felt that it was worthwhile participating in the collaborative, although one in 12 practices would not recommend it. One-fifth of GPs cited a lack of resources as a constraint, and some expressed concerns about the trade-off between immediate access and continuity of care. Conclusion: Advanced Access helped practices to improve availability of GP appointments, and was well received by the majority of practices.