Audit of deaths in general practice: pilot study of the critical incident technique.

OBJECTIVE: To develop and pilot a method for conducting an audit of deaths in general practice by the critical incident technique. DESIGN: Prospective use of the technique within a primary health care team, with the aid of a facilitator, to analyse the events surrounding patients' deaths. SETTING: One inner city academic general practice. PARTICIPANTS: Practice team, comprising general practitioners, trainee, practice manager, practice nurse, and attached health visitor and district nurses. MAIN MEASURES: Identification and classification of critical incidents associated with the case studies of eight recently decreased patients in the practice and subsequent impact on the practice. RESULTS: Among the eight case studies, 57 critical incidents were identified (mean 7.1 per case, range 2 to 15). A failure of communication was the most common factor identified in incidents giving rise to concern, but positive factors in patient care were also identified. Changes in practice included developing protocols for follow up of bereaved relatives and carers and a checklist to ensure completion of administrative follow up tasks resulting from the patient's death; cases of recent deaths and terminally ill patients were reviewed monthly. The practice team found the method acceptable and felt that the discussions had provided useful opportunities for reflecting on their role in patient care. CONCLUSIONS: The critical incident technique fulfils the needs of an audit of deaths in general practice; however, further evaluation based on more cases from different practices is now required.

Primary and community health services in Newcastle upon Tyne--a joint statement of intent.

In the absence of a single primary health care authority (except in Scotland) district health authorities and family practitioner committees must cooperate in planning health services for the community. Equally, in the field, the potential for teamwork between salaried district health authority nursing staff and the independent general practitioners remains largely unrealized. Yet the government has restated its commitment to the development of primary health care teams as the best means of delivering health care in the community. In Newcastle upon Tyne the local medical committee and the community health services management team have set out their shared aspirations for future development in a joint 'Statement of intent'. This statement, since endorsed by the district health authority and family practitioner committee, includes a number of key principles as a basis for future joint working. These principles emanate from an understanding of the complementary nature of general practice and district health authority community services, and firmly support the primary health care team approach. This statement of intent could serve as a useful model for collaboration and planning of services elsewhere in the country.

Improving immunisation: coverage in a province in Papua New Guinea.

The effect on immunisation coverage of applying guiding principles to the management of primary health care services in a province in Papua New Guinea is described. These principles were: (a) Each health centre should have a defined geographical area of responsibility. (b) Each health centre should be responsible for a defined population. (c) Each health centre should have defined target groups for immunisation and child health clinic enrollment. (d) An accurate and meaningful reporting system is essential. (e) Each health centre should receive regular feedback on its achievements. Immunisation coverage in the province, as judged by the proportion of children under 1 year of age receiving their second dose of triple antigen, improved from 57-67% in 1980-2 to 89-94% in 1983-4. Immunisation is the most cost effective preventive activity undertaken in child health care. The application of these guiding principles would be relevant in the United Kingdom.

PIP: The effect on immunization coverage of applying guiding principles to the management of primary health care (PHC) services in a province in Papua New Guinea is described. These principles were: a) Each health center should have a defined geographical area of responsibility. b) Each health center should be responsible for a defined population. c) Each health center should have defined target groups for immunisation and child health clinic enrollment. d) An accurate and meaningful reporting system is essential. e) Each health center should receive regular feedback on its achievements. Immunization coverage in the province, as judged by the proportion of children under 1 year of age receiving their 2nd dose of triple antigen, improved from 57-67% in 1980-82 to 89-94% in 1983-84. A national goal is that 80% of children should have received at least their 2nd triple antigen and polio immunizations by the age of 1 year. As there is no compulsory registration of birth and death in Papua New Guinea, there is no certain method of ascertaining the target group for immunization. An estimate of the number of children under 1 year is available from national censuses that are carried out infrequently. The last was in 1980. Based on an estimated 3.3% of the total East New Britain population as the target group and using the monthly immunization returns from the health centers, the National Health Department is able to compile yearly % immunisation coverages for the province. The application of these guiding principles would be relevant in the United Kingdom. A national survey in Britain into vaccine acceptance showed that 1/2 of the health districts surveyed provide feedback of statistical information to individual treatment centers. A recent plan for the development of PHC in Britain through general practice included proposals for a computerised reporting system linked with target setting for preventive programs and feedback results. By the criteria given in this paper, uptake of immunization is now higher in the province of East New Britain in Papua New Guinea than in Britain. Developed countries, with their vastly greater resources, and developing countries could achieve much improved population coverage for a variety of preventive programs through PHC using similar methods.

Practice receptionists: poorly trained and taken for granted?

Seventy receptionists from 20 general practices in Newcastle upon Tyne were interviewed using a questionnaire to determine their demographic and social characteristics, tasks performed and training experience. The majority of receptionists were mature married women working part-time; only 13% had received any formal training. Most receptionists had no career structure and only 9% had ever been given a written job description. Thirty-one per cent of receptionists did not feel appreciated by their general practitioners and more (49%) felt unappreciated by the general public. However, they believed their main function was to help patients. From the description of their work receptionists are clearly integral and essential members of the primary health care team.To achieve the development of primary care services it is likely that practices will need to employ more ancillary staff, and these staff will require more pre-service and in-service training.

Can rational prescribing be assessed?

The prescribing of a group of young general practitioners was assessed, before and after educational intervention, using five parameters of rational prescribing. The proportion of drugs prescribed by their generic name, and the proportion falling within a basic formulary for general practice increased significantly even though the participating doctors had neither been involved in the compilation of the formulary nor been given a copy of it. Items prescribed bygeneric name rose from 45 to 74% and the proportions of new and repeat items within the formulary rose by 73 to 83% and 68 to 77% respectively. It appears that discussions about rational prescribing lead to similar changes in prescribing as involvement in the compilation of a formulary.The notion of an ;essential drugs list' for general practice is described, and three easily applied measures of rational prescribing are suggested: (1) the proportion of patients not given a prescription, (2) the proportion of drugs written in their generic form and (3) the proportion of drugs falling within a general practice ;essential drugs list'.

Repeat prescribing: a study prior to the imposition of the limited list.

A diverse group of general practitioners from separate practices kept a record of their repeat prescriptions for a week in March 1985, just prior to the imposition of the Government's limited list of drugs which could be prescribed on the National Health Service. Up to one-fifth of repeat prescriptions needed to be altered to comply with the eventual list. An unexpected finding was the wide differences among the doctors in the proportion of repeat prescriptions that were written as the approved generic names. While the anxieties about generic prescribing have yet to be resolved, the problems of converting repeat prescriptions into generic names requires not only a change in doctors' behaviour, but also clear explanation to reception staff and patients. Such a change could produce considerable financial savings, and might be more effective in this than further imposed restrictions.

The future of general practice in Newcastle upon Tyne.

A plan is presented for the future of general practice in Newcastle upon Tyne, in which general practices rather than individual practitioners would be responsible for providing a package of guaranteed minimum services. The services would include, at least, 24 h care of acute illness, continuity of care, management of specified chronic conditions according to agreed protocols, and certain preventive programmes. A computerised reporting system linked to computerised patient registration would enable targets to be set for the preventive programmes. Such an approach to primary health care follows the philosophy of Health for All, and could form the basis of a new general practitioner contract. Appropriate government funding in the future might be assured if general practice could demonstrate its ability to deliver a cost-effective service.

Development of a limited formulary for general practice.

Over a period of 1 year, a diverse group of general practitioners from separate practices constructed a limited formulary for general practice. The formulary contains 137 drugs and is intended to provide adequate and appropriate treatment for 90% of general practice patients. The study provides a model for development of agreed local formularies which do not infringe clinical freedom and offer an alternative to imposed limited lists as a means of reducing the cost of prescriptions. Development of such a list can be an enjoyable and dynamic educational exercise and can lead to more rational and safer prescribing.