Age, pattern of consultation, and functional disability in elderly patients in one general practice.

OBJECTIVE: To examine how functional disability varies with sex, age, and other variables in patients aged 75 and over living in the community and to ascertain whether a statistical model derived from the variables in this population usefully predicted functional disability in another of similar age. DESIGN: Retrospective study of data collected by interview and by examination of medical records. SETTING: An urban general practice with five partners and a list of 15,000 patients, very few of whom belonged to ethnic minorities. PATIENTS: 775 Patients (252 men, 523 women) aged 75 and over living in the community between September 1985 and August 1986; 13 other patients considered to be unsuitable and 14 who declined an interview were excluded. Also 94 patients who became 75 or joined the practice after August 1986. MAIN OUTCOME MEASURE: The proportions of fit, partially disabled, and severely disabled (housebound) patients. RESULTS: 90 Men (35.7%) and 128 women (24.5%) were fit, and 27 men (10.7%) and 116 women (22.2%) were housebound; in all age groups women were significantly more likely to be disabled than men. A significant trend towards greater disability was shown with increasing age and, more noticeably, with pattern of consultation when patients were divided into three categories based on the number of times they had attended the surgery and been visited at home over about two years. Statistical models gave the forecast percentage of fit and severely disabled patients for each sex, age group, and pattern of consultation, and a simple scheme was derived to identify from information wholly contained in medical records most of those patients most prone to severe disability. The scheme was verified applying it to a population of 94 elderly patients in 1988-9. CONCLUSION: Sex, age, and pattern of consultation together provide a quick indication of elderly patients' tendency to severe disability, which can help in screening and in day to day consultations.

Audit of 26 years of obstetrics in general practice.

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

Narrowing the health gap between a deprived and an endowed community.

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

A study of telephone advice in managing out-of-hours calls.

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

Comparison in use of health services between a deprived and an endowed community.

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

Deprivation and health in one general practice.

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