Changes in patient satisfaction and experience in primary and secondary care: the effect of general practice fundholding.

BACKGROUND: The contributions of patients' opinions to the evaluation of health care is widely acknowledged. This study investigates whether the patients of a fundholding practice perceived any changes in the services offered. AIM: To examine the effect of general practice fundholding on patient satisfaction with both primary and secondary care services. METHOD: In April 1992, questionnaires were sent to 180 patients in each of four second-wave fundholding practices and four non-fundholding practices in the former South East Thames region. This took place before any changes were made in the practices as a result of fundholding. Repeat questionnaires were sent 30 months later. RESULTS: The overall response rate was 70% in 1992 and 66% in 1994/1995. Satisfaction levels were generally high for primary care services and changed little over time. There was no evidence to suggest that fundholding GPs were less inclined to prescribe or refer to secondary care services. Waiting times for the first appointment with a consultant in secondary care had reduced between 1992 and 1994 for patients referred from the fundholding practices. However, there were no differences in the time patients had to wait for subsequent treatments or further investigations. One-fifth of the fundholding patients referred to secondary care were seen by the specialist in their doctor's surgery, and those seen in this setting preferred it. CONCLUSION: Patients perceived no major differences in primary care services over the period between the two surveys. There was some evidence of preferential treatment for patients of fundholding practices, but only in waiting times for the first appointment with the secondary care specialist.

Fundholding in the south Thames Region.

BACKGROUND: The general practice fundholding scheme is now at the forefront of the National Health Service (NHS) reforms and should lead to the more efficient use of services by making general practitioners more aware of the financial consequences of their clinical decisions. However, there is a concern that adverse effects may also occur. AIM: To monitor the changes occurring in a sample of fundholding and non-fundholding practices between 1992 and 1995, including providing care nearer to patients, the mixed economy of care, the efficiency and costs of fundholding, and the commitment of fundholders. METHOD: Fifteen first-wave practices, four second-wave practices, and four non-fundholding practices in the former South East Thames Region took part in the study. Information was collected using interviews, questionnaires, prescribing data, and annual fundholders' income and expenditure accounts. RESULTS: Consultant clinics were set up in 10 different practices in 15 different specialties, and paramedical clinics in 12 different practices. Physiotherapy and mental health clinics constituted over 90% of the paramedical hours. Fundholders had private arrangements with an individual consultant or practitioner for approximately half of the contracted hours in both types of clinics. Fundholders had lower overall prescribing costs than non-fundholders, but the overall costs for prescribing for all groups had risen by about one third over three years. CONCLUSION: While outreach clinics may help to provide for the needs of patients with common conditions, they may lead to the fragmentation of services. The provision of primary care by those who are not NHS employees needs careful consideration. Recent policies for general practice have emphasized its role in disease prevention and in coordination of care for chronic illness. Fundholding also promotes two additional roles, the purchasing of care and the development of in-house facilities. Combining these different functions presents a considerable challenge.

Links between mental health care professionals and general practices in England and Wales: the impact of GP fundholding.

BACKGROUND: Fundholding general practitioners are able to determine the type of contracts they place with providers of mental health care, and are able to employ some categories of mental health care professionals directly. The impact of this on the care of the mental health of patients in non-fundholding practices is not yet fully known. AIM: A survey was undertaken of 100 fundholding general practices and 100 similarly sized non-fundholding practices in order to investigate the changes in mental health provision made by general practitioners. METHODS: A sample of 100 fundholding general practices in England and Wales was randomly chosen from the list supplied by the Association of Fundholders and matched to a similarly randomly chosen sample of non-fundholding practices. Postal questionnaires were sent to the senior partner and to the practice manager in each practice. RESULTS: The number of mental health care professionals who are either employed by or attached to general practices, or who visit the general practice on a regular basis appears to have increased substantially since 1991. This increase was particularly marked in fundholding practices. The results suggest that general practitioners with specific links to particular mental health care providers were more satisfied with the service provided by the mental health care team, and more likely to increase referrals to that service in the last 2 years, than general practitioners without such links. There was little evidence to suggest that increasing the number of mental health care professionals in primary care had brought about a major reduction in referrals to psychiatrists. CONCLUSION: General practitioners, particularly fundholders, are increasing their links with mental health professionals, and community psychiatric nurses, psychiatrists, psychologists and counsellors are spending more time either based in general practice or visiting regularly. While the shift of resources to primary care, particularly to fundholders, may increase the treatment options available to patients with less severe illnesses, this may have the effect of reducing the services available for the long-term and severely mentally ill.

Working with community mental health professionals: a survey among general practitioners.

Links between general practitioners and mental health professionals, such as counsellors, psychiatrists, community psychiatric nurses, clinical psychologists and social workers, are increasing in number and type. The aim of this survey was to elicit general practitioners' attitudes to these workers, comparing those with a link with a mental health worker and those without. General practitioners in two district health authorities were surveyed and a response rate of 70% was obtained. General practitioners linked to a mental health professional were more likely to have made a referral to that service in the previous three months and, on the whole, were more satisfied with that service. The commonest problem reported by respondents was the length of waiting lists. Regarding liaison with social workers, inadequate feedback and difficulty with contact were the problems mentioned most by doctors. A number of general practitioners expressed a desire for closer contact with all these mental health services. While caution is required in ascribing causality to these relationships, it is clear that a closer working relationship between general practitioners and mental health workers is productive and is valued by general practitioners. The challenge for policy makers is to structure mental health provision in such a way that more general practitioners are able to benefit than at present.

Psychosexual dysfunction in women with gynaecological cancer following radical pelvic surgery.

OBJECTIVE: To assess the prevalence and severity of psychosexual dysfunction in women treated for cancer of the cervix and vulva by radical vulvectomy, Wertheim's hysterectomy and pelvic exenteration; and to identify the risk factors for sexual morbidity and ways in which it might be reduced. DESIGN: Retrospective study of patients by questionnaire and semistructured interview, 6 months to 5 years following surgery. SETTING: Gynaecology-Oncology Unit of a general hospital. PATIENTS: 105 English speaking women with gynaecological cancer. RESULTS: 90% of the women in relationships had been sexually active prior to surgery. Of this group, 24% had no sexual difficulties post-operatively; 66% of the latter still had problems more than 6 months later, and 15% of the latter never resumed intercourse (excluding those with a colpectomy). 82% of those aged less than 50 years who had had radiotherapy suffered sexual dysfunction. Lack of desire was the commonest problem, and half the women felt that their sexual relationship had deteriorated, yet only 16% felt that their marriage had worsened. Younger women were more likely to attribute personal and marital distress to their sexual problems. More information on sexual matters would have been liked by 28% of the women. CONCLUSIONS: Sexual dysfunction is common following radical pelvic surgery and tends to remain a chronic problem. As well as organic causes there is a strong psychogenic element brought about by loss of fertility, disfigurement, depression and anxiety about one's desirability as a sexual partner. The presence of a stable relationship before the diagnosis of cancer helps women cope better, and young single women are a very vulnerable group. Patients want more information on sexual matters and the provision of sexual counselling may improve outcome in the future.

Psychosocial adjustment following major gynaecological surgery for carcinoma of the cervix and vulva.

One-hundred and five women had undergone major gynaecological surgery for carcinoma of the cervix and vulva were interviewed retrospectively to elicit post-operative psychosocial and psychosexual problems. This interview took place between 6 months and 5 yr after surgery. Responses to the Hospital Anxiety and Depression Scale indicated that 20% of the women were 'probable' cases of anxiety and 21% were 'definite' cases. On the depression scale, 18% were 'doubtful' cases and 14% were 'definite' cases. Scores on the scales were not associated with age of the woman, the type of operation or the time period between being interviewed and the operation. Two-thirds of the women who were sexually active prior to the operation indicated ongoing sexual problems when interviewed and the presence of these problems was found to be significantly associated with the woman's level of anxiety.

A survey of links between mental health professionals and general practice in six district health authorities.

The aim of this study was to obtain an estimate of the extent to which collaborative schemes exist between general practice and mental health professionals and to assess the influence of practice size and district on these schemes. A questionnaire asking about such links was sent to each general practice in six randomly selected health districts in England. The response rate was 75%. Half of the 261 responding practices had a link with a community psychiatric nurse, 21% with a social worker, 17% with a counsellor, 15% with a clinical psychologist and 16% with a psychiatrist. Practices with more general practitioners were significantly more likely to have a link with a counsellor, after allowing for marked differences between the sizes of practices in the different districts. There was a tendency for some practices to have many links, while others had few. This poses questions about the efficiency and equity of collaborative schemes in primary care. Further research is required to investigate the quality of these links and the extent to which they serve the interests of the patient.

Behavioural psychotherapy in the treatment of irritable bowel syndrome.

The irritable bowel syndrome is a highly prevalent condition whose underlying aetiology is not understood. While many patients respond to a combination of gastrointestinal antispasmodics, bulking agents and dietary manipulation, controlled clinical trials have suggested that the benefit is only marginal and is due mainly to the large placebo effect found in this condition, which has been calculated to range between 54 and 81%. Associations between the syndrome and psychological and social stresses suggest, however, that treatment involving a systematic approach to the management of symptoms may hold out real therapeutic possibilities. In the current study, 42 IBS patients were randomly allocated to either medical treatment or to behavioural psychotherapy with a nurse therapist. They were assessed initially and at 4 and 9 months. There was a general improvement over the 9 months on a number of physical and psychological symptoms measured. However, no differences were found between treatment groups except for changes in two avoidance scores. A significant correlation was found, however, between improvement in the bowel symptoms of IBS (stomach pain and diarrhoea) and improvement in the psychological symptoms measured by the Clinical Interview Schedule, suggesting a close interrelationship between the two.

A survey of 658 women who report symptoms of premenstrual syndrome.

A treatment trial was briefly mentioned in two British publications and women suffering from premenstrual syndrome were invited to write to us. After initial screening, postal questionnaires were sent to all eligible women. Six-hundred and ninety-nine questionnaires were returned and of these 658 were included in the analyses. Although the results of the study need to be considered cautiously because of the unrepresentative nature of the sample, the survey was helpful in ascertaining the views of women who report PMS symptoms and what they had found helpful. The majority of respondents were aged in their 30s and were married with children. Over 60% were chronic sufferers, having had symptoms for 5 years or more. High proportions of the women experienced both psychological and somatic symptoms but it was the psychological symptoms which were perceived as the most distressing. Over 60% of the sample were ascertained as suffering from some degree of psychological distress and the same proportion had one or more social problems. Overall 84% had visited their GP for this problem and many had also visited gynaecologists, family planning clinicians and psychiatrists. Agencies offering alternative medicine were also frequently contacted and often found more helpful. Most women had tried more than one type of medication but no one treatment was found to be particularly helpful.

A survey of professional help sought by patients for psychosocial problems.

A sample of patients aged 25-75 years was drawn from one general practice. The patients were sent a postal questionnaire to ascertain whether they had had a personal or emotional problem in the last 10 years and whom they had confided in. Of the 396 respondents 281 (71%) admitted to having had such a problem. It was found that significantly more women then men had had a problem. Of these 281 individuals, 94% had confided in someone, mainly friends and relatives, 47% had consulted one or more professionals or agencies and 37% had confided in their general practitioner. Although the majority had found the contact with the agency or professional helpful, those with depression/anxiety or problems following a bereavement were less likely to feel that they had been helped. The provision of practical advice, sympathy and support were most often mentioned as being helpful. This study demonstrates the important role of the general practitioner in the management and treatment of psychosocial problems.

Physical symptom severity, psychological and social dysfunction in a series of outpatients with irritable bowel syndrome.

Details of physical symptoms, psychological and social dysfunction of 42 outpatients diagnosed as having irritable bowel syndrome (IBS) were collected by interview and questionnaire. Social stresses and problems were also elicited as well as the impact of symptoms on their subjects' daily lives. High proportions of subjects were handicapped in their social, sexual and working lives by IBS symptoms and social stresses and problems were common. Forty-eight per cent were classified as having a 'minor psychiatric illness' using the Clinical Psychiatric Interview. Women were more severely affected by physical symptoms (with the exception of diarrhoea) and were more likely to be in pain longer and for more days in the month. They were also more likely than men to be diagnosed as having a psychiatric illness.

Sex differences in general practice attendance and help seeking for minor illness.

Women's rates of utilization of almost all health care services are higher than men's. General practice surveys endorse these findings with women attending more frequently, particularly in the child bearing years. The present study sought to explore the variables associated with consultation and help seeking behaviour for minor illnesses. Samples of male and female low and high attenders aged between 20 and 45 were drawn from one general practice to investigate which factors were important in explaining sex differences in consultation. Analysis of the results suggests that attendance and help seeking in men and women was closely linked to physical illness, the presence of physical symptoms was predictive of more frequent consultation in both men and women. The presence of psychosocial problems or distress, however, predicted consultation behaviour in women but not in men. The women had more confidants and contacted more social agencies than the men, also suggesting that they found it easier to divulge personal information to others than the men. There was no evidence from this study that such enabling factors as physical accessibility and time available were related to differential attendance rates.

The treatment of premenstrual syndrome.

Premenstrual syndrome is commonly found among GP female attenders of childbearing age. This article discusses the main types of drug therapies used to treat premenstrual syndrome. Guidelines are also given on the management of these patients incorporating nondrug treatments such as behavioural methods and supportive counselling for associated psychosocial difficulties.

Managing the difficult patient: practical suggestions from a study day.

A study day for general practitioners was arranged on the subject of managing the difficult patient. Participants were asked to supply written details of their most difficult patient and the problems they associated with him or her. The issues raised were addressed in a number of formal presentations and formed the basis for discussion in workshops. This paper focuses on the underlying similarities between the patients and discusses a practical approach to their management.

Development and use of a short self-rating instrument to screen for psychosocial disorder.

This paper describes the preliminary testing and use of a short self-report instrument designed to identify psychosocial disorder. It combines a shortened version of the social problem questionnaire with the 12 item general health questionnaire. In a survey of 100 patients attending a health centre in inner London 46% recorded a psychiatric problem on the general health questionnaire compared with 35% identified by the general practitioner. For social problems 54% of patients assessed themselves as having one or more social problem compared with 23% detected by the general practitioner. The instrument normally takes five to 10 minutes for the patient to complete and thus can be filled out in busy situations such as a general practice surgery or a hospital outpatient department.

Marital problems and treatment outcome in depressed women. A clinical trial of social work intervention.

In a clinical trial investigating the effectiveness of social work intervention with depressed women patients in general practice, 80 women were randomly allocated to an experimental group for referral to attached social workers or to a control group for routine treatment by their GPs. They were reassessed at 6 and 12 months. The results indicated that women who had major marital problems were more likely to be depressed at follow-up than those with good relationships. However, patients with marital difficulties in the experimental group made more improvement than the controls. Women initially assessed as suffering from 'acute on chronic' depression and having major marital difficulties were found to benefit most from social work intervention.

Marriage guidance counselling in general practice.

This paper discusses the results of a survey of all general practitioners and counsellors involved in attachments in the area covered by the London Marriage Guidance Council. The replies of both counsellors and doctors were generally enthusiastic and few problems with attachments were encountered. However, while subjective accounts are positive, it seems essential that more objective research into effectiveness should be conducted if counsellors are to argue their case for being paid.