Clinical trial: a primary-care-based model for the delivery of anti-viral treatment to injecting drug users infected with hepatitis C.

BACKGROUND: Injecting drug use is the main risk factor for hepatitis C virus (HCV) infection. Secondary-care-based strategies for the management of HCV do not effectively target this vulnerable population. AIMS: To evaluate the feasibility, safety and efficacy of a primary-care-based model for the delivery of HCV services including anti-viral therapy to injecting drug users. METHODS: A partnership between a clinical nurse specialist employed by, and working under the supervision of, a secondary-care-based hepatitis service and drug workers and general practitioners. Three hundred and fifty-three clients attending opiate substitution clinics in primary care were evaluated. Outcomes were: number of new diagnoses of HCV infection, number of clients assessed as suitable for anti-viral treatment, and number of patients treated. RESULTS: 174 HCV antibody positive clients were identified. Of these, 124 were chronically infected with HCV of whom only six had been previously identified. Of 118 new chronically-infected individuals, 86 entered the care pathway, 43 were assessed as suitable for anti-viral treatment and 30 have so far been treated. Outcomes of anti-viral treatment are comparable with those obtained in secondary care settings. CONCLUSION: A primary-care-based model offers a new paradigm for the treatment of HCV in injecting drug users.

Providing welfare rights advice in primary care.

OBJECTIVE: To evaluate the introduction of dedicated open access welfare rights advice sessions in a general practice setting. DESIGN: A retrospective study of 416 client visits over a 11 month period from August 1995. A prospective questionnaire survey of 34 attendees over a three month period from April 1996. Semi-structured interviews with 11 involved primary care staff. SETTING: An inner city health centre. OUTCOMES: Social characteristics of clients attending; problems presented; benefit uptake; views from the health centre staff and welfare rights advisers and comments on future development. RESULTS: A total of 270 new clients used the service during the study period with 146 repeat visits (35%). Of the new clients, 158 out of 270 (59%) reported that they were disabled and 50% of the 158 had specific disability based welfare rights enquiries. 15% of new clients (40 out of 270) were found to be owed money by the current benefit system. Of these, 24 clients obtained one-off payments totalling l15,863 and 16 clients obtained regular payments totalling l539 a week. 58% of interviewed clients had not previously accessed any welfare rights advisory services. The welfare rights service was considered by the primary health care team to be a very useful contribution in a highly deprived area. CONCLUSIONS: The advice service increased the uptake of social security benefits in 15% of all new attendees. An open access service may not have been the most efficient method of delivering such advice. However, the high proportion of new clients who reported having a disability suggested that a health centre setting may be particularly accessible for those reporting disability. Further work is required to explore these findings and the most effective and efficient method of delivering the service in a deprived inner city setting.

The relationship between primary care and psychiatry: an opportunity for change.

The past two decades have seen the development of a symbiotic relationship between primary care and psychiatric services. The changes which have taken place, however, have been piecemeal and variable in their extent. With some exceptions, they have followed an empirical route, and have come about largely because individual practitioners intuitively felt that they yielded positive results or attractive patterns of working. For the most part, they have not followed the elaboration of a specific theory and although a great deal of subsequent research has been carried out in order to analyse their benefits and limitations, routine practice has been slow to change. The recent reorganization of the health service has yet to exert an appreciable effect on the relationship between the two disciplines. Owing to the newly developing structures and patterns of care, future change is inevitable and brings with it both opportunities and dangers. This paper sets out some of the arguments in favour of a new contract between psychiatry and primary care based on an equal partnership.

Attitudes of doctors to the Alma Ata recommendations in Sri Lanka.

A detailed postal questionnaire was sent to 400 general practitioners, hospital doctors, and Ayurvedic practitioners in Sri Lanka as part of a wider study to investigate the delivery of primary medical care. The responses to questions that were related to the Alma Ata recommendations, which aim at providing "health for all by the year 2000," and the perceived health needs of the population are reported. Basic sanitation, clean water, adequate nutrition, and improved health education were considered to be the most important needs. When asked to suggest one change in health care 30% of the doctors recommended the integration of primary and secondary care services.

Can teachers cross continents? Experiences in Sri Lanka.

We describe our experience of planning and running a workshop in Sri Lanka to prepare doctors for teaching a postgraduate diploma in general practice. We explore whether British models of education for general practice are applicable in other cultures and put forward a check-list of questions which teachers of general practice who are invited to work abroad should ask themselves.

Psychotropic prescribing. What am I doing?

A descriptive survey of five weeks' psychotropic prescribing by one general practitioner is presented. Out of 1,543 total contacts, 330 had, by defined criteria, a significant psychological problem. A total of 25 different psychotropic drugs were given to 231 different patients. A number of recommendations for change are suggested to provide a more rational pattern of prescribing.