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LETTERS: Tom Hennell and Azeem Majeed Role of general practitioners in NHS must not be undervalued BMJ 1999; 318: 1420b [Full text]

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Telephone encounters are rare in hospitals and common in GP

Adrian Midgley   (21 May 1999)

Where did the estimate of '90%' come from?

Tom Hennell   (22 May 1999)

Telephone encounters are rare in hospitals and common in GP 21 May 1999
Adrian Midgley, GP Exeter Send response to journal: Re: Telephone encounters are rare in hospitals and common in GP	Patients may occasionally present to specialists with multiple problems, they commonly do so to GPs. Statistically it must be rare for a patient to present with two problems in a specialty, but all problems fall within General Practice, even if only for as long as it takes us to refer them on. Telephone consultations in general practice amount to large numbers, in which considerable substantive work is done. This is not the case of the specialties - it was the subject of a filler piece in a BMJ a year or so ago when a consultant chose to do follow-ups by telephone, not something usual. The numbers and proportion of new or recurrent problems dealt with in this way does as Hennell says alter the figures presented. The proportion of the NHS' clinical work done in General Practice is between 70 and 90%, and closer to the middle of that range than the bottom.
Where did the estimate of '90%' come from? 22 May 1999
Tom Hennell, strategic analyst NHS Executive North West Send response to journal: Re: Where did the estimate of '90%' come from?	EDITOR - Any exercise that attempts a one-dimensional assessment of all medical care must inevitably involve a gross simplification. Majeed's preference is to reduce counts to distinct 'doctor contacts' - suggesting that about 70% of these occur in General Practice. I proposed a re- examination of the same data-sources to extract distinct 'episodes of medical care' - over 80% of which may be estimated as occurring in General Practice. Which approach is the more appropriate is a matter for personal judgement. I fully agree with Majeed that, in so far as such broad generalisations may inform debate (as I think they can), then it is important to be clear of the basis for the particular figures chosen. Two further points: I believe I can recall the derivation of the original claim; that 90% of episodes of medical care occur in General Practice. Hospital activity for England was taken from the counts on the old 'SH3' returns - discharges & deaths, day cases, new outpatients, new accident and emergency attendances. These totalled to 24.2 million in 1981. These could be compared to a total GP consultation rate of 4.3 per year from the 1982 General Household Survey - or 201 million. Hence an estimated 'GP proportion' of 89%. Majeed is quite correct to dispute this calculation - firstly in that 'follow-up' attendances were included in the GP counts but excluded for out-patients; but also in that the respondents to the General Household Survey, then as now, were inclined to report all recent GP consultations - even though they might not strictly fall within the 'two week' reference period - resulting in an over-stating of the grossed-up annual rate. Secondly, and leaving the numbers game on one side, the different results arising from the two summary categorisations of doctor-patient encounters - contacts versus episodes - tend to illustrate a distinction in patient expectations; in that the 'agenda' for a primary care consultation may be regarded as manifold and open-ended (on both sides) to a greater extent than would be the case within a hospital out-patient clinic. While it may well be the case that repeat outpatient appointments can present with new problems or with exacerbations of old problems, this is not quite the same thing. Tom Hennell Strategic Analyst