Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
concern
- Charmaine Andrews (12 August 2001)
-
Adjusting for practitioner, practice and population factors
- Chris Griffiths (13 August 2001)
-
15% Difference versus 30% list inflation in sigle handed practices
- David Lloyd (13 August 2001)
-
Erroneous conclusions based entirely on unexplained choice of covariates
- Debbie A Lawlor (13 August 2001)
-
A Patient's View
- J Eitrem (14 August 2001)
-
In some repescts, yes
- Christopher Anton, Anthony Cox (12 September 2001)
-
Re: In some repescts, yes
- Peter Seavers (3 October 2001)
-
Re: Re: In some respects, yes
- Christopher Anton, Anthony Cox (25 October 2001)
-
Group practices of Flemish GPs
- Nicole Boffin (12 November 2001)
|
|
|||
|
Charmaine Andrews, none none
Send response to journal:
|
I honestly believe that single handed practices offer not poorer care but not enough care for the individual patience. A few years ago I had some experience with a single practice that has put me off them for life. I had taken my daughter see the doctor and he/she kept changing his/her mind about the diagnosis of the problem and when i changed GPs to a group practice I was advised to see a certain doctor who was good with children and straight away he/she diagnosed exzma now why couldn`t the single practice doctor diagnosed that in the first place. With group practices they have a lot more to offer and a wider range of experience.Thats why single practices always seem to get a bad name not because they offer a poorer practice, they have only their own experience to rely on. |
|||
|
|
|||
|
Chris Griffiths, Reader in Primary Care Department of General Practice and Primary Care, Queen Mary's School of Medicine, London E14NS.
Send response to journal:
|
It is reassuring that Hippisley-Cox and colleagues found no important differences in the care provided between singlehanded and group practices.1 However, it seems illogical to adjust in their analysis for gender of practitioners and vocational training status as these are aspects of the practitioners themselves and their style of practice. They rightly adjust for the characteristics of the practice populations served, and could in addition have adjusted for resources allocated to practices, such as the employment of a practice nurse.2 These minor changes to their method would probably cancel each other out, since losing gender and training status in the analysis would tend to increase the differences in outcomes, whilst including resources would decrease differences. One final point about the choice of outcomes: it would be a bold general practitioner who believed the care he or she provided had a statistically significant influence on the rate of pregnancies amongst teenagers on a practice list. 1. Hippisley-Cox J, Pringle M, Coupland C, Hammersley V, Wilson A. Do single handed practices offer poorer care? Cross sectional survey of processes and outcomes. BMJ 2001;323:320-3. 2. Griffiths C, Sturdy P, Naish J, Omar R, Dolan S, Feder G. Hospital admissions for asthma in east London: associations with characteristics of local general practices, prescribing, and population. BMJ 1997;314:482-6. |
|||
|
|
|||
|
David Lloyd, GP Harrow
Send response to journal:
|
This study makes no mention of list inflation. In my local experience, practices have widely different rates. Computer linked practices tend to have lower rates and single handed practices have lower rates of linkage. Big differences in inflation might make dramatic differences to referral or admission rates. I am ready to say that single handed practices are an anachronism in today's medical climate and are hindering the development of better primary care. |
|||
|
|
|||
|
Debbie A Lawlor, Lecturer in epidemiology and public health medicine Department of Social Medicine, University of Bristol
Send response to journal:
|
Dear editor The conclusions by Hippisley-Cox et al cannot necessarity be drawn from the data presented and this paper adds little to the important debate relating to quality of care in different types of primary care practice teams. In addition to the limitations pointed out by the authors themselves there
are two very important problems with this paper. Firstly, it is not clear
which of 2 possible research questions the paper is addressing -
Secondly, the authors main conclusions are determined entirely by the factors that they have chosen to adjust for in the final multivariate models. There is no discussion of the rationale for chosing some factors and not others that are presented in table 1 and by putting all factors simultaneously into one model the authors demonstrate a complete lack of a conceptual framework.(1) In particular including gender of practitioner and training status in the model as if this behaved in the same way or provided similar information to factors such as deprivation score is unhelpful. It would be useful to know, for example, whether single handed practitioners (having controlled for deprivation, rurality and other practice factors that cannot be directly influence by health service providers) were less likely to reach immunisation targets and cytology targets. A second model could then be presented with the gender of the practitioner added - if the result was to attentuate any difference then useful information is obtained: i.e. it may show that patients of single handed practitioners are less likely to be immunised or have cervical smears because single handed practitioners are more likely to be male. If this is so - clearly it does not suggest that single handed practitioners are poor performers but it does highlight a possible way of improving services for some patients who may be recieving poorer services. For example, female session workers could be employed. The 'put everything in together' model presented in this paper does not allow any such use of the available data. Further, since the authors give no reason why other factors, that have a clear difference between singlehanded practices and partnerships (e.g. fundholding, age of practitioner, research practice) and which are also likely to influence the outcomes, are not included in the model it is impossible to determine whether covariates were cherry-picked to produce the desired result. These investigators clearly have powerful data which could produce some useful conclusions, but this paper fails to do so because it lacks a conceptual framework and appropriate epidemiological modelling. Debbie A Lawlor Reference 1. Victoria CG, Huttly SR, Fuchs SC, Olinto MTA. The role of conceptual frameworks in epidemiological analysi: a hierarchial approach. International Journal of Epidemiology 1997;26:224-227. |
|||
|
|
|||
|
J Eitrem
Send response to journal:
|
As a patient I am shocked that after the case of the GP who has obviously murdered hundreds of people that single practices have not been totally disallowed. It goes without saying that a single practice brings with it a total lack of any form of accountability on the part of the GGP running it. The Shipman case would probably never have happened had he had at least one other partner. No category of professonal who has be charge of life or death such as members of the medical profession should be totallly unaccountable as a single practice GP quite obviously is. For those who wish to misuse it gives undiluted power over people who cannot complain. Only a solicitor was able to point the finger at Shipman even after patients and other medical staff had been trying in vain for years. I find it quite startling that you would actually even start a "study" of this nature when the answer to this question is so plain. Patients in this country are powerless and the price of medical care is total subjucation often having to accept rude and insulting behaviour in GP practices because of fear of been removed from the practice and not having any maybe urgently needed medical help. I am a former patient who was thrown off practice after GP practice after insisting that I had a near strangulating hernia when I did have one. Not one GP ikknew how to do a proper hernia examination. Accountability must be brought to the profession. I am certain that you will ignore this artice. Jill Eitrem, |
|||
|
|
|||
|
Christopher Anton, Administrative Co-ordinator and ADR Pharmacist West Midlands Centre for Adverse Drug Reaction Reporting, Anthony Cox
Send response to journal:
|
Dear Editor Hippisley-Cox and colleagues concluded that there is no evidence that single-handed general practitioners are under-performing clinically.[1] We hypothesized that the number of reports from health districts in our region would be inversely correlated with the proportion of single handed GPs. There was a significant relationship [2] (r = -0.56, p < 0.02, Kendall's Rank Correlation) and we proposed that it might be because single-handed GPs with their larger list sizes were too busy to report - one of Inman's seven deadly sins.[3] More recent data tend to confirm this original finding. In 3 health authorities all with more than the regional average of single-handed GPs the number of Yellow Card reports submitted to us in the 2 years up to the end of July 2001 are shown in the table. Comparison of the two proportions shows a significant difference (p < 0.0001). Single-handed 8 reports, 65 GPs (0.12 reports per GP) 2 or more partners 124 reports, 389 GPs (0.32 reports per GP) This disparity remains when the figures are broken down to PCG level. We do not make allowances for cards which bypassed the regional monitoring centre, but this was very few in the 2 years studied. Reporting adverse drug reactions is an important feature of clinical governance and in this respect single-handed GPs do not perform as well as their colleagues in larger practices. References 1. Hippisley-Cox J, Pringle M, Coupland C et al. Do single handed practices offer poorer care? Cross sectional survey of processes and outcomes. BMJ 2001; 323: 320-3. 2. Anton C, Ferner RE. What identifies districts with low reporting rates for adverse drug reactions? Poster presented at European Society of Pharmacovigilance annual meeting, Cambridge 1995. 3. Inman WHW. Detection and investigation of drug safety problems. In Gent and Shigamatsu (eds.) Epidemiological issues in reported drug-induced illnesses. Hamilton, Ontario: McMaster University Library Press, 1976. |
|||
|
|
|||
|
Peter Seavers, General practitioner Burnley
Send response to journal:
|
I fail to see anything except a casual relationship between "Yellow Card" notifications and number of single handed practitioners in any region. It could just as easily be countered that single handed practitioners are more judicious and cautious in prescribing, maybe being conservative in the use of newer "black triangle" drugs. However the arguments are spurious unless related to prescribing patterns, to which I am not privy and add nothing to the central tenet of the original article, that there is little difference in care provided between single handed and multihanded practices. |
|||
|
|
|||
|
Christopher Anton, Adminstrative Co-ordinator and ADR Pharmacist West Midlands Centre for Adverse Drug Reaction Reporting, Anthony Cox
Send response to journal:
|
The MCA does not just ask for yellow card reports associated with black triangle drugs. Adverse reactions can occur with all drugs, and it is one of the strengths of the yellow card scheme that drugs are monitored regardless of the length of time they have been marketed (terfenadine and oral contraceptives being two recent examples). The majority of reports the MCA receives each year are to NON-black triangle drugs, and whereas a lower reporting rate may be associated with better or more conservative prescribing it probably has little to do with the amount of black triangle prescribing. |
|||
|
|
|||
|
Nicole Boffin, Staff Member Research Division Scientific Society of Flemish General Practitioners (WVVH) B 2600 Antwerp
Send response to journal:
|
In your study no evidence was found that single handed general practitioners are underperforming clinically. These results caused a heated debate in the Flemish medical press in spite of limitations of the study and characteristics of the Flemish health care system and group practices. A recent survey of Flemish group practices showed that in only 14% of the group practices other caregivers are practising and in only five a nurse is available. Data on age and gender of the GPs in group practices were comparable but there is no evidence that GP practice form is related with deprivation of the patient population. Single handed GPs feel supported by your results. In Flanders the government as well as academic family practice and the Scientific Society of Flemish General Practitioners are promoting group practices in general practice. Their concerns are not as much that single handed general practitioners are underperforming clinically but rather that the prevailing model with more than 80% of the GPs in solo status, won’t survive the next decade. Solo practices lack resources, staffing and equipment to cope with increasing complex care demands. Young GPs and GPs working in group practices prefer group practices as well. 1 Overall job satisfaction and personal well-being might explain these preferences. Since 1999 one of our projects investigates and supports co-operation between GPs. We studied the literature on quality of care, especially in solo and group practices and concluded that there is hardly any evidence on this matter. A Dutch validated Visitation Instrument to assess Practice management and organisation (VIP) showed not only that single handed practices scored higher on accessibility and availability (as cited in your article) but also that they scored lower on delegated tasks to practice assistants and that they have less equipment.2 A small scale feasibility test in four Flemish practices showed that many VIP items and questions should be revised to improve comprehension and precision. But would valid and reliable data on practice management bring us any further since research on VIP also concludes that practice management (structure) and actual performance (process) may contribute to patient outcome independently of each other? 3 As you state, the unclear link between performance indicators, including those for outcome, and the clinical activity of doctors demands a cautious interpretation of your results. Measuring quality of care in different practice forms is no longer the primary objective. Supporting co-operation in family practice by description of exemplary models and providing a legal framework, education, training and facilitating of teamwork seems more important to us. Nicole Boffin, Paul Van Royen, 1 Bogaert K, De Prins L, De Maeseneer J. [Women/men power planning in family practice in Belgium. Scenario for 2010 and 2020]. Gent: RU, Vakgroep Huisartsgeneeskunde en Eerstelijnszorg, 1998. 2 van den Hombergh P, Grol R, van den Hoogen HJ, van den Bosch WJ. Assessment of management in general practice: validation of a practice visit method. Br J Gen Pract 1998;48(436):1743-50. 3 Ram P, Grol R, van den Hombergh P, Rethans JJ, van der Vleuten C, Aretz K. Structure and process: the relationship between practice management and actual clinical performance in general practice. Fam Pract 1998;15(4):354-62. |
|||