Client-centred practice: what does it mean and does it make a difference?

During the past 15 years, occupational therapists in Canada, through the Canadian Association of Occupational Therapists, have worked to develop and implement guidelines for practice of a client-centred approach to occupational therapy. One of the difficulties with the current Guidelines for the Client-Centred Practice of Occupational Therapy is the lack of a definition and discussion of the concepts and issues fundamental to client-centred practice. In this paper, key concepts of client-centred practice: individual autonomy and choice, partnership, therapist and client responsibility, enablement, contextual congruence, accessibility and respect for diversity are discussed. Two practice examples are used to illustrate these ideas and raise issues about obstacles to the practice of client-centred occupational therapy. Research evidence about the effectiveness of client-centred concepts in enhancing client satisfaction, functional outcomes and adherence to health service programmes is reviewed.

Reviewing audit: barriers and facilitating factors for effective clinical audit

OBJECTIVE

To review the literature on the benefits and disadvantages of clinical and medical audit, and to assess the main facilitators and barriers to conducting the audit process.

DESIGN

A comprehensive literature review was undertaken through a thorough review of Medline and CINAHL databases using the keywords of "audit", "audit of audits", and "evaluation of audits" and a handsearch of the indexes of relevant journals for key papers.

RESULTS

Findings from 93 publications were reviewed. These ranged from single case studies of individual audit projects through retrospective reviews of departmental audit programmes to studies of interface projects between primary and secondary care. The studies reviewed incorporated the experiences of a wide variety of clinicians, from medical consultants to professionals allied to medicine and from those involved in unidisciplinary and multidisciplinary ventures. Perceived benefits of audit included improved communication among colleagues and other professional groups, improved patient care, increased professional satisfaction, and better administration. Some disadvantages of audit were perceived as diminished clinical ownership, fear of litigation, hierarchical and territorial suspicions, and professional isolation. The main barriers to clinical audit can be classified under five main headings. These are lack of resources, lack of expertise or advice in project design and analysis, problems between groups and group members, lack of an overall plan for audit, and organisational impediments. Key facilitating factors to audit were also identified: they included modern medical records systems, effective training, dedicated staff, protected time, structured programmes, and a shared dialogue between purchasers and providers.

CONCLUSIONS

Clinical audit can be a valuable assistance to any programme which aims to improve the quality of health care and its delivery. Yet without a coherent strategy aimed at nurturing effective audits, valuable opportunities will be lost. Paying careful attention to the professional attitudes highlighted in this review may help audit to deliver on some of its promise.

Collaboration and partnerships: developing the evidence base

Despite the growing literature that collaboration is a 'good' thing, there are calls emphasising the need for evidence of its effectiveness. However, the nature of the evidence to assess effectiveness is less clear. This paper examines the components that contribute to the challenges that confront evidence on collaboration. It considers the differing interpretations that have been placed on evaluation and explores how ways of determining the outcomes of collaboration and the levels of outcome measurement to assess collaborative effectiveness are influenced by the multifactorial nature of the concept. Evidence on the impact of collaboration is influenced by the diversity of perspectives and conceptual facets, and difficulty in measurement of the notions involved. Other factors discussed are the choice of macro or micro evaluation, of proximal or distal indicators, of short and long-term effects, or of individual-level or collective community-level outcomes. The suitability of randomised controlled trials for the measurement of collaborative outcomes as well as the requirement of mixed methods evaluations are highlighted. An evaluation of five community partnerships in South Africa is employed as an example to link the evaluation concepts that are discussed to a real enquiry. If collaboration is to be successful in making a difference in the lives of people, then increasing the precision and context of appraising its effectiveness will reduce the nature of inconclusive evidence and is likely to improve the practice of partnerships, coalitions and joint working in health and social care.

Using patient and general practice characteristics to explain variations in cervical smear uptake rates

OBJECTIVES

To produce practice and patient variables for general practices from census and family health services authority data, and to determine the importance of these variables in explaining variation in cervical smear uptake rates between practices.

DESIGN

Population based study examining variations in cervical smear uptake rates among 126 general practices using routine data.

SETTING

Merton, Sutton, and Wandsworth Family Health Services Authority, which covers parts of inner and outer London.

MAIN OUTCOME MEASURE

Percentage of women aged 25-64 years registered with a general practitioner who had undergone a cervical smear test during the five and a half years preceding 31 March 1992.

RESULTS

Cervical smear uptake rates varied from 16.5% to 94.1%. The estimated percentage of practice population from ethnic minority groups correlated negatively with uptake rates (r = -0.42), as did variables associated with social deprivation such as overcrowding (r = -0.42), not owning a car (r = -0.41), and unemployment (r = -0.40). Percentage of practice population under 5 years of age correlated positively with uptake rate (r = 0.42). Rates were higher in practices with a female partner than in those without (66.6% v 49.1%; difference 17.5% (95% confidence interval 10.5% to 24.5%)), and in computerised than in non-computerised practices (64.5% v 50.5%; 14.0% (6.4% to 21.6%)). Rates were higher in larger practices. In a stepwise multiple regression model that explained 52% of variation, five factors were significant predictors of uptake rates: presence of a female partner; children under 5; overcrowding; number of women aged 35-44 as percentage of all women aged 25-64; change of address in past year.

CONCLUSIONS

Over half of variation in cervical smear uptake rates can be explained by patient and practice variables derived from census and family health services authority data; these variables may have a role in explaining variations in performance of general practices and in producing adjusted measures of practice performance. Practices with a female partner had substantially higher uptake rates.

Physician dual practice

Physicians employed in government clinics and hospitals also frequently have private practices. The economic theory of such dual practice is relatively limited and recent. We provide a summary and comparison of five models of dual practice, including one we have developed based on total compensation theory and contracting limitations. We also discuss whether theoretical predictions are consistent with empirical evidence from developed and developing countries. We argue that the social trade-off between the benefits and costs of dual practice hinge on the quality of a country's contracting institutions. The conclusion outlines a proposed research agenda for better understanding this widespread phenomenon in the health sector and in other segments of society.

Hospital admissions for asthma in east London: associations with characteristics of local general practices, prescribing, and population

OBJECTIVE

To determine the relative importance of appropriate prescribing for asthma in explaining high rates of hospital admission for asthma among east London general practices.

DESIGN

Poisson regression analysis describing relation of each general practice's admission rates for asthma with prescribing for asthma and characteristics of general practitioners, practices, and practice populations.

SETTING

East London, a deprived inner city area with high admission rates for asthma.

SUBJECTS

All 163 general practices in East London and the City Health Authority (complete data available for 124 practices).

MAIN OUTCOME MEASURES

Admission rates for asthma, excluding readmissions, for ages 5-64 years; ratio of asthma prophylaxis to bronchodilator prescribing; selected characteristics of general practitioners, practices, and practice populations.

RESULTS

Median admission rate for asthma was 0.9 (range 0-3.6) per 1000 patients per year. Higher admission rates were most strongly associated with small size of practice partnership: admission rates of singlehanded and two partner practices were higher than those of practices with three or more principals by 1.7 times (95% confidence interval 1.4 to 2.0, P < 0.001) and 1.3 times (1.1 to 1.6, P = 0.001) respectively. Practices with higher rates of night visits also had significantly higher admission rates: an increase in night visiting rate by 10 visits per 1000 patients over two years was associated with an increase in admission rates for asthma by 4% (1% to 7%). These associations were independent of asthma prescribing ratios, measures of practice resources, and characteristics of practice populations.

CONCLUSIONS

Higher asthma admission rates in east London practices were most strongly associated with smaller partnership size and higher rates of night visiting. Evaluating ways of helping smaller partnerships develop structured proactive care for asthma patients at high risk of admission is a priority.

The blood bank: from provider to partner in treatment of massively bleeding patients

BACKGROUND

Continued hemorrhage remains a major cause of mortality in massively transfused patients of whom many develop coagulopathy. Reviewing transfusion practice for these patients, we found that at our hospital more than 10 percent received a suboptimal transfusion therapy and that survivors had a higher platelet count than nonsurvivors. We therefore investigated whether the blood bank could improve its service and hence improve the outcome.

METHODS

The blood bank introduced monitoring of the delivery of blood products and contacted the clinician provided there was an imbalance in the transfusion practice. For massively transfused patients, transfusion packages, including five red blood cells, five fresh-frozen plasma, and two platelet concentrates, were introduced to improve hemostatic competence. The Thrombelastograph (TEG) Haemostatic System (Haemoscope Corp., Niles, IL) was implemented, aiding in the diagnosis and treatment of coagulopathy.

RESULTS

The fraction of suboptimally transfused patients declined from more than 10 percent to less than 3 percent. The transfusion package administered intraoperatively to patients operated on for a ruptured abdominal aortic aneurysm resulted in decreased postoperative transfusion requirements and improved 30-day survival (66% vs. 44%) compared with controls. Performing TEG alone in patients with significant bleeding as judged by the anesthetist reduced the number of analyses by approximately 85 percent, while those patients with coagulopathy remained identified. The TEG showed a 97 percent predictability in identifying a surgical cause of bleeding in postoperative patients. Ten percent of the massively bleeding trauma patients had hyperfibrinolysis as the major cause of bleeding, whereas 45 percent were hypercoagulable.

CONCLUSION

The initiative from the blood bank has improved the transfusion practice and, hence, survival in massively transfused patients at our hospital.

Partnerships, community participation and intersectoral collaboration in South Africa

Five community partnerships (CP) were initiated in South Africa as demonstration projects aimed at the re-orientation of health professionals' education (HPE) to be more community responsive and interprofessional. A cluster evaluation of these partnerships has demonstrated that, in addition to motivating all stakeholders to forge closer working relationships, it is necessary for partnerships to pay close attention to a variety of structural and operational dimensions, the lack of which could prove to be major constraints to effective partnership functioning. This study critically reviews the challenges to collaborative working as experienced by the South African cluster. Within the context of the post-apartheid restructuring and development, the discussion highlights the insights that partnerships offer to clarify the extent to which potential barriers could affect the stakeholder groups. The paper identifies potential impediments, and makes explicit how they impact on partnership fostering. Evidence is also presented for their early detection and possible solutions are identified. The lessons learnt from these South African cases are that wide representation, commitment and a sense of ownership, sound leadership skills, regular and effective communication, reliable member expertise and capabilities and attention to power issues are crucial elements in the partnership equation. The paper concludes with an invitation to health administrators and partnership executives to devote attention to the array of interacting components that, collectively, could impinge on the effectiveness of the multifaceted nature of interprofessional joint working arrangements.

Patients' experiences of receiving telephone advice from a GP co-operative

BACKGROUND

The use of the telephone to deliver health care advice has increased considerably in recent years. Little research has been carried out to explore the experience of patients who receive such advice and its acceptability.

OBJECTIVES

The aim of this study is to describe the expectations of patients, or third party callers, who had contacted a GP out-of-hours co-operative and their satisfaction with telephone advice received.

METHODS

Semi-structured interviews were conducted by telephone 7-10 days after contact with one inner city GP co-operative.

RESULTS

A total of 47 telephone consultations were followed up with an interview. Of these, 23 (48.9%) callers had expected to be offered a home visit when they called. Reasons for wanting a home visit were either to do with the nature of the condition and its perceived severity, problems in being able to attend the primary care centre and the risks of travel, or because of problems in communicating over the telephone. Satisfaction with telephone consultations centred mostly on the doctor being able to provide reassurance and give adequate time to allay concerns. The most common reasons given for dissatisfaction were the caller feeling that the doctor could not make a correct diagnosis without having seen the patient, or the caller being made to feel that they were wasting the doctor's time. Many patients were anxious about their ability to describe symptoms over the telephone, or understand and follow the advice that they received.

CONCLUSIONS

There appears to be a need for patients to be better informed about the service they can expect to receive from GP co-operatives. Recent developments such as NHS Direct may have an influence on the telephone consultation rate to GP co-operatives.

Mutual influences of general practitioners in partnerships

The aim of this study was to find out whether or not general practitioners (GPs) within the same partnership show more similarities in attitudes and behaviour than GPs in different partnerships, and what the causes of these similarities might be. Knowledge of the causes of patterns of similarities within medical teams contributes to understanding medical practice variation, which is crucial in developing effective health care policies. Data were used from the Dutch National Survey of General Practice ('87/'88), consisting of a stratified sample of 161 Dutch GPs, who served 335,000 patients in total. To find out whether GPs in the same partnership are indeed more similar than GPs randomly chosen from different partnerships, we constructed two kinds of pairs: all possible pairs of GPs working in the same partnership (actual pairs), and randomly constructed pairs of GPs who are not working in the same partnership (random pairs). For each pair difference scores were computed for a variety of attitudes and behaviour. Difference scores for actual and random pairs were analysed using multi-level analysis. Most differences in attitudes and behaviour were smaller for actual pairs than for random pairs. Furthermore, in the majority of the cases differences were no longer statistically significant after explanatory variables indicating selection, gradual adaptation and rapid adaptation through shared circumstances were taken into account. It was found that Dutch GPs working in the same partnership showed more resemblance in attitudes and behaviour than GPs not working in the same partnership. Most indications point towards circumstances, and to a lesser extent towards adaptation, as an explanation of similarities within partnerships. The implication of this study is that medical practice variations are not merely individual differences in preferred practice style, but are patterned by social processes in partnerships and local circumstances.

Graduates speak: the employment experience of 1995 graduates of diagnostic radiology and radiation oncology training programs

PURPOSE

To determine the initial employment experience of 1995 graduates of radiology programs.

MATERIALS AND METHODS

A questionnaire was mailed to all graduates of radiation oncology programs and to a stratified, random sample of 600 graduates of diagnostic radiology programs. The final response rate was 66%.

RESULTS

After graduation, 4%-10% of graduates worked for a period as locum tenens, worked in a job unrelated to radiology, or were unemployed. Immediate postgraduation unemployment was 2%-5%; 7-12 months later, it was less than 0.5%. Median actual salary was approximately equal to median expected salary. Radiation oncology fellowship graduates often had poorer outcomes. Almost half of the graduates with posttraining employment had a job with at least one characteristic regarded as unfavorable by some commentators (most commonly, undesirable location or no opportunity to become a partner), and at least one-fifth had and disliked such a characteristic. Geographic constraints, including the need to find employment for a spouse or companion, did not adversely affect employment outcome.

CONCLUSION

Eventual unemployment was low, and starting salaries have not collapsed. Generally, the implications of job characteristics are best assessed by monitoring trends, but the prevalence of non-partnership track employment may well have increased.

Influences of practice characteristics on prescribing in fundholding and non-fundholding general practices: an observational study

OBJECTIVE

To investigate the variation in prescribing among general practices by examining the contribution to this variation of fundholding, training status, partnership status, and the level of deprivation in the practice population and to investigate the extent to which fundholding has been responsible for any changes in prescribing.

DESIGN

Analysis of prescribing data (PACT) for the years 1990-1 (before fundholding) and 1993-4 (after fundholding), Use of multiple linear regressions to investigate the variation among practices in total prescribing costs (net ingredient cost per prescribing units), and mean cost per item in each of the two years and also the change in these variables between years.

SETTING

Former Mersey region.

SUBJECTS

384 practices.

RESULTS

The models developed explained the variation in cost per item (43% of variation explained for 1990-1, 38% for 1993-4) and prescribing volume (34% for 1990-1, 38% for 1993-4) better than the variation in total prescribing costs (3% for 1990-1, 7% for 1993-4). The models developed to explain the change in these variables between years did not explain more than 10% of the variation. Most of the explained variation in the change in total prescribing costs was accounted for by fundholding. Of the pounds 3.71 saved by first wave fundholders compared with non-fundholders pounds 3.57 was attributable to fundholding alone.

CONCLUSION

In neither year did fundholding make a major contribution to the variation in prescribing behaviour among practices, which was better explained by deprivation, training status, and partnership status, but it did seem largely responsible for differences in the rise of total prescribing costs between fundholders and non fundholders.

Long-term benefits for Mäori of an asthma self-management program in a Mäori community which takes a partnership approach

BACKGROUND

In 1991, an intervention trial of the efficacy of an asthma self-management plan was carried out in partnership with a rural Mäori community. The program relied on Mäori community health workers and other health professionals working in partnership, was delivered through clinics in traditional Mäori community centres and Mäori processes were followed throughout. The plan was shown to be effective in reducing asthma morbidity.

OBJECTIVE

To assess whether the long-term benefits of the program extent beyond reduced asthma morbidity and the extent to which any additional benefits may be related to the partnership approach employed by the program.

METHOD

Forty-seven (68%) of the original program participants were surveyed in August 1997. Participants were questioned on the program's impact in areas such as cultural development, health service access and lifestyle.

RESULTS

In addition to the improvements in asthma morbidity, the program was found to have four key benefits: cultural affirmation; improved access to other health services; a greater sense of control for participants; and positive impacts on the extended family.

CONCLUSIONS

The program's benefits extended beyond reduced asthma morbidity and were not due simply to the introduction of the asthma self-management plan but also to the partnership approach employed by the program.

IMPLICATIONS

The study provides support for providing public health services for indigenous communities that take a partnership approach, utilise community expertise and are delivered in a way that is consistent with each community's cultural processes.

B.M.A. deputizing service in Sheffield, 1970

Seventy-four per cent. of Sheffield general practitioners and 78% of those in Nottingham used a deputizing service in 1970. In each city the deputizing service was used by about 80% of single-handed general practitioners, 90% of doctors in two-doctor practices, and 60% of those in partnerships of three or more.The Sheffield deputizing service handled 15,988 new calls in the year, an average of 106 per subscribing doctor, and in addition made 339 revisits. The median number of calls handled for single-handed doctors was 98, for those in two-doctor practices 95, and for those in partnerships of three or more 75. The growth of group practice has not eliminated the demand for deputizing services.Sixty-six per cent. of consultations were with deputies who were primarily hospital doctors, 20% with a full-time deputy, 11% with deputies who were primarily general practitioners, and 3% with the switchboard staff, who were also trained nurses. The deputies had been qualified, on average, for eight years. Seventy-two per cent. of patients attended were seen within one hour of receipt of the call.Calls handled by the deputizing service represented approximately 1% of all the subscribers' consultations, 5% of their home visits, and half their calls between midnight and 07.00 hours. At this level of activity the concept of "personal doctoring" was not threatened.

The views of singlehanded general practitioners: a qualitative study

OBJECTIVES

To examine the concerns of singlehanded general practitioners working in an inner London area and to compare the views of general practitioners in partnerships.

DESIGN

Qualitative analysis of semistructured interviews with a random sample of singlehanded general practitioners and a sample of general practitioners from partnerships matched for age and sex.

SETTING

The area covered by Lambeth, Southwark, and Lewisham Family Health Services Authority.

RESULTS

The singlehanded general practitioners were more likely to be older, male, and first qualified abroad than general practitioners in partnerships. Their major concerns were inadequate premises, maintaining their singlehanded status, and coping with recent changes to their contract. Most were very satisfied with their solo status and did not see the provision of 24 hour care as stressful.

CONCLUSION

Singlehanded general practitioners saw themselves as providing a unique service for patients, and their status as an alternative for general practitioners who were unhappy in partnerships. Such practices are unlikely to wither away as a pattern of provision. Any comprehensive development of primary care must take their needs into account.

Roles for specialty societies and vascular surgeons in accountable care organizations

With the passage of the Affordable Care Act, accountable care organizations (ACOs) represent a new paradigm in healthcare payment reform. Designed to limit growth in spending while preserving quality, these organizations aim to incant physicians to lower costs by returning a portion of the savings realized by cost-effective, evidence-based care back to the ACO. In this review, first, we will explore the development of ACOs within the context of prior attempts to control Medicare spending, such as the sustainable growth rate and managed care organizations. Second, we describe the evolution of ACOs, the demonstration projects that established their feasibility, and their current organizational structure. Third, because quality metrics are central to the use and implementation of ACOs, we describe current efforts to design, collect, and interpret quality metrics in vascular surgery. And fourth, because a "seat at the table" will be an important key to success for vascular surgeons in these efforts, we discuss how vascular surgeons can participate and lead efforts within ACOs.

Advancing Reliable Data for Cancer Control in the Central America Four Region

The Central America Four (CA-4) region, comprising Guatemala, Honduras, El Salvador, and Nicaragua, is the largest low- and middle-income country region in the Western Hemisphere, with over 36 million inhabitants. The CA-4 nations share a common geography, history, language, and development indices, and unified with open borders in 2006. The growing CA-4 cancer burden among the noncommunicable diseases is expected to increase 73% by 2030, which argues for a regional approach to cancer control. This has driven efforts to establish population-based cancer registries as a central component of the cancer control plans. The involvement of international and academic partners in an array of initiatives to improve cancer information and control in the CA-4 has accelerated over the past several years. Existing data underscore that the infectious cancers (cervical, stomach, and liver) are a particular burden. All four countries have committed to establishing regional population-based cancer registries and have advanced significantly in pediatric cancer registration. The challenges common to each nation include the lack of national cancer control plans and departments, competing health priorities, lack of trained personnel, and sustainability strategies. General recommendations to address these challenges are outlined. The ongoing regional, international, and academic cooperation has proven helpful and is expected to continue to be a powerful instrument to contribute to the design and implementation of long-term national cancer control plans.

Women doctors in urban general practice: the doctors

A large study of general practitioners in Manchester showed that women doctors were younger than men doctors, and few were single handed or worked in deprived inner city areas. They had closely similar patterns of care to their male colleagues, and although they worked slightly fewer hours in surgery, they had almost identical consultation times per patient. Women general practitioners were less active in politics and education than men.

Palliative care module within a required geriatrics clerkship: taking advantage of existing partnerships

OBJECTIVE

LCME has recently required that all graduating medical students learn about end-of-life care. This program describes the design and integration into an existing geriatrics clerkship of a palliative care module that teaches the foundations of end-of-life and palliative care to medical students.

DESCRIPTION

Faculty experts in geriatrics met during a series of weekly meetings in 1999 to design a mandatory four-week-long clinical clerkship in geriatrics. Since the palliative care program is based within the geriatrics department, faculty members with interest and expertise in both geriatrics and palliative care were invited to design a palliative care module that can be integrated into the clerkship. Since LCME does not specify details of what students must learn about end-of-life care, and our goal is to educate and prepare students for any chosen specialty, we wanted to design a basic core curriculum in palliative care that would be useful to any graduating student. After reviewing potential palliative care topics, and given limited curriculum time, we condensed the medical student core curriculum to the following sessions: (1) Systematic Pain Assessment Management, (2) Management of Distressing Symptoms, (3) Communicating Bad News, and (4) Advance Directives. We developed PowerPoint presentations, teaching case vignettes, and a set of reference articles, which can be distributed to students as well as to help faculty teachers prepare for the sessions. Teaching sessions occur in small groups, using case discussions and interactive lectures. Sessions 3 and 4 are co-facilitated by palliative care physicians and ethicists, who use role-plays, reflections, and discussions to teach the topics. At the end of the clerkship, students practice these communication skills with videotaped standardized patient encounters, and debrief with faculty members about their performances and ways to improve their communication skills.

DISCUSSION

Palliative care sessions are welcomed by the students, who traditionally have not received much teaching in this area. Even though students have learned about mechanisms regulating pain and other symptoms in the past, they have not learned to assess or treat symptoms in a systematic way. Students often have good questions about the decision-making, legal, and ethical issues that emerge for patients near the end of life. Thus, co-facilitation of physicians with ethicists presents both the practical clinical and the theoretical perspectives, and provides a good model for team teaching. In terms of teaching style, students are more involved and participatory when teachers use case vignettes as compared with slide presentations, even if they are case-based. When using role-plays to teach students how to communicate bad news, we found that students need to feel safe in that environment, need to know they can call for time out when necessary, and want to have seen one done before they are asked to do one.

Health Initiatives for Youth: a model of youth/adult partnership approach to HIV/AIDS services

Health Initiatives for Youth (HIFY) in San Francisco, California, is an innovative organization providing health-related services for and by young people funded in part by the Special Projects of National Significance (SPNS) Program. The HIFY Youth Health Initiative (YHI) is composed of eight youth staff and aims to bring about individual and systemic change, enhance the quality of life for human immunodeficiency virus (HIV)-positive and at-risk young people, and increase the responsiveness and youth sensitivity of organizational and community systems. Comprehensive services have been delivered to 136 young men under 25 years, 33.1% of whom are HIV positive, and 164 young women, of whom 12.2% are HIV positive. In addition, thousands of youth and young adults have received lower-intensity services through dozens of educational workshops and presentations. YHI services are implemented through a comprehensive collection of education, training, and support activities that benefit the youth staff who produce them, along with the participants who benefit from the services provided. These activities include a speaker's bureau, health and advocacy trainings, internships, return-to-work and life skills training, publications, and conferences. Regional and national findings suggest that many youth do not yet comprehend their risk for HIV infection or understand the impact of HIV on their community. In direct response to these needs, HIFY programs inform and encourage access to counseling and testing, and provide meaningful access to adolescent care, treatment, and services.

General practice partnerships: till death us do part?

OBJECTIVES

To investigate applications for general practice partnership vacancies by established general practitioner principals, the reasons for changing partnerships, and the disincentives to these moves.

DESIGN

Confidential postal questionnaire.

SUBJECTS

Applicants to 367 general practices in the United Kingdom advertising for a new full time partner.

MAIN OUTCOME MEASURES

The proportion of job applications containing at least one application from established principals, proportion of principals appointed as new partners, incentives and disincentives to changing partnership.

RESULTS

Of 325 replies (89% response rate) received, 292 were suitable for further analysis. 210/241 (87%) of all applications contained some applications from at least one established principal. 12% of all applications were made by principals. 41/296 (14%) of the newly appointed partners had previously been an established principal. The main reasons for leaving the previous partnership were a desire to move locality or not getting on with previous partners. The disincentives to changing partnerships were largely financial, including the cost of the move and loss of income.

CONCLUSIONS

It is possible for established principals in general practice to overcome the disincentives and to change partnerships. There did not seem to be any overall prejudice against appointing principals, in contrast to previously published views.