Vol. 8, No. 4
Famity Practice © Oxford Uriveraity Pros 1901
Printed in Great Britain
Prevention of Lifestyle-related Disease: General Practitioners' Views About Their Role, Effectiveness and Resources Bruce N and Burnett S. Prevention of lifestyle-related disease: general practitioners' views about their role, effectiveness and resources. Family Practice 1991; 8: 373-377. An interview survey of GPs working within one district health authority was carried out in order to examine their views on the prevention of lifestyle-related disease. The 48 doctors (89%) who took part considered that prevention was an important part of their work, but were cautious about their effectiveness and over achieving change in many of their patients. Many expressed considerable concern about their ability to cope with the anticipated workload and the conflict with curative work, particularly when considering numbers of staff that could be made available. The views of the doctors in this study reflect uncertainty about their ability to carry out effective prevention of lifestyle-related disease for the general population. This uncertainty is not unexpected given that the important risk factors are widely distributed in the population, and greatly influenced by social norms. This has important implications for the planning of health promotion activities. Although additional resources and skills for the organization and conduct of health education work are also required, this need must be dealt with alongside the concerns expressed by the doctors in the study. These problems might be addressed by a coordinated district strategy for the prevention of lifestyle-related disease, developed in conjunction with other agencies responsible for public health, and with community groups.
INTRODUCTION Over the last 20 years, preventive work has become increasingly important for the general practitioner. Through a number of documents, the Royal College of General Practitioners has sought to discuss and encourage preventive activity in heart disease,1 child health,2 alcohol-related problems,3 and psychiatric illness.4 The special opportunities that exist for preventive work in general practice are well recognized; almost universal registration with GPs and contact with the practice within a period of a few years, the life-long records and the potential for comprehensive family care. Over the years, general practice has shown a variable response to these developments, but the new general practice contract5 has now prescribed a pattern of systematic screening activity for universal adoption. The recent policy statement on the prevention of coronary heart disease from the Coronary Prevention Group emphasizes an important role for primary care.6
For the doctor and the practice team, the workload which can arise from different preventive activities varies considerably. At one end of the spectrum, childhood immunization generates little extra work once administered. Cervical screening carries a somewhat greater burden since the GP will usually be involved in ensuring adequate follow-up and in advising women with abnormal smears. At the other end of the spectrum lies the area of detection and management of the common lifestyle risk factors such as smoking, excess alcohol consumption, obesity and poor diet, lack of exercise, and emotional disorders. The nature and social context of these problems means that very considerable efforts will often be required to achieve positive results. There is evidence of some success with smoking7 and alcohol,3-8but the management of weight reduction and dietary change9 and emotional problems10" is less certain. One important reason is the relatively high proportion of the population which is involved; for instance, it is now recognized that usual population behaviour contributes more to the overall burden of disease associated with high serum
Department of Public Health and Primary Care, Royal Free Hospital School of Medicine, Rowland Hill St, London NW3 2PF, UK.
373
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NIGEL BRUCE A N D SHIRLEY BURNETT
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FAMILY PRACTICE—AN INTERNATIONAL JOURNAL 12
METHODS All 54 doctors working in 29 practices within Hampstead DHA as of June 1989 were contacted, and agreement sought to conduct an interview in two parts; the first on liaison in primary care and the second dealing with prevention. Only the latter part is reported here. An interview was successfully completed with 48 (89%) of the doctors; one did not wish to be interviewed: three were unable to find the time for the second (prevention) part of the interview; one was ill, and one other on sabbatical. All but four of the 29 practices (86%) were represented in the study. All of the interviews were carried out by SB between June and December 1989. The doctors were asked about their views on the role of the GP in prevention and health education work. Subsequent questions focused on prevention of lifestylerelated disease, and covered the effectiveness of the GP (with available help), confidence in coping with the workload, and the adequacy of staff that could be made available. For each question, the theme was presented neutrally with a range of pre-coded responses on flashcards, and additional comments were canvassed by asking whether the doctor had any doubts and if so what the reasons were. These com-
ments were subsequently grouped and then coded independently by NB and SB, with the disagreements being resolved by further discussion between the authors. Some previous studies have examined different aspects of lifestyle such as alcohol, smoking and drugs separately.14-13 During the development of the present study, the need for separating these lifestyle items was discussed with the GPs, but it was felt that a global question gave sufficient opportunity to express their views. Any discomfort on the part of the doctors in the main study interviews arising from this arrangement could have been recorded in the comments, but in the event this did not prove necessary. The questionnaire was pre-tested and piloted in practices outside the DHA area. The development stage included a discussion with each doctor to assess whether the interview had given them the opportunity to express their views adequately. For the purposes of analysing the doctors' responses by year of qualification, the sample has been divided approximately equally with 25 (52%) qualifying between 1949 and 1968, and the remaining 23 (48%) in 1969 or later. Sixteen (33%) of the doctors were women, and 10 (21%) were members of the Royal College of GPs. In order to facilitate generalization to other areas which might be judged similar to this inner city district, 95% confidence intervals (CI) are given for key responses in the results section. It should be noted, however, that these confidence intervals do not apply to the results for the district itself, since no sampling error is involved. This issue, and the general question of representativeness of the results, is considered further in the discussion. RESULTS The Role of the GP in Prevention Doctors were asked what part prevention and health education should play at the present time in a GP's work. Just over half thought it to be an important although minor part (Table 1); one-third (CI 20-46%) of the doctors felt that prevention should form at least half of their work. In comments made by 26 GPs, some emphasized that attending to the sick must come TABLE 1 The role of the GP in prevention; 'Do you believe that at the present time prevention and health education work should be' Response No part of the GP's work A rather minor part of the GP's work An important, but still minor part About half of the GP's work The major part of the GP's work Total •1 missing.
Number 1 4 26 13 3 47*
2 8 54 27 6 97
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cholesterol and alcohol consumption3 than do the limited numbers of people with more extreme levels of risk factors. Furthermore, the GP is often attempting to change behaviour against the prevailing social and commercial tide. l2 Many unhealthy aspects of lifestyle are probably adopted or perpetuated partly in response to emotional distress and material deprivation,13 and the GP can be faced with a formidable and daunting task in trying to alter these underlying pressures on behaviour. Furthermore, there are other important influences on behaviour such as marketing and pricing policy that are effectively beyond the influence of the general practitioner. Thus, although there is good evidence that general practice can be very effective in health education with some patients,7'8 this does not necessarily mean that it can or should be the main agent of change for the general population. It might be expected that many GPs would be sensitive to these issues, and as a result face considerable uncertainties in the development of health education work. There is evidence from previous studies that doctors may not feel competent to advise on aspects of lifestyle that they nevertheless see as important. u The views on this subject held by General Practitioners serving the residents of a district health authority (DHA) are of considerable importance to the success of local efforts to develop health promotion. The purpose of this study was to investigate within one DHA the attitudes of the doctors to their role and effectiveness in the prevention of lifestyle related disease, and to consider ways of integrating their views and experience into the plans for health promotion activity in the district.
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VIEWS ON PREVENTATIVE MEDICINE
first (6), that there should be more emphasis on external factors and sources of changes such as the media and the government (7), and that people should take more responsibility for their own health (4). There was some evidence that the younger doctors (qualifying in 1969 or later) were more positive about the preventive role of the GP: none felt that prevention should be a minor part or no part of the GP's work, compared to five of the older doctors (Fisher's exact test; P=0.055, two-sided).
TABLE 3 Confidence about workload; 'How confident do you feel that you, and the practice, can cope with the amount of work that this general lifestyle preventive activity might generate?' Response Very unconfident Fairly unconfident A bit confident Fairly confident Very confident Total
Number
10 11 5 15 7 48
21 23 10 31 15 100
Adequacy of Staff Available for Preventive Work Doctors were asked whether the number of staff TABLE 2 Effectiveness of GP in prevention; 'How effective do you believe the GP (with available help) can be in general available for the amount of preventive activity they lifestyle prevention and health education' thought appropriate was adequate. This wording was Response Very ineffective Somewhat ineffective A bit effective Fairly effective Very effective Total
Number
1 6 16 16 9 48
2 13 33 33 19 100
Confidence about Coping with the Workload Generated by Preventive Activity On this topic, the doctors appeared to fall into two groups; 21 (44%; CI 30-58%) reported being fairly or very unconfident, 22 (46%; CI 32-60%) were fairly
chosen to explore what doctors felt their needs should be, rather than what they might have to provide to carry out externally imposed tasks which they might not have thought justified. A majority (60%; CI 46-74%) of the doctors felt that the level of staff they could make available was a bit or very inadequate (Table 4). Comments were made by 32 doctors; 29 wanted more staff, while 15 of the 29 specified that they required more space and/or financing to employ the extra staff. DISCUSSION This study was carried out in the second half of 1989, prior to the introduction of the new contract,5 and does not necessarily describe how the doctors view prevention under the new arrangements. The process
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The Effectiveness of the GP in the Prevention of Lifestyle-related Disease When asked about the effectiveness of the GP in this aspect of prevention, nearly half (CI 34-62%) of the doctors were rather cautious and felt that they were at best only partly effective (Table 2). Among the comments made by 41 of the doctors, five reiterated their certainty about effectiveness, for instance with the view that 'It is the most effective way to teach people about drugs, alcohol, smoking and diet'. However, most doctors reported much less positive views. Twelve felt that people generally do not listen or take notice, and this was expressed particularly strongly by the comment of one GP that 'You can talk till you are blue in the face, and they'll still be boozing and smoking'. Sixteen felt themselves to be effective with some people (sometimes very effective), but that it depended on the patient's circumstances: they had more effect when the patient was ill, or for some other reason more directly aware of the adverse consequences of failing to change an unhealthy lifestyle. Typical comments in this group were 'It depends on who you are dealing with, some patients don't want to know', and 'People don't take much notice unless ill or frightened'. Nine doctors said that the evidence for effectiveness and/or efficiency of prevention is poor, and six others felt that the GP is only one source, mentioning the importance of the media.
or very confident, and only five (10%; CI 2-18%) adopted the middle ground (Table 3). Comments were made by 41 doctors, and the major concern was about shortage of time resulting from an open-ended work load (21), and fears of conflict with the curative side of their work (8). These views are well expressed by one GP who commented that 'The task is bottomless—we could do it to the exclusion of all acute work'. There was no marked difference in the pattern of these views according to the gender of the doctor, although there was some evidence of a relationship with the year of qualification which was not statistically significant. Thirteen (56%) of the doctors qualifying afteT 1968 were fairly or very unconfident as opposed to eight (32%) of those qualifying before (X2=2.02, df = 1, P = 0.15), but there was still evidence of a bimodal distribution in both groups. In their comments however, 12 (54%) of the 22 fairly or very confident doctors did admit concern, mainly about time (6), the need for more staff (5), and the conflict with curative work (2). All of the 21 unconfident doctors added further comments, mostly about the time (13) and conflict with curative work (5).
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TABLE 4 Available staff; 'Do you feel that the staff you can make available for the amount of preventive work you think appropriate is'
Response Very adequate Just about adequate A bit inadequate Very inadequate Total
Number 6 13 14 15 48
13 27 29 31 100
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and outcome of preventive work under the new contract will need to be investigated, but it is felt that the views expressed in this study relate to an underlying problem which will probably be brought more sharply into focus as doctors try to decide how much of their time and staff to devote to the management of common lifestyle problems. Although relatively small, this study achieved a response rate of 89%, and can be considered representative of the range of attitudes and experience of the GPs working within one district. Since all of the doctors working within the district were approached, there is no sampling error so far as the results for the district are concerned. However, in order to judge how far the results can be generalized to other areas, it is necessary to consider whether the characteristics and views of local doctors are typical of those elsewhere. It is notable that, compared to the country, this district has a much higher proportion of single-handed doctors (29% in the district, 11.5% nationally1*), although this is very similar to the 27% found in the whole of the local Family Health Services Authority (FHSA) area in 1989.l6 One-third of the local doctors were female, a slightly higher proportion than the national figure of 23% in 1989.16 There were about 0.4 WTE practice nurses per partnership in the study sample, midway between the national Figure (0.51) and that for the FHSA area (0.23)." In general, the district sample was fairly similar to the FHSA area which represents almost 100 inner city practices, but shows the expected difference in partnership size when compared to the country. While the local sample of practices may have characteristics which are fairly typical of an inner city area, what is most important here is the extent to which the views of the study GPs are representative of other areas. This issue is best examined by considering the findings of other studies of health education and prevention in primary care. Although some other studies of attitudes to health education have been representative of GP populations,15 others have sampled specific groups such as GP advisers and course organizers," members of the RCGP,14 and GP trainees.18 Since the present study describes a well defined population of GPs working within the district, it is possible to consider the findings in the context of local
policy involving the health authority and other agencies. This is of particular relevance as the work of the District Health Authority and Family Health Services Authority become more closely linked. The GPs were generally favourably disposed towards prevention as an important part of their work, and this was particularly true for the younger doctors. However, most expressed rather more caution about effectiveness, especially in their comments. There appeared to be a strong sense of fruitlessness in quite a few, or a qualification that it depended on the situation—if a patient really wanted to alter his or her lifestyle, perhaps due to illness, then success was more likely. In addition, some were concerned that evidence about the effectiveness or efficiency of this work was lacking. It is interesting that the doctors' views were divided when asked about their confidence in coping with the work likely to be generated by preventive work, a finding that is only in part attributable to the lower confidence reported by younger doctors. Whether this pattern is due to an unwillingness on the part of some to admit lack of confidence, or a genuine belief in the ability to cope is not clear, but about half of the confident doctors did express some concerns in their comments. Furthermore, a majority of doctors felt that they were not able to provide enough staff for the amount of preventive work they saw as desirable. That most doctors are in favour of preventive work is in agreement with other studies,14'13 as is the tendency for younger doctors to be more positive about this role." There is also support from other studies for the finding that many of the doctors were concerned about effectiveness.l4'13'18 However, the design of the present study with probing by an interviewer for additional unstructured comments may have allowed a greater expression of perceived problems than would be apparent from a self-administered questionnaire alone. This may also be true of the confidence which doctors expressed in coping with the amount of work that might arise, since when given the opportunity a majority felt that time was a problem. This is in contrast to the findings of one other study where only 21 % felt that GPs did not have enough time for preventive work,14 although all the doctors were members of the Royal College of GPs. On the other hand, in a study of GP trainees which specifically asked about barriers to health education in general practice, 78% mentioned time and workload as problems." In the same study, 40% of the trainees thought that resistance by the patients would be a barrier to health education. The reason why doctors might hold these views are complex. The subject of this study, namely the theoretical implications of GPs attempting to change aspects of behaviour that are highly prevalent and deeply embedded in our social and economic system, provides one possible contributory factor. Other factors include practical issues such as inadequate premises, staff and practice organization which will
VIEWS ON PREVENTATIVE MEDICINE
ACKNOWLEDGEMENTS Thanks to the Hampstead and South Barnet GP Forum for giving their support to the study, and to all the general practitioners who took part.
1
2
3
REFERENCES Prevention of Aerterial Disease in General Practice. Report from General Practice 19. Royal College of General Practitioners, 1981. Healthier Children—Thinking Prevention. Report from General Practice 22. Royal College of General Practitioners, 1982. Alcohol—A Balanced View. Report from General Practice 24. Royal College of General Practitioners, 1986.
Prevention of Psychiatric Disorders in General Practice. Report from General Practice 20. Royal College of General Practitioners, 1981. 5 General Practice in the National Health Service—A New Contract. Department of Health, 1989. 6 Coronary Prevention Group. Risk assessment in the prevention of coronary heart disease: a policy statement. Br J Gen Pract 1990: 40: 467-469. 7 Jamrozik K, Vessey M, Fowler G, Wald N, Parker G, Vunakis HV. Controlled trial of three different antismoking interventions in general practice. Br Med J 1984; 288: 1499-1503. 8 Wallace P, Cutler S, Haines A. Randomised controlled trial of general practice intervention in patients with excessive alcohol consumption. Br Med J 1988; 297: 663-668. 9 Baron JA, Gleason R, Crowe B, Mann JI. Preliminary trial of the effect of general practice based nutritional advice. J R Coll Gen Pract 1990; 40: 137-141. 10 Robson MH, France R, Bland M. Clinical psychologist in primary care: controlled clinical and economic evaluation. BrMedJ\9U\ 288: 1805-1808. " Freeman GK, Button EJ. The clinical psychologist in general practice: a six year study of consulting patterns for psychosocial problems. J R Coll Gen Pract 1984; 34: 377-380. 12 Rose G. Strategy of prevention: lessons from cardiovascular disease. Br Med J 1981; 282: 1847-1851. 13 Black D, Morris JN, Smith C, Townsend P. Inequalities in Health, The Black Report. Penguin, 1983; 114-123. 14 Wood N, Whitfield M, Bailey D. How do general practitioners view their role in primary prevention? Health Educ 71989; 48: 145-149. 15 Williams A, Bucks R, Whitfield M. General practitioners' attitudes to prevention. Health Educ J 1989; 48: 3032. 16 NHS Management Executive. Health Services Indicators, 1991. 17 Calnan M, Boulton M, Williams A. Health Education and General Practitioners: a critical appraisal. In: Rodmell S, Watt A (eds), The Politics of Health Education. Routledge and Kegan Paul, London 1986; 191-193. 18 Boulton MG, Williams AJ. Health education and prevention in general practice—the views of GP trainees. Health Educ J 1986; 45: 79-83. 19 Calnan M, Boulton M, Williams A. Health Education and General Practitioners: a critical appraisal. In: Rodmell S, Watt A (eds), The Politics of Health Education. Routledge and Kegan Paul, London 1986; 198-199. 20
21
Fullard E, Fowler G, Gray M. Facilitating prevention in primary care. Br Med J 1984; 289: 1585-1587. Health Circular HC(FP) (90)8/HC(90)15. Health Service
Developments— Working for Patients. Medical A udit in the Family Practitioner Services. Department of Health 1990; 1-3.
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inevitably place limitations on the development of prevention work. The nature of the doctor-patient relationship is also thought to be important. The traditionally dominant role of the doctor may restrict the potential for people to make their own decisions about lifestyle and health," and this will be reflected in how doctors perceive the patients' attitudes to change. Although the relative contribution of these problems will vary between localities according to the social circumstances and skills of the doctors, all are important and should be addressed together in strategies for preventing lifestyle-related disease. The results of this study suggest that one way to deal with the problems of population prevention would be to develop a comprehensive prevention strategy for the district, within which there would be guidelines for the role of general practice. These guidelines should be based on the available evidence for cost effective intervention in general practice, and developed in consultation with GPs, the Family Health Services Authority, other agencies with a responsibility for public health, as well as with community groups." Guidelines developed in this way should then be discussed with individual doctors and practices to assist with implementation and evaluation, and this would be an appropriate development of the role that has been described for the general practice facilitator. "•20 It remains to be seen whether this proposal would be compatible with the specifications on health promotion in the new contract.5 Nevertheless, the current developments in general practice information associated with the new contract, and plans for medical audit,21 should in any case provide useful information for monitoring progress in the control of important lifestyle problems including smoking, alcohol consumption and obesity.
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Famity Practice © Oxford Uriveraity Pros 1901
Printed in Great Britain
Prevention of Lifestyle-related Disease: General Practitioners' Views About Their Role, Effectiveness and Resources Bruce N and Burnett S. Prevention of lifestyle-related disease: general practitioners' views about their role, effectiveness and resources. Family Practice 1991; 8: 373-377. An interview survey of GPs working within one district health authority was carried out in order to examine their views on the prevention of lifestyle-related disease. The 48 doctors (89%) who took part considered that prevention was an important part of their work, but were cautious about their effectiveness and over achieving change in many of their patients. Many expressed considerable concern about their ability to cope with the anticipated workload and the conflict with curative work, particularly when considering numbers of staff that could be made available. The views of the doctors in this study reflect uncertainty about their ability to carry out effective prevention of lifestyle-related disease for the general population. This uncertainty is not unexpected given that the important risk factors are widely distributed in the population, and greatly influenced by social norms. This has important implications for the planning of health promotion activities. Although additional resources and skills for the organization and conduct of health education work are also required, this need must be dealt with alongside the concerns expressed by the doctors in the study. These problems might be addressed by a coordinated district strategy for the prevention of lifestyle-related disease, developed in conjunction with other agencies responsible for public health, and with community groups.
INTRODUCTION Over the last 20 years, preventive work has become increasingly important for the general practitioner. Through a number of documents, the Royal College of General Practitioners has sought to discuss and encourage preventive activity in heart disease,1 child health,2 alcohol-related problems,3 and psychiatric illness.4 The special opportunities that exist for preventive work in general practice are well recognized; almost universal registration with GPs and contact with the practice within a period of a few years, the life-long records and the potential for comprehensive family care. Over the years, general practice has shown a variable response to these developments, but the new general practice contract5 has now prescribed a pattern of systematic screening activity for universal adoption. The recent policy statement on the prevention of coronary heart disease from the Coronary Prevention Group emphasizes an important role for primary care.6
For the doctor and the practice team, the workload which can arise from different preventive activities varies considerably. At one end of the spectrum, childhood immunization generates little extra work once administered. Cervical screening carries a somewhat greater burden since the GP will usually be involved in ensuring adequate follow-up and in advising women with abnormal smears. At the other end of the spectrum lies the area of detection and management of the common lifestyle risk factors such as smoking, excess alcohol consumption, obesity and poor diet, lack of exercise, and emotional disorders. The nature and social context of these problems means that very considerable efforts will often be required to achieve positive results. There is evidence of some success with smoking7 and alcohol,3-8but the management of weight reduction and dietary change9 and emotional problems10" is less certain. One important reason is the relatively high proportion of the population which is involved; for instance, it is now recognized that usual population behaviour contributes more to the overall burden of disease associated with high serum
Department of Public Health and Primary Care, Royal Free Hospital School of Medicine, Rowland Hill St, London NW3 2PF, UK.
373
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NIGEL BRUCE A N D SHIRLEY BURNETT
374
FAMILY PRACTICE—AN INTERNATIONAL JOURNAL 12
METHODS All 54 doctors working in 29 practices within Hampstead DHA as of June 1989 were contacted, and agreement sought to conduct an interview in two parts; the first on liaison in primary care and the second dealing with prevention. Only the latter part is reported here. An interview was successfully completed with 48 (89%) of the doctors; one did not wish to be interviewed: three were unable to find the time for the second (prevention) part of the interview; one was ill, and one other on sabbatical. All but four of the 29 practices (86%) were represented in the study. All of the interviews were carried out by SB between June and December 1989. The doctors were asked about their views on the role of the GP in prevention and health education work. Subsequent questions focused on prevention of lifestylerelated disease, and covered the effectiveness of the GP (with available help), confidence in coping with the workload, and the adequacy of staff that could be made available. For each question, the theme was presented neutrally with a range of pre-coded responses on flashcards, and additional comments were canvassed by asking whether the doctor had any doubts and if so what the reasons were. These com-
ments were subsequently grouped and then coded independently by NB and SB, with the disagreements being resolved by further discussion between the authors. Some previous studies have examined different aspects of lifestyle such as alcohol, smoking and drugs separately.14-13 During the development of the present study, the need for separating these lifestyle items was discussed with the GPs, but it was felt that a global question gave sufficient opportunity to express their views. Any discomfort on the part of the doctors in the main study interviews arising from this arrangement could have been recorded in the comments, but in the event this did not prove necessary. The questionnaire was pre-tested and piloted in practices outside the DHA area. The development stage included a discussion with each doctor to assess whether the interview had given them the opportunity to express their views adequately. For the purposes of analysing the doctors' responses by year of qualification, the sample has been divided approximately equally with 25 (52%) qualifying between 1949 and 1968, and the remaining 23 (48%) in 1969 or later. Sixteen (33%) of the doctors were women, and 10 (21%) were members of the Royal College of GPs. In order to facilitate generalization to other areas which might be judged similar to this inner city district, 95% confidence intervals (CI) are given for key responses in the results section. It should be noted, however, that these confidence intervals do not apply to the results for the district itself, since no sampling error is involved. This issue, and the general question of representativeness of the results, is considered further in the discussion. RESULTS The Role of the GP in Prevention Doctors were asked what part prevention and health education should play at the present time in a GP's work. Just over half thought it to be an important although minor part (Table 1); one-third (CI 20-46%) of the doctors felt that prevention should form at least half of their work. In comments made by 26 GPs, some emphasized that attending to the sick must come TABLE 1 The role of the GP in prevention; 'Do you believe that at the present time prevention and health education work should be' Response No part of the GP's work A rather minor part of the GP's work An important, but still minor part About half of the GP's work The major part of the GP's work Total •1 missing.
Number 1 4 26 13 3 47*
2 8 54 27 6 97
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cholesterol and alcohol consumption3 than do the limited numbers of people with more extreme levels of risk factors. Furthermore, the GP is often attempting to change behaviour against the prevailing social and commercial tide. l2 Many unhealthy aspects of lifestyle are probably adopted or perpetuated partly in response to emotional distress and material deprivation,13 and the GP can be faced with a formidable and daunting task in trying to alter these underlying pressures on behaviour. Furthermore, there are other important influences on behaviour such as marketing and pricing policy that are effectively beyond the influence of the general practitioner. Thus, although there is good evidence that general practice can be very effective in health education with some patients,7'8 this does not necessarily mean that it can or should be the main agent of change for the general population. It might be expected that many GPs would be sensitive to these issues, and as a result face considerable uncertainties in the development of health education work. There is evidence from previous studies that doctors may not feel competent to advise on aspects of lifestyle that they nevertheless see as important. u The views on this subject held by General Practitioners serving the residents of a district health authority (DHA) are of considerable importance to the success of local efforts to develop health promotion. The purpose of this study was to investigate within one DHA the attitudes of the doctors to their role and effectiveness in the prevention of lifestyle related disease, and to consider ways of integrating their views and experience into the plans for health promotion activity in the district.
375
VIEWS ON PREVENTATIVE MEDICINE
first (6), that there should be more emphasis on external factors and sources of changes such as the media and the government (7), and that people should take more responsibility for their own health (4). There was some evidence that the younger doctors (qualifying in 1969 or later) were more positive about the preventive role of the GP: none felt that prevention should be a minor part or no part of the GP's work, compared to five of the older doctors (Fisher's exact test; P=0.055, two-sided).
TABLE 3 Confidence about workload; 'How confident do you feel that you, and the practice, can cope with the amount of work that this general lifestyle preventive activity might generate?' Response Very unconfident Fairly unconfident A bit confident Fairly confident Very confident Total
Number
10 11 5 15 7 48
21 23 10 31 15 100
Adequacy of Staff Available for Preventive Work Doctors were asked whether the number of staff TABLE 2 Effectiveness of GP in prevention; 'How effective do you believe the GP (with available help) can be in general available for the amount of preventive activity they lifestyle prevention and health education' thought appropriate was adequate. This wording was Response Very ineffective Somewhat ineffective A bit effective Fairly effective Very effective Total
Number
1 6 16 16 9 48
2 13 33 33 19 100
Confidence about Coping with the Workload Generated by Preventive Activity On this topic, the doctors appeared to fall into two groups; 21 (44%; CI 30-58%) reported being fairly or very unconfident, 22 (46%; CI 32-60%) were fairly
chosen to explore what doctors felt their needs should be, rather than what they might have to provide to carry out externally imposed tasks which they might not have thought justified. A majority (60%; CI 46-74%) of the doctors felt that the level of staff they could make available was a bit or very inadequate (Table 4). Comments were made by 32 doctors; 29 wanted more staff, while 15 of the 29 specified that they required more space and/or financing to employ the extra staff. DISCUSSION This study was carried out in the second half of 1989, prior to the introduction of the new contract,5 and does not necessarily describe how the doctors view prevention under the new arrangements. The process
Downloaded from http://fampra.oxfordjournals.org/ at Heriot-Watt University on December 29, 2014
The Effectiveness of the GP in the Prevention of Lifestyle-related Disease When asked about the effectiveness of the GP in this aspect of prevention, nearly half (CI 34-62%) of the doctors were rather cautious and felt that they were at best only partly effective (Table 2). Among the comments made by 41 of the doctors, five reiterated their certainty about effectiveness, for instance with the view that 'It is the most effective way to teach people about drugs, alcohol, smoking and diet'. However, most doctors reported much less positive views. Twelve felt that people generally do not listen or take notice, and this was expressed particularly strongly by the comment of one GP that 'You can talk till you are blue in the face, and they'll still be boozing and smoking'. Sixteen felt themselves to be effective with some people (sometimes very effective), but that it depended on the patient's circumstances: they had more effect when the patient was ill, or for some other reason more directly aware of the adverse consequences of failing to change an unhealthy lifestyle. Typical comments in this group were 'It depends on who you are dealing with, some patients don't want to know', and 'People don't take much notice unless ill or frightened'. Nine doctors said that the evidence for effectiveness and/or efficiency of prevention is poor, and six others felt that the GP is only one source, mentioning the importance of the media.
or very confident, and only five (10%; CI 2-18%) adopted the middle ground (Table 3). Comments were made by 41 doctors, and the major concern was about shortage of time resulting from an open-ended work load (21), and fears of conflict with the curative side of their work (8). These views are well expressed by one GP who commented that 'The task is bottomless—we could do it to the exclusion of all acute work'. There was no marked difference in the pattern of these views according to the gender of the doctor, although there was some evidence of a relationship with the year of qualification which was not statistically significant. Thirteen (56%) of the doctors qualifying afteT 1968 were fairly or very unconfident as opposed to eight (32%) of those qualifying before (X2=2.02, df = 1, P = 0.15), but there was still evidence of a bimodal distribution in both groups. In their comments however, 12 (54%) of the 22 fairly or very confident doctors did admit concern, mainly about time (6), the need for more staff (5), and the conflict with curative work (2). All of the 21 unconfident doctors added further comments, mostly about the time (13) and conflict with curative work (5).
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FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
TABLE 4 Available staff; 'Do you feel that the staff you can make available for the amount of preventive work you think appropriate is'
Response Very adequate Just about adequate A bit inadequate Very inadequate Total
Number 6 13 14 15 48
13 27 29 31 100
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and outcome of preventive work under the new contract will need to be investigated, but it is felt that the views expressed in this study relate to an underlying problem which will probably be brought more sharply into focus as doctors try to decide how much of their time and staff to devote to the management of common lifestyle problems. Although relatively small, this study achieved a response rate of 89%, and can be considered representative of the range of attitudes and experience of the GPs working within one district. Since all of the doctors working within the district were approached, there is no sampling error so far as the results for the district are concerned. However, in order to judge how far the results can be generalized to other areas, it is necessary to consider whether the characteristics and views of local doctors are typical of those elsewhere. It is notable that, compared to the country, this district has a much higher proportion of single-handed doctors (29% in the district, 11.5% nationally1*), although this is very similar to the 27% found in the whole of the local Family Health Services Authority (FHSA) area in 1989.l6 One-third of the local doctors were female, a slightly higher proportion than the national figure of 23% in 1989.16 There were about 0.4 WTE practice nurses per partnership in the study sample, midway between the national Figure (0.51) and that for the FHSA area (0.23)." In general, the district sample was fairly similar to the FHSA area which represents almost 100 inner city practices, but shows the expected difference in partnership size when compared to the country. While the local sample of practices may have characteristics which are fairly typical of an inner city area, what is most important here is the extent to which the views of the study GPs are representative of other areas. This issue is best examined by considering the findings of other studies of health education and prevention in primary care. Although some other studies of attitudes to health education have been representative of GP populations,15 others have sampled specific groups such as GP advisers and course organizers," members of the RCGP,14 and GP trainees.18 Since the present study describes a well defined population of GPs working within the district, it is possible to consider the findings in the context of local
policy involving the health authority and other agencies. This is of particular relevance as the work of the District Health Authority and Family Health Services Authority become more closely linked. The GPs were generally favourably disposed towards prevention as an important part of their work, and this was particularly true for the younger doctors. However, most expressed rather more caution about effectiveness, especially in their comments. There appeared to be a strong sense of fruitlessness in quite a few, or a qualification that it depended on the situation—if a patient really wanted to alter his or her lifestyle, perhaps due to illness, then success was more likely. In addition, some were concerned that evidence about the effectiveness or efficiency of this work was lacking. It is interesting that the doctors' views were divided when asked about their confidence in coping with the work likely to be generated by preventive work, a finding that is only in part attributable to the lower confidence reported by younger doctors. Whether this pattern is due to an unwillingness on the part of some to admit lack of confidence, or a genuine belief in the ability to cope is not clear, but about half of the confident doctors did express some concerns in their comments. Furthermore, a majority of doctors felt that they were not able to provide enough staff for the amount of preventive work they saw as desirable. That most doctors are in favour of preventive work is in agreement with other studies,14'13 as is the tendency for younger doctors to be more positive about this role." There is also support from other studies for the finding that many of the doctors were concerned about effectiveness.l4'13'18 However, the design of the present study with probing by an interviewer for additional unstructured comments may have allowed a greater expression of perceived problems than would be apparent from a self-administered questionnaire alone. This may also be true of the confidence which doctors expressed in coping with the amount of work that might arise, since when given the opportunity a majority felt that time was a problem. This is in contrast to the findings of one other study where only 21 % felt that GPs did not have enough time for preventive work,14 although all the doctors were members of the Royal College of GPs. On the other hand, in a study of GP trainees which specifically asked about barriers to health education in general practice, 78% mentioned time and workload as problems." In the same study, 40% of the trainees thought that resistance by the patients would be a barrier to health education. The reason why doctors might hold these views are complex. The subject of this study, namely the theoretical implications of GPs attempting to change aspects of behaviour that are highly prevalent and deeply embedded in our social and economic system, provides one possible contributory factor. Other factors include practical issues such as inadequate premises, staff and practice organization which will
VIEWS ON PREVENTATIVE MEDICINE
ACKNOWLEDGEMENTS Thanks to the Hampstead and South Barnet GP Forum for giving their support to the study, and to all the general practitioners who took part.
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REFERENCES Prevention of Aerterial Disease in General Practice. Report from General Practice 19. Royal College of General Practitioners, 1981. Healthier Children—Thinking Prevention. Report from General Practice 22. Royal College of General Practitioners, 1982. Alcohol—A Balanced View. Report from General Practice 24. Royal College of General Practitioners, 1986.
Prevention of Psychiatric Disorders in General Practice. Report from General Practice 20. Royal College of General Practitioners, 1981. 5 General Practice in the National Health Service—A New Contract. Department of Health, 1989. 6 Coronary Prevention Group. Risk assessment in the prevention of coronary heart disease: a policy statement. Br J Gen Pract 1990: 40: 467-469. 7 Jamrozik K, Vessey M, Fowler G, Wald N, Parker G, Vunakis HV. Controlled trial of three different antismoking interventions in general practice. Br Med J 1984; 288: 1499-1503. 8 Wallace P, Cutler S, Haines A. Randomised controlled trial of general practice intervention in patients with excessive alcohol consumption. Br Med J 1988; 297: 663-668. 9 Baron JA, Gleason R, Crowe B, Mann JI. Preliminary trial of the effect of general practice based nutritional advice. J R Coll Gen Pract 1990; 40: 137-141. 10 Robson MH, France R, Bland M. Clinical psychologist in primary care: controlled clinical and economic evaluation. BrMedJ\9U\ 288: 1805-1808. " Freeman GK, Button EJ. The clinical psychologist in general practice: a six year study of consulting patterns for psychosocial problems. J R Coll Gen Pract 1984; 34: 377-380. 12 Rose G. Strategy of prevention: lessons from cardiovascular disease. Br Med J 1981; 282: 1847-1851. 13 Black D, Morris JN, Smith C, Townsend P. Inequalities in Health, The Black Report. Penguin, 1983; 114-123. 14 Wood N, Whitfield M, Bailey D. How do general practitioners view their role in primary prevention? Health Educ 71989; 48: 145-149. 15 Williams A, Bucks R, Whitfield M. General practitioners' attitudes to prevention. Health Educ J 1989; 48: 3032. 16 NHS Management Executive. Health Services Indicators, 1991. 17 Calnan M, Boulton M, Williams A. Health Education and General Practitioners: a critical appraisal. In: Rodmell S, Watt A (eds), The Politics of Health Education. Routledge and Kegan Paul, London 1986; 191-193. 18 Boulton MG, Williams AJ. Health education and prevention in general practice—the views of GP trainees. Health Educ J 1986; 45: 79-83. 19 Calnan M, Boulton M, Williams A. Health Education and General Practitioners: a critical appraisal. In: Rodmell S, Watt A (eds), The Politics of Health Education. Routledge and Kegan Paul, London 1986; 198-199. 20
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Fullard E, Fowler G, Gray M. Facilitating prevention in primary care. Br Med J 1984; 289: 1585-1587. Health Circular HC(FP) (90)8/HC(90)15. Health Service
Developments— Working for Patients. Medical A udit in the Family Practitioner Services. Department of Health 1990; 1-3.
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inevitably place limitations on the development of prevention work. The nature of the doctor-patient relationship is also thought to be important. The traditionally dominant role of the doctor may restrict the potential for people to make their own decisions about lifestyle and health," and this will be reflected in how doctors perceive the patients' attitudes to change. Although the relative contribution of these problems will vary between localities according to the social circumstances and skills of the doctors, all are important and should be addressed together in strategies for preventing lifestyle-related disease. The results of this study suggest that one way to deal with the problems of population prevention would be to develop a comprehensive prevention strategy for the district, within which there would be guidelines for the role of general practice. These guidelines should be based on the available evidence for cost effective intervention in general practice, and developed in consultation with GPs, the Family Health Services Authority, other agencies with a responsibility for public health, as well as with community groups." Guidelines developed in this way should then be discussed with individual doctors and practices to assist with implementation and evaluation, and this would be an appropriate development of the role that has been described for the general practice facilitator. "•20 It remains to be seen whether this proposal would be compatible with the specifications on health promotion in the new contract.5 Nevertheless, the current developments in general practice information associated with the new contract, and plans for medical audit,21 should in any case provide useful information for monitoring progress in the control of important lifestyle problems including smoking, alcohol consumption and obesity.
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