The effective planning of a system and the training of personnel to run it requires accurate data regarding the use to be made of the system. For a health care system such data, apart from actual numbers of patients, will include age/sex distribution, patient requests and expectations, and common presenting symptoms and diagnoses. Studies have been conducted in various countries to collect such data and while they have demonstrated general similarities among countries, they have also shown important regional differences. The present study arose as a result of discussions during a course on Family Medicine held by the University of Malta attended by ten doctors working in Government Health Centres, as it was noted that no such information has been published for Malta. The main objectives of the study were to determine the content of general practice in Malta; compare general practice experience in Government Health Centres and in private practice; determine and compare referral rates in Government Health Centres and in private practice.peer-reviewe

Agius Muscat, Hugo

Carabott, Paul

English

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rr-\-Maltesc Medical-lournal 34 volulll c I Issuc 11 lm·m The Content of General Practice in Malta A pilot study comparing Health Centre and Private practice in Malta with each other and with General Practice (as reported for The effective planning of a system and the training of personnel to run it requires accurate data regarding the use to be made of the system. For a health care system such data, apart from actual numbers of patients, will include age/ sex distribution, patient requests and expecta tions, and common presenting symptoms and diagnoses . Studies have been conducted in various countries to collect such data' and while they have demonstrated general similarities among countries, they have also shown important regional differences. The present study arose as a result of discussions during a course on Family Medicine held by the University of Malta attended by ten doctors working in Govern­ment Health Centres, as it was noted that no such information has been published for Malta. The main objectives of the study were to: 1. 	 determine the content ofgeneral practice in Malta; 2. 	 compare general practice experience in Government Health Centres and in private practice; 3. 	 determine and compare referral rates in Government Health Centres and in private practice. METHOD Physicians taking part in the Family Medicine course were asked to document each of their encounters with patients, both at Health Centres and in their private practices starting at 08.00 on Monday 25 January and ending at 08.00 on Monday 8 February 1988. Eight physicians took part in the study and the encounters were recorded on a purposely designed form. The data thus collected were entered into a computerised database. Diagnoses were coded according to the International Classification of Health Problems in Primary Care (ICHPPC-2)2 and the codes a lso entered in the database. Specific counts of the data were then carried out. The participating physicians were working full time in Government-run Health Centres staffed for twenty four hours a day and they saw patients in the office, in the satellite other countries) Hugo Agius-Muscat Paul Carabott dispensaries, "Bereg", (open for one or two hours on most mornings) , in the clinic treatment room and at home. During the time of the study, they were also attending a course on Family Medicine for three mornings every week. Private practice varied considerably due to doctor prefer­ences and differences in time off from Government duty. It included a number of home visits to industrial workers consisting mostly of sickness certification and verif­ication and was mainly carried out in the afternoons and evenings. The short time during which the encounters were recorded and the physician factors noted above may have introduced certain biases but we believe that the overall picture presented is accurate. RESULTS AGE DISTRIBUTION OF PATIENTS (Fig. 1-5) For private practice the malelfemale distrib­ution is very similar (fig. 1). The industrial patients were all in the 20-44 age group with one female under 20 and one male over 45. Total numbers were small however. The Health Centres (and not the dispensaries) show a small excess of males over females in the 20-34 year age group possibly related to work injuries that present there most often but otherwise there is also a uniform distribution (fig. 2). In fact, injuries appear more often for males than for females. The dispensaries show a marked excess of older patients, both male and female, compared to the Health Centres (fig. 3). This may reflect in part the high number of patients suffering from chronic conditions attending dispensaries mostly for renewal of regular prescriptions. Less patients in this group were seen in private =- F: I - - l I .i ,I , \ ,I r:; \ . -: ~ ~'.' -'- ' c>. 2 '-- 'c - L' ,c. "g O L ---'.c...c...'.-,e " 7:; -r--~ "' , ~ t·\ ",, . " J - _ _ ", 30 1'01 1:L-- ~ 1-'-"~___ '::"~E ' H:' LE':, 3 f--J E..~. I_T r, r= l lj--;- F :::: ':" :· E r IS T "' 1 8 '_' ~ !: I , ~ -, :: -]1 ., c " 1 " 1 " i 3·: ­1,r ~.,.. '. .,-------,----, - - '.,-----,------,- - -- ­1,: - 1 .l. ::: _ ::~ 3 ·) - 5':' 4 	 < -L. : JI:: TF' I::,UTIO II r :'J1 ~. L E::. r·e· , ' '' _ _T- CE:17F( · O c.p practice. A peak was observed for private female patients in the 20-34 year age group (fig. 4). This may partly be accounted for by the number of Antenatal Care visits which, in the Health Centres, are done by visiting specialists. Hugo Agius-Muscat M.D. Paul Carabott M.D. Members, Family Physician Group(Malta) i'_ < Maltese Medical JOUrI],]1 35 volullle I Issue 11 IDH~) 5 - ::.- -- C- , ,-, " - 'I -' ' , !~L E S 6 PAT I E~H PEC'UE'OTC PRESCRIPTIONS AND"r-­ PAPERWORK (Fig. 8)"I " j This histogram (fig. 8) shows the relative 8 PF: ESC F'I f-' i ICH ", A.~ID PAPER S 8 -( r' ~lI C: ln TI " E PATIENT REQUESTS NATIONAL INSURANCE r----· (Fig. 6) CERTIFICATION (Fig. 7) The large section of patients attending A group of patients with very chronic healih centres and dispensaries asking for disabling diseases attend at their local , prescriptions for free drugs, mostly on form dispensary for their intermediate national 3:---< DH46, represents a considerable amount of insurance certificates, which have to be clerical work. This seems to be particularly renewed weekly, rather than at the main so for the dispensaries where around 70% of health centres or at private clinics. Patients the encounters were of this nature, For such requiring NI30 certificates for injuries paperwork as passport and driving licence sustained at work presented solely at the applications and similar forms, many more health centres during the study. c=J ' 'C::: F fO '.' patients attend the health centres. The 7 =- i- - ICi' L-~E:: , [ co r l E number of requests for blood pressure check, - -----_.._-- -- - - - -­while consuming a large part of the doctor's time, perhaps reflects low public under­ COMMON DIAGNOSIS standing of their health and interest in (Fig. 9-10) preventive health care; the first to be corrected and the second to be fostered. A Diagnoses were recorded in open language specific search of 468 encounters in the by the participating physicians but were dispensaries showed that only 28 patients then coded according to the ICHPPC-2 (2). (5''',) -did NOT request a blood pressure This system was chosen because of its check, repeat prescription or a national suitability for coding of problems in general insurance certificate. practice many of which are often not ._--,-_._. _:_i:..cr~_ _ ~J c= [ ,lOP r:---1 C::J II>j D TOP FIVE I FIG. 9 - ANALYSIS OF COMMON REASONS FOR CONSULTATION (with relative percentages to allow comparison) Grand Health Bereg Govt. Private Company Non-Govt. Total Centres Total Work Total Total No. of Patients 2282 1083 468 1551 635 96 731 % ofh.c. % of Bereg % of priv. % of indus. total total total total Top Five reasons for consultation: 1. V680 (pure paperwork) ..... 604 21.1'71, 71.2% 561 6.8% 0.0% 43 2. 460 (acute URTI) .. . ....... 272 10.9% 2.4% 129 18.9% 24.0'!1, 143 3. V70 (preventive exam) ..... 156 9.0% 3.8% 115 6.5% 0.0% 41 4. 40117962 (raised BP) ....... 118 2.4% 15.2% 97 3.3% 0.0% 21 5. 463 (ac. tonsillitis) .......... 63 3.1% 0.9% 38 3.5% 3.1% 25 All other reasons ... . .... . ... 1069 53.5% 6.5% 611 61.0% 72.9% \ \ / i . "i 30 1 "JI I ,' "---~ j ~., &_~- ' D i ---.- ---~ - --~.:. ~~ -., ... ~c- " .:. '1[ __ E:Zl c:::=J ('I S > c::::J numbers of patients receiving prescriptions for antibiotics, psychotropic agents, and non steroidal anti inflamatory agents. It also shows the amount ofpatients receiving a "white" form (DH46) for medicines supplied free by Government, and "green" form (DH129) for narcotic and psychotropic medications. The "other" section includes investigation forms, drug control card renewal, income tax relief forms, etc. Maltese Medical Journal 36 Volullle I Issue 11 IBHB FIG. 10 - COMMONEST REASONS FOR CONSULTATION IN SPECIFIC GROUPS OF PATIENTS (ICHPPC - 2 codes, ranked in descending order) GOVERNMENT OFFICE-VISITS 	 GOVERNMENT HOME-VISITS MALE FEMALE 	 MALE FEMALE 1. 	V680 - pure paper V680 - pure paper 460 - acute URTI (28) 460 - acute URTI (13) work (266) work (286) 2. 	 V70 - preventive V70 - preventive 463 - tonsillitis (10) 464 - tonsillitis (11) exam (53) exam (59) 3. 	 460 - acute URTI (46) 401 - hypertension (48) 536 - stomach V70 - preventive disorders (5) medical exam (4) 4. 	 401-hypertension (42) 460 - acute URTI (42) 558 - diarrhoea, 466 - ac. bronchitis (3) non-infectious (4) 5. 	 V999- V999- 7873 - gas problems/ 536 - stomach unclassifiable (30) unclassifiable (20) wind (4) disorders (3) PRIVATE OFFICE-VISITS PRIVATE HOME-VISITS MALE FEMALE MALE FEMALE V680 ­ pure paper 460 ­ acute URTI (22) 460 ­ acute URTI (39) 460 ­ acute URTI (19) work (22) 460 ­ acute URTI (20) V680 ­ pure paper 463 ­ tonsillitis (14) V70 ­ preventive work (18) medical exam (8) V70 ­ preventive V70 ­ preventive 558 ­ diarrhoea, 558 ­ diarrhoea, exam (12) exam (17) non-infectious (6) non-infect. (7) 401 - hypertension (7) V220 ­ antenatal 250 ­ diabetes care (4) mellitus (5) COMPANY HOME-VISITS 1. 460 - acute URTI (11) 460 - acute URTI (12) NOTE: The numbers in brackets are the numbers of patients seen in each category. classifiable by the International Classif­	 practice was 2.5%.18 of the 57 referrals inREFERRAL RATESication of Diseases version 9 (lCD-9)~ . Government practice were to the ophthal­This choice was subsequently justified by (Fig. 11) mology service. These are mostly patient the fact that almost 65% of problems seen in generated requests for "eye-sight check" for Government practice and almost 48')h of various reasons. Taking this into account, problems seen in private practice were in The referral rate from Government practice referral rates in government and private these categories. The timing ofthe survey in waS 3.7% overall, while that from private practice are comparable in our study. winter probably accounts for the large number of respiratory system conditions encountered. Of interest is the relatively FIG. 11 - REFERRAL OF PATIENTSgreater number of bronchitics as well as diabetics and hypertensives seen in private practice. Trauma was met more often in the main Health Centres.Also of note is the Government: Private: more varied medical "diet" that was met by 18 Ophthalmic 4 Casualty doctors in private practice where less time 9 Casualty 4 Orthopaedic was spent on routine form filling (6.8')10 in 5 Dermatology 2MOP private practice and 71.2% in dispensaries) 5 Dental 2S0P and more on a large group of less common 4 Podology 2 Dental conditions (61.0'11, in private practice, 53.5% 3E.N.T. 1 Psychiatric in the Health Centres and 6.5% in the 3 Schedule V 1 E.N.T. dispensaries). (Fig. 9). 2MOP 1 Family planning 2 Orthopaedic 1 Podology 1 SOP 1 Psychiatric 1 Labour wardWe also have some data regarding selected 3 Unspecified prescribing habits that appear to show that relatively more patients in private practice Total: 57 referrals Total: 18 referralsreceive prescriptions for antibiotics, psycho­No. of patients seen: 1551 No. of patients seen: 731tropic and non steroidal anti-inflammatory Referral Rate: 3.7% Referral Rate: 2.5%drugs. This is an arguable conclusion when the different proportions of acute and non­ (Excl. Ophthalmic Government practice referral rate: 39/1551: 2.5%acute conditions seen in private and referrals): Private practice referral rate: 18/731: 2.5%government practice are considered. cont. on pg. 45 l Maltese l\\c(\icaIJourllal 45 Volullle I Issuc 11 Imm -,"~ -cont. fr. pg. 36 CONCLUSION This was a pilot study carried out between regular work and study sessions and we can only claim to have partly quantified general practice in Malta. We have confirmed that a larger part of Health Centre work is devoted to what is mainly routine clerical work. In fact, clerical work is the only feature in which the content of general practice in Malta differs signif­icantly from what we have seen reported for other countries l Diagnoses encountered in private practice tend to be more varied and therefore more likely to maintain physician interest and motivation. It is felt that this limited study has been useful and has already led to other work aimed at improving data collection and analysis in primary care, that could form the basis of a more comprehensive study in the future. SUGGESTIONS The results of this study suggest that an effort could be made to reduce the General Practitioner's clerical workload as this would leave more time available for clinical work. Ways of achieving this coulll include revision of existing policies regarding prescription and certification, revision of the relevant stationery, and/ or by deleg­ation of part of the work to paramedical personnel or even to machines. This could apply to prescription for Schedule V, intermediate National Insurance certific­ation, and to the "Pink card" system for free medicinals. Expansion of form DH46 (the "white prescription") to accept more than three drugs would result in an immediate saving of time and effort. A "repeat previous prescription" option for Schedule V could also be considered. Computer aided repeat prescribing, as already carried out in some countries, could be a desirable and attain­able goal. Implementation of continuity-of-care at the Health Centres would place the family physician in a position to take fuller responsibility for patient management and would make for better liaison with hospital staff. This would lead to a reduction in unreasonable patient demands, which are difficult to control in the present situation. Another point worth considering is the setting up of specific blood pressure clinics. These could have a protocol for screening and monitoring of blood pressure, perhaps by trained nurses, and periodic review of patients by the physician. Patient education, preferably through the mass media, could take us a long way towards achieving better utilisation of our human resources (e.g. doctors and nurses) and material resources (e.g. drugs and clinic facilities) especially when these are provided free of charge. ACKNOWLEDGEMENTS We would like to thank Dr John J. Giglio, Chief Government Medical Officer, for allowing us to collect data on patients in Government clinics, the physicians taking part in the survey for collecting data in the middle of busy work sessions and also Professor D.H. Johnson ofthe University of Toronto for his encouragement and advice. REFERENCES l. 	 McWhinney, Ian R: An Introduction to Family Medicine. (Oxford University Press, 1981) pp. 48-49. 2. 	 International Classification of Health Problems in Primary Care (1979 Rev­ision) (ICHPP-2). W.O.N.C.A. Classif­ication Committee. (Oxford Medical publications, 1979). 3. 	 International Classification of Diseases: manual of the international statistical classification of disease, inj uries and causes of death, 9th revision W.H.O. Geneva 1977. The copyright of this article belongs to the Editorial Board of the Malta Medical Journal. The Malta Medical Journal’s rights in respect of this work are as defined by the Copyright Act (Chapter 415) of the Laws of Malta or as modified by any successive legislation. Users may access this full-text article and can make use of the information contained in accordance with the Copyright Act provided that the author must be properly acknowledged.  Further distribution or reproduction in any format is prohibited without the prior permission of the copyright holder. This article has been reproduced with the authorization of the editor of the Malta Medical Journal (Ref. No 000001)  

Ian R: An Introduction to Family Medicine.

International Classification of Health Problems in Primary Care

The content of general practice in Malta : a pilot study comparing health centre and private practice in Malta with each other and with general practice (as reported for other countries)

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The content of general practice in Malta : a pilot study comparing health centre and private practice in Malta with each other and with general practice (as reported for other countries)

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