General Practitioners and Nursing Staff: A Complete Attachment Scheme in Retrospect and Prospect

Abstract

The history of the Oxford general-practitioner/nursing-staff attachment scheme is briefly recorded from the first experimental full-time attachment of a health visitor to a partnership of three in November 1956 to the complete attachment of all nursing staff by 4 March 1965. For the past three years every practice, large and small, has hed at least one health visitor, one district nurse, and one midwife, either full-time or parttime according to its need. The concept of the general practitioner as leader of the domiciliary team is working actively in practice throughout the whole city, to the advantage of patients, doctors, and nurses. It is believed that Oxford is still the only local health authority to have a complete attachment scheme, so that an account of our experience may be of interest to others. Materials Available Oxford, which is very much an industrial centre as well as a university city, had a population of 104,500 at the commencement of the scheme in 1956, and this has increased only slightly to 109,320 in 1965 when the scheme was completed. The city is divided longitudinally by the rivers Cherwell and Isis, and practices, on the whole, tend to concentrate on one side or the other. At the beginning of the scheme there were 32 practices, comprising 68 doctors, of whom 14 were in single-handed practice, seven had two partners, nine had three, two had four, and one had five partners. The nursing staff establishment, which remained static throughout the scheme, comprised 19 health visitors, 21 district nurses, and 10 midwives. This gives a ratio of one health visitor to 3.6 doctors, one district nurse to 3.4 doctors, and one midwife to 6.8 doctors. It also means that there is one health visitor to 5,700 population, one district nurse to 5,200 population, and one midwife to 10,900 population. Methods Concept Membership of the health visitors working party emphasized the conclusion already reached by me that the future of health visitors lay in working in the closest possible relation with general practitioners. All the recognized means of achieving cooperation , including liaison schemes, had already been tried in Oxford, but in spite of great goodwill they were largely ineffective. General practitioners just did not understand the work of health visitors, and it was felt that they never would until both were responsible for the same patients and met

The British are coming: Some observations on health care teams in Great Britain*

“…This nurse-trained, community-based, health prevention and health education-focused member of the team has a unique role, which is somewhat different from anything in this country, except possibly for some visiting nurse programs. Because of their community outreach and follow-up activities and potential, health visitors were the very earliest professionals attached to general practitioners (Fry et al, 1965;Warin, 1968). Such collaboration was seen as logical and desirable in that health visitors played a large role in clinical follow up of patients in the community, especially newborns.…”

“…In Britain, on the other hand, physicians usually outnumber nurses and health visitors by three or four to one (Fry et al, 1965;Warin, 1968), although administrative staff tend to increase on a one-to-one basis for each physician added, possibly because 70 percent of their cost is reimbursed (Williams & Dajda, 1979). Most practices also have some form of midwife attachment.…”

“…Most practices also have some form of midwife attachment. Their usefulness is usually a function of demand and their hospital based role, so that mid-wives frequently serve more than one smaller practice and the usual ratio of mid-wife to physician probably is closer to 1 to 7 or 8 (Warin, 1968;Fry, 1982). In addition, over half of the local health authorities in Britain currently provide attachments of social workers to general practitioners, and the proportion of social workers to physicians in these is probably smaller (Gilchrist et al, 1978).…”

“…Early reports in Britain used the term ''team'' freely to describe any form of collaboration or association between the physician and another primary care workergenerally a nurse or health visitor (Fry et al, 1965;Hasler et al, 1968;Warin, 1968), whereas the literature from the U.S. often has described a number of participating disciplines and emphasized a major effort at mutual collaboration.…”

“…Most offices employed a secretary/receptionist and/or an office nurse, and in the single handed practice of the time, it was not unusual for the wife of the doctor to carry on both functions. Stimulated by concurrent experiences in the Scandinavian countries which paired public health nurses with general practitioners, the first experiments with what is now known as ''attachment'' of nurses to general practitioners in Great Britain were established in the mid-1950's in Oxford (Warin, 1968), and in Hampshire (Swift & MacDougall, 1964). These primarily involved health visitors at first, but shortly thereafter began to include district (home) nurses.…”