CONTAMINACION EN EL AREA DE ESTUDIO

For the prompted group, diabetic care was no longer routinely available as it previously had been at the hospital clinic, where the relevant services, (including laboratory investigations, doctor review, retinal screening, dietary advice and chiropody) were all available under one roof in a single package. In place of this 'one stop* diabetic care package, prompted care offered devolved 'several stop' care provided within a network. It was apparent that the smooth running of this network of care could be vulnerable to break down at a number of different points. It was therefore important to gauge the network's operation and form a v i e w about its acceptability to patients early on in the study, in case a significant defect or oversight in the design and working of the prompting system needed adjustment or correction.

In May 1989, 12 months after prompting began, a detailed

questionnaire comprising 50 question stems was sent to all those patients (n=42) who had, by that stage, received 5 separate community care prompts. It was sent, therefore, to all those patients wh o should have completed, by that stage, an entire cycle of prompting had they been fully compliant (see Figure 2). The covering letter w hich accompanied the questionnaire stressed the absolute confidentiality and of the replies.

Thirty-nine patients (93%) returned the questionnaire completed and their responses are documented in Appendix 11. The questionnaire was divided into sections representing the key elements involved in an

entire prompting cycle. Section 1 (questions 1-10) sought views on the acceptability of arrangements provided by the prompting system for obtaining blood and urine tests. As can be seen from the responses, despite the availability of phlebotomy services at local health centres, 72% of prompted patients preferred to attend their previous hospital laboratory instead (i.e: Royal Northern or Whittington Hospital). Phlebotomy services proved accessible to patients; they were judged to be less than a mile from home by 57%, and took less than 30 minutes for patients to reach for 72% of respondents. In 1989, there was no cost incurred for a return journey for phlebotomy for 70% of patients, and most had to wait less than 30 minutes after arrival before they were attended to.

Overall, 95% of prompted patients surveyed felt that these

arrangements for blood and urine tests were acceptable.

Section 2 of the questionnaire (questions 11-22) sought views on the test results and prompted clinical review forms sent to patients to take to their general practitioner. Although 64% said they read their diabetic record and test results, only 21% of patients claimed to understand most of what was on the record. Ten percent stated that they thought the record was incomplete but did not indicate what sort of information they felt was missing. Only 8% confessed to being upset or worried by something they had read on their diabetic record; in the case of three patients this was the result of concern they felt about high plasma glucose or weight gain. No one felt that the records which they received were factually wrong, or contained inappropriate information. Half the respondents felt that it would be helpful if they could keep a copy of their diabetic record, and three commented that they would like some of the records* terms explained.

Section 3 (questions 23-29) requested information on patients* perceptions of the role of the general practitioner in prompted care. Almost 60% of patients said they made an appointment to see their GP on receipt of the test results, rather than turning up for a diabetic review in a non appointment surgery. 62% aimed to see a particular doctor for a diabetes review rather than whoever happened

to be available in the practice. 72% of patients remembered the GP discussing their blood sugar tests w ith them w h e n they consulted, and 56% felt that their GP applied the same standard of blood sugar control that had been applied previously by the hospital diabetic clinic. Over half of patients felt that the GP had performed a thorough assessment of their diabetes though 8% classed the GP assessment as poor. Overall, 90% believed that they could trust their GP to monitor their diabetes as well as, or better than, the hospital diabetic clinic. Of the 4 patients who made comments about their GPs (in response to question 29), one felt that time spent w i t h the GP was too short, another complained that the GP only asked about urine tests, one felt that GP explanations were inadequate, and another professed trust in their GP in virtue of the fact that the GP was a diabetic tool

Section 4 of the questionnaire (questions 30-40) enquired about the arrangements for retinal screening in the prompted group. Ten of the 39 patients who returned the questionnaire attended a hospital eye clinic at the start of the study and were consequently not prompted for regular eye tests by an optometrist. Of the 29 patients who returned the questionnaire who had received an eye test prompt, 65% stated that they had attended a participating optometrist within a mile of home. Travel to the optometrist was estimated to take less than 30 minutes in the case of over half the patients. The return journey had been made free of charge for 80% of the patients. The vast majority of patients (83%) remembered receiving mydriatic eye drops w hen they attended for retinal screening, though 52% had no memory of any warning concerning subsequent glare from bright light. Only 28% could remember being told what to do if they felt the onset of pain in their eyes within 24 hours of receiving mydriatic drops. Overall, 79% of responding patients felt that the eye examination by an optometrist was as good as, or better than, the eye checks previously received in the hospital diabetic clinic. 97% of patients found these arrangements for retinal screening acceptable.

Section 5 of the questionnaire (41-46) was designed to bring to light any difficulties patients may have experienced in the event of

being referred for services such as dietary advice, or chiropody. Very few of the patients surveyed had been referred, by this time, for these services. This meant that only a couple of patients responded to the questions in this section. No problems had been encountered by these patients over referral to dietetics or chiropody.

Section 6 (questions 46-50) was designed to gauge an overall patient v i e w on the operation of prompted care in comparison to previous hospital clinic care. To question 46, 111 of patients felt that prompted care was as good as hospital clinic care, 51 felt it was better and 10% judged it to be worse. In response to question 47, w h i c h sought views on the best aspects of prompted care, 3 patients found it had been easier to contact their GP for advice than the hospital clinic, 7 mentioned nearness of the GP*s surgery to home as an advantage, and 7 mentioned that the short wait to see their GP as positive features. Two patients mentioned that continuity of care by the GP was better than by the hospital clinic. Comments in response to question 48 which elicited views on the worst aspect of prompted care included unhappiness at feeling that the GP was 'too rushed*, and another that 'one check-up involves several journeys'. Two patients stated that, in their view, there was nothing bad about GP care. These responses need to be contrasted w i t h memories of the

best aspects of hospital clinics revealed in replies to question 49 w hich included 'one visit to do everything' (5 patients), 'staff at the hospital have more time', and 5 patients who felt that more explanation and more expertise had been available in hospital. One

patient wrote that 'I only changed because of a two year

experiment'. Another stated that 'I felt special w hen attending the hospital clinic' w i t h the implication that this 'specialness' had disappeared once transferred to prompted care. On the other hand, memories of the worst aspects of the hospital clinic included the following: 3 patients who found that the hospital was too far away, 18 who mentioned poor time-keeping in the clinic w i t h long waiting times, and four patients who stated that there was 'nothing wrong w i t h the hospital clinic'.