Maternal and infant health in primary care following childbirth is an important area which has recevied little research attention. Very little is known about primary health service use following childbirth and its determinants. The aim of this exploratory study was to test the hypothesis that place of birth is independently associated with mother and baby consultation patterns in the first year of life. This is a descriptive study of 453 pregnancies of 338 mothers from an inner city general practice between 1987 and 1996. There were 86 intended home births, 126 intended domino births and 240 intended hospital births, with one woman unbooked. Of these, 69 women had home births, 97 had domino births, 286 women had hospital deliveries and one baby was born in an ambulance. The outcome of interest was mother and baby consultation rates in the year following birth. In an attempt to control for pre-existing ill health we also calculated the women's consultation rate in the year prior to conception and substracted this from the mother and baby consultation rate in the year following birth. We analysed the data according to both intended and actual place of birth. Women intending a home birth had fewer mother and baby consultations in the year following birth compared to women intending domino births, who in turn had fewer consultations than women intending hospital care during labour (P < 0.001). This gradient persisted when pre-existing maternal ill health was accounted for. A similar gradient of increasing consultation rates through home births, domino birth, normal vaginal delivey in hospital and assisted delivery in hospital was demonstrated when data were analysed according to actual place of birth. Other maternal characteristics independently associated with increased mother and baby consultation patterns were: primiparity, manual occupational class, not breastfeeding, maternal smoking, infertility prior to pregnancy, and recorded anxiety, depression or life events before or after birth. Women intending and having a home birth were older (P < 0.001) and less likely to be primiparous (P = 0.055) or of manual occupational class (P < 0.001). Babies born at home were heavier (P < 0.001), and women experienced less perineal trauma (P < 0.001) and were more likely to breastfeed at birth (P < 0.001). The conclusion we draw from this cohort of births, is that there is an association between women intending a home birth and women who actually have home births and lower mother and baby consultation rates postnatally, when compared with women having normal vaginal domino or hospital births. This is independent of maternal age, parity, smoking during pregnancy, occupational class, a history of infertility or miscarriage in the year prior to conception, anxiety, depression or life events in the year prior to conception or after birth, breastfeeding, sex of baby and birth weight.

Non-attendance in general practice is increasing. In contrast to hospital non-attendance little research has been undertaken on the topic. The aim of this study was to identify the characteristics of non-attending patients and to determine the reasons for general practice non-attendance, so that strategies to reduce it could be devised. Four hundred and ninety-three consecutive non-attenders from five practices in Exeter, Devon were studied. A questionnaire was sent enquiring about the reasons behind the patient's non-attendance and possible strategies to reduce future non-attendances. Of 17 264 appointments 493 (3.9%) were not attended. Females accounted for 278 (56.4%) of the non-attenders. The highest number of non-attenders was in the age group 25–44 years. One hundred and seventy-four (35%) responded to the questionnaire, of whom 60 (35% of responders) had forgotten the appointment. Strategies to reduce general practice non-attendance should focus on assisting the patient to remember the appointment.

The literature shows that patients' positive opinions of general practice care are associated with being older, of lower educational level, lower social status and being married, but there is no association with the sex of the patient. The health related characteristics of patients, such as self-reported health status, chronic condition and utilization of care, also predict judgements of the quality of some aspects of general practice care. This study investigated whether, in addition to individual effects, combinations of patient characteristics can also influence opinions of care, and whether these findings are valid in different European countries.

A self-completion questionnaire was developed and given to consecutive patients in five general practices in each of eight European countries. There were 48 questions covering five aspects of care: availability and access, organisation and co-operation, medical care, relationship and communication, information and support and an overall opinion. There were a further 16 questions on patient characteristics. One way analysis of variance, using SPSS software, was used to compare mean scores for each aspect of care for different values of the patient characteristic. Multivariate analysis was used to investigate the interaction effects between pairs of patient characteristics, which, individually were found to influence opinion. Further tests were made to identify any interaction between the effect of each patient characteristic and the country of residence.

1008 (response rate 63%) questionnaires were completed. The patient characteristics which influence patients' opinions were found to be age, levels of education and professional qualification, length of relationship with the practice, and whether they have a chronic condition. However, there are no interaction effects between these characteristics. Importantly these effects were found to be valid in all countries in this study. The patient characteristics which do not appear to influence opinions of care are sex, levels of utilization of care and self-reported health status.

When surveying opinions of patients about general practice care, since patients of different characteristics will give different views of the same service, the sample of patients whose views are surveyed should aim to account for these predictable differences. Decisions on changes in care provision should be based only on the results of patient opinion surveys in which the characteristics of the sample of patients responding to the survey were taken into account.

There is increasing interest in collecting morbidity data from general practice. We describe our experience from Northumberland MEDICS, one of the first morbidity data collection projects in the UK. All Northumberland practices were invited to participate. Data were initially collected every 3–6 months and included the prevalence of chronic diseases, disability in the over 75s, and recording of health markers, such as smoking status. Thirty-three out of 52 practices participated. There was marked variation in prevalences and recording of health markers between practices. Recorded prevalence of hypertension and diabetes increased steadily from 1994 to 1998. Outcomes, judged by the original objectives, were mixed. However, as the project evolved, evidence emerged that MEDICS was contributing to a culture in which the use of data from practice clinical systems to improve patient care has become a core objective. Key lessons from our experience include appreciating: the importance of data quality and minimising workload for practices; the difficulties practices face in recording morbidity data consistently and systematically; the limitations of GP morbidity data for health needs assessment and commissioning at district level; and the need to focus on providing useful and relevant data for individual practices. MEDICS now covers all 53 Northumberland practices. The project focuses on recording and analysing data to help practices improve structured patient care. Increasingly data collection in general practice in Northumberland is seen as a core activity with the current dataset linking closely with local priorities and reflecting national initiatives such as Clinical Governance and National Service Frameworks.

Data from a cross-sectional sample of 21 620 Swedish-born individuals and 2072 foreign-born individuals, aged 16–74 years were used to examine the association between socio-economic status (SES), country of birth (as an indicator of migration experiences), self-reported health status (SRHS) and diabetes. The survey included 31 foreign- and 446 Swedish-born individuals with diabetes mellitus. After accounting for age, sex, circulatory disease, SES (education, car ownership), social network, physical activity, smoking and body mass index, diabetics demonstrated a 3.7 higher risk of poor SRHS than non-diabetics. Foreign-born individuals had the same risk of self-reported diabetes as Swedish-born individuals. All three SES indicators: low/intermediate attained level of education, no car ownership, or renting a dwelling, were significant independent risk factors of diabetes mellitus after adjustment for age, sex, country of birth, circulatory disease, social network and life style. Moreover, low SES was an important risk factor of poor SRHS among diabetics. There was a nonsignificant borderline association between country of birth and poor SRHS among diabetics. These findings suggest that individuals with diabetes have a substantially increased risk of poor SRHS, and that low SES and country of birth (migration experiences) may contribute to further augment poor health among diabetics.

Aim: To describe a general practice commissioning project including 19 nonfundholding practices in Buckinghamshire: its structure, aims, representativeness, outcomes, costs and sustainability, and lessons learned from the process over the first 18 months.

Method: Examination of project documentation; postal questionnaire to all 73 participating GPs and to eight key players in the Health Authority (response rate 72%); and in-depth interviews with six Health Authority staff and 15 general practitioners (GPs).

Results: A representative structure and process were established for GP involvement in commissioning. 75% of GPs were involved. Mutual understanding improved between the GPs and the Health Authority. Service improvements identified included developments in orthopaedics, community psychiatric nursing, physiotherapy and ophthalmology. Lessons were learned about the importance of open and continued communication; clarity about expectations, accountability, power and responsibility; development of relationships and understanding in joint working; the time required to achieve tangible results; and the need to develop GPs' commissioning skills.

The project cost about £10000 in cash and £32500 in staff time in the first year. Participants perceived their input as sustainable.

Conclusion: The results of the study suggest that the success of Primary Care Groups will depend on ensuring engagement of all parties in the process, clarifying roles, responsibilities and expectations, identifying shared agendas, developing explicit and achievable goals, and a commitment among all parties to implement recommendations. The work and time involved in developing mutual respect and shared understanding, and in developing commissioning skills need to be acknowledged.