Comparison of psychogeriatric domiciliary visitservice between urban and suburban sectors

This study presents a comparison between the dom iciliary consultation services in urban and suburban sectors of the Croydon Health District. Urban general practitioners requested less domiciliary visits (DV) and tended to be less satisfied with this service than their suburban counterparts. Sociodemographic factors such as population density and multi-ethnicity in the urban sector may be responsible for a smaller referral rate and the degree of satisfaction with the psychogeriatric DV service in Croydon.

Despite recent criticism and declining trend, the domiciliary visit (DV)remains a major component of a modern psychogeriatric service (Donaldson & Hill, 1991;Forsythe, 1991). Few studies have examined the DV service in geriatric psychiatry (e.g. Hardy- Thompson, 1992;Orrell et al 1992), and none has looked at the service in different types of communities.
A higher number of DV requests from the southern (suburban) sector of Croydon prompted us to investigate the difference be tween the North (urban) and the South. This study is an attempt to evaluate and compare the DV service in urban and suburban halves of Croydon by investigating general practitioners' (GP) views of the service.
Croydon is the largest of the London boroughs with a population of 320 000 people, of whom 43 000 (13.8%) are aged over 65. Nearly 95% of them live independently in their own homes (Health in Croydon, 1994-95). Each half of the health district has a nearly equal population, 21 000 in the North and 22 000 in the South, and each has a consultant-led elderly community mental health service.
Croydon has a higher proportion of ethnic minority communities than the rest of England and Wales, with 19% of black, and 24.6% of Asian ethnic groups, and 6% are elderly people (Health in Croydon, 1994-95). Its two halves are different in their socioeconomic and demo graphic characteristics.
The northern-half is part of south-east London and shares its urban characteristics. It is much more densely popu lated than South Croydon which is suburban, containing a higher proportion of private nur sing homes and more elderly people requiring special care.

Findings
Out of 170 GPs, 113 (66.5%) returned the completed questionnaires, 64/97 (66%) from the North and 49/73 (67%) from the South. More GPs (76%) from the South than the North (50%) requested DVs, but less than 17% had attended any in the previous six months. Among reasons given for inability to attend, lack of time was the commonest (36%), and more so in the North (42%) than the South (29%). A higher proportion of GPs in the South thought it unnecessary (16%), inconvenient (16%), or had not been asked to attend (18%). The majority were satisfied with the service, but their proportion in the North was significantly less (66%) than in the South (86%: P< 0.005). Among GPs who requested DVs, 87% were satisfied compared to 55% who were not (P< 0.0001; 84% in the North and 89% in the South). Most (58%) reported their requests were met within 72 hours; there was no significant difference between North and South.
The factor GPs considered most important in their decision to request a DV was the consul tant's opinion (38%) while the least important was to facilitate admission to psychiatric hospital (6%). A higher proportion of GPs from the South considered psychiatric emergency (43% versus 33%) and patient's physical disability (20% versus 9%) important, but the differences did not reach statistical significance.
There was an association between the request for DVs and the degree of satisfaction with the service: 60/90 (67%) GPs who had requested any DV in the previous six months were satisfied (P< 0.0005), 86% in the North and 88% in the South.

Comment
This study highlights differences in the DV service between the two halves of Croydon, particularly frequency and rate of referral, and degree of satisfaction with the service.
That only 6% of GPs requested a DV in order to facilitate admission was far less than the 32% and 47% reported by Coupland & Todd (1985) and Hardy-Thompson et al (1992) respectively. This difference in our results may reflect a change in the style of practice in primary care as well as the development of psychiatric services towards community care models.
Mental and physical disorders frequently coex ist in the elderly. In Hardy-Thompson et al's study, a higher proportion (n=46, 54%) of GPs thought that the patient's physical disability was important in influencing their decision to request a DV. In our study, 20% suburban and 9% urban GPs felt that this was so. This discrepancy may be related to easier access to the District General Hospital by the population in the North of the borough and the presence of a special interest service for dementia cases run by a local geriatrician which preceded the establishment of a full-time psychogeriatric service in the same locality by two years.
Our study confirmed previous findings of a low rate of GP attendance at DVs, mainly because of lack of time or awkward timing (Hardy-Thompson et al 1992).
Hardy- Thompson et al (1992) showed that 69.5% GPs in an outer London area were satisfied with the psychogeriatric DV service. Our study showed similar results in the urban North of the borough but satisfaction ratings were signifi cantly higher for the suburban South. A possible explanation is that a psychogeriatric service with a complete multidisciplinary team had been established in the South one year before the same development in the North. Also, the South being geographically vast might have prevented frail and elderly patients living alone or as residents in nursing and residential homes in the area from attending the out-patient clinic. Longer out-patient lists in the South may have meant that some patients developed acute crises prior to their appointment, hence requiring urgent visits.
GPs with a high use of the service are more satisfied with the service (Orrell et al 1992). This might have been why those GPs who had requested any DV in the previous six months were more satisfied with the service. However, there was no association between the degree of satisfaction and frequency of DV requests in the South. Nine out of 12 GPs (75%) in the South were satisfied with the service without having requested a DV in the previous six months. These results may reflect differences in the GP popula tion between the two sectors.
One further difference between the two sectors related to the high concentration of Asian population in the North. This ethnic group is generally underrepresented in out-patient psy chiatric departments (Leff, 1988).
This study can be criticised as the views of patients, their relatives and carers were not included. But our aim was to qualify the desirability and efficiency of the DV service at the level of the network of primary and secondary care for elderly patients.

Urbanisation
and better transport facilities may negatively affect rates of referrals for psychogeriatric domiciliary consultations. De spite this, and sociodemographic differences between urban and suburban sectors, our study confirmed that the DV service in Croydon is valued by GPs over and beyond expediting admissions.