Enhancing Sustainable Development through Web Based 3D Smart City Model Using GIS and BIM. Case Study: Sheikh Hamad City Journal of Geographic Information System
2019

Maher A El-Hallaq
Civil Engineering Department
Engineering College
Islamic University of Gaza
GazaPalestine

Abdelkhalek I Alastal
Geography and GIS Department
Arts College
Islamic University of Gaza
GazaPalestine

Raed A Salha
Geography and GIS Department
Arts College
Islamic University of Gaza
GazaPalestine

M A El-Hallaq
Enhancing Sustainable Development through Web Based 3D Smart City Model Using GIS and BIM. Case Study: Sheikh Hamad City Journal of Geographic Information System

Journal of Geographic Information System
11201910.4236/jgis.2019.113019Received: May 8, 2019 Accepted: June 15, 2019http://www.scirp.org/journal/jgis ISSN Online: 2151-1969 ISSN Print: 2151-1950 321 Journal of Geographic Information System This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).BIMGISSheikh Hamad CitySmart CityWeb 3D City Model
Smart sustainable city is that uses the technology to transform their core systems and optimize the exploitation of limited resources; it is a knowledge-based system that provides real-time insights to stakeholders. As a result of the challenges facing the cities of the Gaza Strip regarding population growth, lack of resources, increased demand for materials, the siege imposed on the Gaza Strip for more than twelve years, the smart city approach can contribute to mitigating these challenges and creating opportunities and solutions for many of these problems. Thus, this study aims to promote sustainable urban development through the adoption of smart city approaches using the city's 3D representation and analysis capabilities to reflect and define the current situation and formulate a future vision using GIS and Building Information Modeling (BIM) considering Sheikh Hamad city as a case study. This involves developing a GIS web-based 3D model of the urban landscape of the city and creating a geometric descriptive database that includes the various elements of the city such as buildings, services and other facilities. The constructed database is to be automatically updated and can be used to facilitate documentation, transparency and help in decision-making process. The 3D smart city can also benefit stakeholders, government officials, private sectors as well as the city citizens. Therefore, urban services will be more efficient, and the cities of the Gaza Strip will be able to achieve sustainable development and competition in difficult economic, environmental and social conditions. This study recommends the use of BIM and GIS technologies in the transformation to a smart city concept as well as the rehabilitation of existing cadres to enable them to use those technologies to achieve the goal of improving the quality of life and facilitating the daily lives of people. How to cite this paper: El-Hallaq, M.A., Alastal, A.I. and Salha, R.A. (2019) Enhancing Sustainable Development through Web Based 3D Smart City Model Using GIS and BIM. Case Study: Sheikh Hamad City. Journal of Geographic Information System, 11, 321-330.

Abstract

Smart sustainable city is that uses the technology to transform their core systems and optimize the exploitation of limited resources; it is a knowledge-based system that provides real-time insights to stakeholders. As a result of the challenges facing the cities of the Gaza Strip regarding population growth, lack of resources, increased demand for materials, the siege imposed on the Gaza Strip for more than twelve years, the smart city approach can contribute to mitigating these challenges and creating opportunities and solutions for many of these problems. Thus, this study aims to promote sustainable urban development through the adoption of smart city approaches using the city's 3D representation and analysis capabilities to reflect and define the current situation and formulate a future vision using GIS and Building Information Modeling (BIM) considering Sheikh Hamad city as a case study. This involves developing a GIS web-based 3D model of the urban landscape of the city and creating a geometric descriptive database that includes the various elements of the city such as buildings, services and other facilities. The constructed database is to be automatically updated and can be used to facilitate documentation, transparency and help in decision-making process. The 3D smart city can also benefit stakeholders, government officials, private sectors as well as the city citizens. Therefore, urban services will be more efficient, and the cities of the Gaza Strip will be able to achieve sustainable development and competition in difficult economic, environmental and social conditions. This study recommends the use of BIM and GIS technologies in the transformation to a smart city concept as well as the rehabilitation of existing cadres to enable them to use those technologies to achieve the goal of improving the quality of life and facilitating the daily lives of people.

Introduction

The smart city is characterized using advanced technology on a large scale and the overall improvement of urban life sustainability, which requires huge and multi-source data for the use of technology and management. Urban services will therefore be more efficient, and cities will be more competitive in their social, economic, environmental and cultural conditions [1]. The features and possibilities offered by GIS and BIM technologies make it used widely in the construction industry, and to achieve maximum benefit through the integration of the diverse possibilities of these technologies [2]. This means that GIS and BIM data play an important and decisive role in smart and sustainable cities at all stages. The BIM model is a record of accurate, updated and detailed graphical and descriptive data for all building elements. This data is of utmost importance to all stakeholders from the designer, the owner, the final consumer, and the support of the decision maker. It also serves the various local organizations responsible for granting permits, providing services and assessing irregularities [3]. For GIS systems, data relating to a given building are directly related to its actual location on the city or region map. For example, a building site can be viewed in the context of other buildings in a neighborhood, its surface areas can be calculated, distances can be calculated for precise services, and satellite image data can be included in GIS systems to provide better visibility. Ubiquitously, accurate and comprehensive spatial data play a critical role in all areas of environmental management and sustainable development.

In order to control the full-cycle of construction effectively, technology of GIS and BIM can be useful because GIS and BIM can handle graphical and non-graphical documents, which make it easier to collect construction project information in a central database. Moreover, it can improve and speed up construction planning as well as ensure data integrity and accuracy. By integrating both GIS and BIM technologies, they can bring spatial analysis in a real-world spatial reference [4]. Shahi [5] emphasizes that the integration of BIM with GIS, will allow evaluation of a construction project in its urban context, allowing many intelligent urban management applications. Alastal et al. [6] aim to pro- Special criteria are adopted for usability evaluation of these two web-based GIS applications. Usability tests have been performed with six graduate users and questionnaires are filled out by these users. Interviews are also conducted with six users to validate the results. Zhang et al. [8] show that data integration is important for effective asset management. Many IT tools such as GIS and BIM are highlighted to facilitate such process in this study. Geospatial analysis is one of the main contributions of GIS for large scale asset management however 3D tools need to be further developed in order to achieve its big potential. Besides acting as a data pool, more benefits of BIM for asset management are still to be clarified.

The 3D City Concept

It is currently observed that cities are undergoing a transition and continuous development, in order to adapt with the rapid demographic, economic, social and environmental changes. By understanding the need for adaptation as an opportunity to develop the city towards greater sustainability and flexibility, most modern cities are trying to introduce innovative tools and methods to involve as many relevant players as possible in planning processes. In this context, 3D city models play an important role as promising techniques for building common understanding among all actors in different areas. In addition, these models include GIS functions with high data representation and analysis capabilities, opening more possible areas of application for public administration and decision support as well as citizen participation. Thus, 3D city models are an integral part of efforts to transform the traditional city into a smart city through information and communication technologies [9].

The 3D city plays an important role in transforming the smart city into the level of technologies and applications used and the development required for the knowledge infrastructure, in order to maximize the benefit to the residents of the city. The 3D city model is a digital representation of the earth's surface and related objects such as construction, trees, vegetation, and some man-made characteristics in urban areas. Demand for 3D city modeling is rapidly increasing in various applications [10]. GIS visualization techniques and 3D modeling of Journal of Geographic Information System building information are applied not only to the region in its current state, but also to the simulation of future scenarios for sustainable and innovative development. Web-based applications are being developed and used to allow clear presentation of new urban development projects and scenarios, and to facilitate citizen participation in the planning and decision-making process. The most important goals and benefits of the 3D city models are [11]:

• It has a great role in quality control, continuity, management and service delivery.

• Through the 3D scenario of the current situation, sustainable and innovative scenarios can be developed, based on the current city data, current plans.

• It assists to map the environmental impacts, and energy mobility data by combining standard model outputs with the 3D GIS database.

• It facilitates to create an interactive 3D portal based on GIS for citizen participation and a decision support panel within the city government so that planners and decision-makers in the city have tools that allow for clear presentation of new projects and scenarios for urban development and allows citizens also to participate.

The 3D city models face a real challenge in three main levels. The first level of challenges relates to intelligent technologies that are essential to implement smart initiatives and projects. The second level of challenges is for intelligent users who will be smart city developers. The third level of challenges relates to the institutional dimension, smart management. The basic requirements for any city to transform to a 3D smart city should involve:

• Data availability in terms of accessibility, quality, and accuracy,

• Availability of qualified technical staff that can convert data in various forms to 3D models, • Hardware and software availability which are very essential to store, process, manage and output data, • Availability of governmental willingness to implement such 3D models.

The Case Study

Gaza Strip faces real challenges regarding population growth, lack of resources, increased demand for materials, the siege imposed on it for more than twelve years. Thus, following the smart city approach can contribute to mitigate these challenges and create opportunities and solutions for many of these problems.

Sheikh Hamad city is selected as a case study to enhance sustainable development of Gaza Strip cities through 3D smart city model using GIS and BIM. The reason to choose Sheikh Hamad as a case study is because that it is considered the most important recently housing project in terms of its urbanization in the Gaza Strip. Its scale and size are also suitable for such study. In addition to, the project is distinctive from traditional planning aspects and is in a government-owned area.

The residential project of Sheikh Hamad city is located in the liberated lands, Journal of Geographic Information System

Methods and Results

With the help of dedicated geoprocessing tools, the provided datasets are imported into the GIS environment. To develop a 3D BIM/GIS model, all geospatial and non-spatial datasets must be processed and homogenized in a geodatabase. With technical 3D modelling technology applied with ArcGIS tools, an almost fully automated modelling process is developed to create 3D visualization.

Finally, a public web-based BIM/GIS application tool is published at ArcGIS platform in order to allow stakeholders and citizens to get access and benefit from this application. The 3D visualization of the city development scenario also helps citizens to better understand the terminology used in the urban planning process. Figure 2 illustrates the methodology framework of this study. The most relevant stages of the processing workflows are discussed below.

Data Acquisition and Processing

Data availability is a fundamental prerequisite in order to accomplish this stage.

High quality data needed in this stage should involve survey data, BIM data, road network, public utilities, green spaces, trees as well as high resolution orthoimages. As part of the data preparation, all datasets of the City should be  processed and georeferenced before they can be integrated and migrated into the GIS environment using GIS geoprocessing tools. In addition, attribute data for each dataset is tabulated with a high level of detail. As a result, a comprehensive geodatabase can be designed including all the necessary and processed datasets as a starting point for modeling the 3D visualization.

3D BIM/GIS Generation

ArcGIS pro v2.2.1 is used to handle 3D data by creating a Global Scene page. For buildings layer, 2D data is transformed to 3D by adding the height of residential buildings and the number of floors for each residential tower. 3D building models and its corresponded data are exported to Google Sketchup with Collada extension multipatch using the ArcGIS Toolbox. Then, the Collada file is opened using the Google Sketchup 2018 software to cover the building models with the facades and pictures to look as a real representation. After the facade of buildings are processed, files are exported back to Collada through Google Sketchup. To share the 3D data on the web, 3D layers must be processed and converted to a scene package. Similarly, the rest of other layers of the city such as water, wastewater, roads, electrical and other networks are processed with the same steps. Figure 3 shows the implementation workflow of the 3D BIM/GIS model development.

Web-Based Application

Active involvement of the citizens and other interested groups to share and benefit from the City data is a fundamental necessity. The web application ( Figure  4) also allows getting online access to the planning documents anytime and anywhere and enables the citizens to state their position by providing their feedback. The 3D visualization of the status and the development scenario helps citizens to better understand the terminology of the planning statutes. The City data is uploaded to the ArcGIS portal/online server. All layers and attribute tables are added to the ArcGIS portal's 3D web browser with the properties of each layer. Figure 4 shows the basic interface of this web application.

The web application allows the user to select a suitable base map from a listed menu, view and navigate through the City scene from different looking directions  The web site also offers measurement tools to compute distances between certain features or area of some objects under consideration. In addition, it provides some analytical tools for sun lighting which enable to monitor the change in shadows, to study lighting angles and their impact on residential towers and apartments throughout the year, to show its impacts on plantations and trees, in addition to the use of these analysis to arrange the well distribution of solar panels. Figure 5 illustrates some examples of the above-mentioned capabilities of the developed 3D web case study application. Journal of Geographic Information System

Case Study Discussion

Based on this case study and its results, there is a great need to adopt a smart 3D city model in order to enhance sustainable urban development in the Palestinian cities, especially the cities of the Gaza Strip using BIM and GIS systems. Unfortunately, there are challenging problems encountered in the implementation process. These challenges are mainly due to unavailability of the City data; either insufficient level of data detail or difficulty of accessing because it is archived among various institutions. Other challenges are technical and input from the inability to implement GIS analysis, environmental impact mapping, and city data by combining standard model outputs with the 3D GIS database, as typical standard outputs are not available to compare with the existing database.

The developed web application gives helpful basic functions that can assist in: • Research, exploration and display: Any information on 3D maps; residential buildings, utilities, services, water network, sanitation and other accessories can be queried and researched with the possibility of updating.

• Analysis and simulation: The analytical tools discussed in the case study allow to suggest more than one scenario and the best choice is taken before the project is launched on the ground. 3D model adds an additional dimension to the presentation and representation of data. It also contributes to the reduction of visually complex information to represent City components in order to better understand such complexity.

• E-collaboration: achieve cooperation between different working teams, facilitate communication, and sharing data between them, and thus save time and effort required to accomplish the tasks.

• Infrastructure and Facilities Management: As a result of the availability of an integrated central geographic database for all elements of the city, the infra-Journal of Geographic Information System structure and facilities in the city can be managed efficiently and effectively in terms of follow-up, maintenance, delivery of services, greatly reducing resource waste and thus quality control to improve quality of life of the City citizens.

• Digitizing planning: To achieve comprehensiveness and avoid repetition.

• Provide planners and decision makers in the city tools to allow a clear presentation of projects and new scenarios for the development of city, and allows the participation of citizens, and promotion. The expected benefits of implementing the city's 3D Smart City strategy in Sheikh Hamad case study help to build and manage a 3D geometric and descriptive database of the various elements city and allows stakeholders from governmental and private institutions, as well as citizens to provide them with a clear vision of effective policies, best practices and consequently support decision-making. It contributes to better management of infrastructure and facilities with a way of more efficiency, more effectiveness, and reduce waste of resources. The strategy also contributes to saving time, effort and resources, which are positively reflected on all processes and projects. Moreover, it improves the quality of services provided to citizens and thus contribute to improving the quality of life. It can also contribute to the development of sustainable and innovative future scenarios for this area and outline project requirements.

Conclusion and Recommendations

The Gaza Strip faces multiple problems of limited space, continuous population growth, and the depletion of already scarce natural resources. In addition, it subjects to a continuous siege and successive destructive wars. All these problems require proper planning and rational use of available resources. Thus, the integrated features and capabilities offered by BIM and GIS technologies make it an important and effective role in managing assets and resources with suitable efficiency and high quality, Urban services will therefore be more efficient and the cities of the Gaza Strip will be more able to achieve sustainable development and competition in difficult economic, environmental and social conditions. Therefore, urban services will be more efficient, and the cities of the Gaza Strip will be able to achieve sustainable development and adaption in difficult economic, environmental and social conditions. In this study, a 3D BIM/GIS model is developed for Sheikh Hamad city in the Gaza Strip as an example. In addition, a web-based application is launched to assist in sharing, viewing, managing, analyzing and supporting decision-making process. This study recommends the use of BIM and GIS technologies in the transformation to a smart city concept as well as the rehabilitation of existing cadres to enable them to use those technologies in order to achieve the goal of improving the quality of life and facilitating the daily lives of people.

mote sustainable urban development by adopting the smart city approach by identifying the concept of smart cities in the reality of the cities of Gaza Strip, considering Khan Younis city as a case study. The study reveals that Khan Younis has 41.7% of the characteristics features of the smart city and needs further improvements in all axes especially the availability of social and economic infrastructures. Song et al. [1] review the applications and future trends of BIM-GIS integra-Journal of Geographic Information System tion in the architecture, engineering and construction (AEC) industry based on the studies of 96 high-quality research articles from a spatio-temporal statistical perspective. Results show that the utilization of BIM-GIS integration in the AEC industry requires systematic theories beyond integration technologies and deep applications of mathematical modeling methods, including spatio-temporal statistical modeling in GIS and BIM simulation and management. Al-Saggaf and Jrade [2] describe the methodology used in developing a model that integrates BIM and GIS to facilitate demolition waste management and control for megaprojects. The suggested BIM-GIS model can contribute to more green and efficient construction management. Khan and Adnan [7] evaluate two web-based GIS applications Google Maps and MapQuest to find out usability problems.

. Beside the residential buildings, it also includes schools, kindergartens, mosques, health center, women's activity center, cultural and social sports club, administrative building, civil defense building, police station and green areas. The city is served with network of main roads, aggregated and local, which has an area of 96,824 m 2 with an occupancy rate of 23.9%[12].

Figure 1 .
1The geographic location of Sheikh Hamad city. Journal of Geographic Information System

Figure 2 .
2The methodology framework.

Figure 3 .
3The workflow development of 3D BIM/GIS model.

Figure 4 .
4The main interface of the developed web model. and consequently imagining and simulating the actual representation of the City. Moreover, it has the ability to perform various queries about the City facilities such as building information, roads inventory, electrical and water utilities characteristics with the possibility of updating this information automatically and periodically. It also can display the electrical, water and sewage networks inside apartments, search for the location of emergency units, in addition to illustrating the architecture distribution of rooms and other services.

Figure 5 .
5Examples of the 3D web interface capabilities.
Journal of Geographic Information System
Conflicts of InterestThe authors declare no conflicts of interest regarding the publication of this paper.
Trends and Opportunities of BIM-GIS Integration in the Architecture, Engineering and Construction Industry: A Review from a Spatio-Temporal Statistical Perspective. Y Song, X Wang, T Yi, P Wu, M Sutrisna, J Cheng, 10.3390/ijgi6120397International Journal of Geo-Information. 6Song, Y., Wang, X., Yi, T., Wu, P., Sutrisna, M. and Cheng, J. (2017) Trends and Opportunities of BIM-GIS Integration in the Architecture, Engineering and Con- struction Industry: A Review from a Spatio-Temporal Statistical Perspective. Inter- national Journal of Geo-Information, 6, 397. https://doi.org/10.3390/ijgi6120397

Benefits of Integrating BIM and GIS in Construction Management and Control. 5th International Construction Specialty Conference of the Canadian Society for Civil Engineering (ICSC). A Al-Saggaf, A Jrade, CanadaAl-Saggaf, A. and Jrade, A. (2015) Benefits of Integrating BIM and GIS in Construc- tion Management and Control. 5th International Construction Specialty Confe- rence of the Canadian Society for Civil Engineering (ICSC), 2015, Canada.

Why Industry Needs Asset Management Tools. Special Issue on Information Technology for Life-Cycle Infrastructure Management. D J Vanier, Journal of Computers in Civil Engineering. 15Vanier, D.J. (2001) Why Industry Needs Asset Management Tools. Special Issue on Information Technology for Life-Cycle Infrastructure Management. Journal of Computers in Civil Engineering, 15, 35-43.

. 10.1061/(asce)0887-3801(2001)15:1(35)15https://doi.org/10.1061/(asce)0887-3801(2001)15:1(35)

Integration of GIS and BIM Techniques in Construction Project Management-A Review, The International Archives of the Photogrammetry. Abdul Basir, W Majid, Z Ujang, U Chong, A , 10.5194/isprs-archives-xlii-4-w9-307-2018Remote Sensing and Spatial Information Sciences. Technology (GGTAbdul Basir, W., Majid, Z., Ujang, U. and Chong, A. (2018) Integration of GIS and BIM Techniques in Construction Project Management-A Review, The Interna- tional Archives of the Photogrammetry, Remote Sensing and Spatial Information Sciences, Volume XLII-4/W9. International Conference on Geomatics and Geospa- tial Technology (GGT 2018), 3-5 September 2018, Kuala Lumpur, Malaysia. https://doi.org/10.5194/isprs-archives-xlii-4-w9-307-2018

Evaluation of Current Construction Permitting Process in City of Toronto and Future of Permitting in the Global Construction Industry. K Shahi, University of Toronto, CanadaMaster ThesisShahi, K. (2018) Evaluation of Current Construction Permitting Process in City of Toronto and Future of Permitting in the Global Construction Industry. Master Thesis, University of Toronto, Canada.

The Reality of Gaza Strip Cities towards the Smart City's Concept. A Case Study: Khan Younis City. A I Alastal, R A Salha, M A El-Hallaq, 10.4236/cus.2019.71006Current Urban Studies. 7Alastal, A.I., Salha, R.A. and El-Hallaq, M.A. (2019) The Reality of Gaza Strip Cities towards the Smart City's Concept. A Case Study: Khan Younis City. Current Urban Studies, 7, 143-155. https://doi.org/10.4236/cus.2019.71006

Usability Evaluation of Web-Based GIS Applications-A Comparative Study of Google Maps and MapQuest. Ali Khan, Z Adnan, M , SwedenBlekinge Institute of TechnologyMaster ThesisAli Khan, Z. and Adnan, M. (2010) Usability Evaluation of Web-Based GIS Appli- cations-A Comparative Study of Google Maps and MapQuest. Master Thesis, Ble- kinge Institute of Technology, Sweden.

Integrating BIM and GIS for large Scale (Building) Asset Management: A Critical Review. Paper for CC2009. X Zhang, Y Arayici, S Wu, C Abbott, G Aouad, UKSchool of the Built Environment, University of SalfordZhang, X., Arayici, Y., Wu, S., Abbott, C. and Aouad, G. (2009) Integrating BIM and GIS for large Scale (Building) Asset Management: A Critical Review. Paper for CC2009, School of the Built Environment, University of Salford, UK.

Visualization of Vibrant Cities and Regions-Identification, Design and Development of 3D-GIS Applications and Modules. REAL CORP 2015-PLAN TOGETHER-RIGHT NOW-OVERALL-From Vision to Reality for Vibrant Cities and Regions. W Wendt, J Mauthner, Proceedings of 20th International Conference on Urban Planning, Regional Development and Information Society. 20th International Conference on Urban Planning, Regional Development and Information SocietyWendt, W. and Mauthner, J. (2015) Visualization of Vibrant Cities and Re- gions-Identification, Design and Development of 3D-GIS Applications and Modules. REAL CORP 2015-PLAN TOGETHER-RIGHT NOW-OVERALL-From Vision to Reality for Vibrant Cities and Regions. Proceedings of 20th International Confe- rence on Urban Planning, Regional Development and Information Society, 695-704.

K Jain, S Singh, V Mandla, 10.5194/isprsarchives-XL-2-W2-73-2013Virtual 3D City Modeling: Techniques and Applications. Conference: 3D GeoInfo. IstanbulJain, K., Singh, S. and Mandla, V. (2015) Virtual 3D City Modeling: Techniques and Applications. Conference: 3D GeoInfo, Istanbul, 27-29 November 2013, 73-91. DOI: 10.5194/isprsarchives-XL-2-W2-73-2013.

Geodesign Apps and 3D Modeling with City Engine for the City of Tomorrow. J Schaller, O Ertac, S Freller, C Mattos, Z Rajcevic, Digital Landscape Architecture 2015-Landscape Architecture and Planning Proceedings. BerlinHerbert Wichmann VerlagVDE VERLAG GMBHSchaller, J., Ertac, O., Freller, S., Mattos, C. and Rajcevic, Z. (2009).Geodesign Apps and 3D Modeling with City Engine for the City of Tomorrow. In: Digital Landscape Architecture 2015-Landscape Architecture and Planning Proceedings, Anhalt University of Applied Sciences, Herbert Wichmann Verlag, VDE VERLAG GMBH, Berlin, 59-70.

Statistical Yearbook of Palestine. Ramallah, PalestinePalestinian Central Bureau of Statistics PCBSPalestinian Central Bureau of Statistics PCBS (2017) Statistical Yearbook of Pales- tine, No. 18, Ramallah, Palestine. http://www.pcbs.gov.ps/Downloads/book2362.pdf


BMC Family Practice How do General Practitioners experience providing care for their psychotic patients?

Marian Jt Oud
Department of General Practice
University Medical Center Groningen
GroningenThe Netherlands

Jan Schuling email@example.com
Department of General Practice
University Medical Center Groningen
GroningenThe Netherlands

Cees J Slooff
Department of Psychiatry
University Medical Center Groningen
GroningenThe Netherlands

Mental Health Center Drenthe
AssenThe Netherlands

Betty Meyboom-De Jong firstname.lastname@example.com
Department of General Practice
University Medical Center Groningen
GroningenThe Netherlands

BMC Family Practice How do General Practitioners experience providing care for their psychotic patients?
10.1186/1471-2296-8-37BioMed Central Page 1 of 7 (page number not for citation purposes) Research article * Corresponding author
Background:In primary care, GPs usually provide care for patients with chronic diseases according to professional guidelines. However, such guidelines are not available in the Netherlands for patients with recurring psychoses. It seems that the specific difficulties that GPs experience in providing care for these patients hinder the development and implementation of such guidelines. This study aims to explore the chances and problems GPs meet when providing care for patients susceptible for recurring psychoses, including schizophrenia and related disorders, bipolar disorder, and psychotic depression.Methods:A qualitative study of focus group discussions with practising GPs in both town and rural areas. Transcripts from three focus groups with 19 GPs were analysed with the computer program 'Kwalitan'. Theoretical saturation was achieved after these three groups.Results: Analysis showed that eight categories of factors influenced the GPs' care for psychotic patients: patient presentation (acute vs. chronic phase), emotional impact, expertise, professional attitude, patient related factors, patient's family, practice organization, and collaboration with psychiatric specialists.Conclusion: Current primary care for psychotic patients depends very much on personal characteristics of the GP and the quality of local collaboration with the Mental Health Service. A quantitative study among GPs using a questionnaire based on the eight categories mentioned above would determine the extent of the problems and limitations experienced with this type of care. From the results of this quantitative study, new realistic guidelines could be developed to improve the quality of care for psychotic patients.

Background

Chronic, relapsing psychoses are psychiatric diseases which have serious implications for the quality of life of both patients and those around them. Usually the general practitioner (GP) is the first contact when disturbing symptoms occur that are severe enough to cause alarm within the family. When the GP recognizes the psychosis and the patient allows himself to be referred to a psychia-trist, the GP becomes a concerned observer. Information is received from the family, the patient, and the specialist.

The GP is the first to be consulted if a patient has physical complaints. However, patients with chronic psychoses are less capable than other patients of interpreting physical signs, as well as solving their problems and caring for themselves, which leads to an increased responsibility on the part of health care workers. For example, the co-morbid conditions of schizophrenia include anxiety, drugs and alcohol abuse, weight gain, diabetes mellitus, cardiovascular diseases, and general consequences of an unhealthy lifestyle [1,2]. In short, this is a group of patients who are chronically ill and for whom the GP is a convenient provider of continuing care with easy access. As with other chronic conditions, guidelines for the primary care of patients with schizophrenia would improve the quality of care [3,4]. The implementation of a protocol outlining such guidelines requires that the interventions are realistic and that the GP is willing to apply them. Or as Paul Rowlands states: implementation is likely to be best achieved through a sense of ownership of the guidelines and a process that borrows from their spirit, which emphasises collaboration, building on the strengths and good practice already present [5,6]. Research has shown, however, that GPs have little interest in psychotic conditions and patients with schizophrenia are less likely to receive physical health checks in primary care [7,8].

A qualitative study was planned which explored what factors affect the willingness of GPs to provide care for patients susceptible to recurring psychoses, including schizophrenia and related disorders, bipolar disorder, and psychotic depression. These results should be taken into account when developing guidelines. The research question was formulated as follows: what variables influence the GP when he or she is caring for patients with psychoses in the acute and chronic phase?

Methods

As this study concerns a relatively uninvestigated area, a qualitative design with focus groups was chosen as research method. It was necessary to explore several aspects of the GPs' care (table 1), and pay particular attention to the problems experienced by GPs [9]. To obtain the possibly varying opinions, the participating GPs should differ in age, gender, and type of practice [10]. The participants were selected by purposeful sampling. A majority of experienced GPs was preferred so as to ensure that our group of respondents had sufficient experience in treating patients with psychoses. Practising GPs were invited by one of the investigators (MO) to participate in the study. All focus group meetings were led by a single moderator: a psychologist and senior staff member of the Department of Vocational Training of General Practice UMCG. Two investigators (MO and JS) working independently, categorized the fragments of text and divided them into themes. The discussions were recorded digitally and later transcribed. Any discrepancies were discussed until a consensus was reached. The analysis was conducted to the rules of qualitative research, based on the elements of grounded theory [11,12]. The software program Kwalitan was used to assign codes to each of the textual segments and to structure them in a decision tree format.

Results

A total of fifty GPs was approached, of whom 19 agreed to participate (table 2). GPs who declined to participate found the time investment (90 minutes excluding travel time) too great.

Three focus groups were organized: two in Groningen and one in Amsterdam. Since the third focus group generated no new aspects and saturation was reached, no further groups were organized.

Nine female and ten male GPs participated and all except one had considerable professional experience, from 7 to more than 25 years. One GP was a locum. Thirteen GPs had their practice in the city, three were practising in suburban areas, and two had rural practices.

The analysis of the data resulted in eight categories being identified: patient presentation, the emotional impact, the expertise, the professional attitude, patient-related factors, the patient's family, the organization of the practice, and the collaboration with secondary health care sources. Psychosis presents itself in many forms: from dramatic crisis situations to calm, clear situations that include patients with chronic schizophrenia who reliably take their antipsychotic medication. Also, GPs encounter addicted patients who display compulsive or threatening behaviour, patients who are vulnerable to bouts of psychotic depression, and patients who are excited and manic. Some GPs also mentioned elderly patients, who hallucinate or are paranoid due to an organic brain syndrome and who require a lot of GP support. The GPs made an important distinction between the acute and the chronic phase of psychosis. Although acute psychotic crises rarely present themselves in the general practice setting, when they do occur, they have a large impact on the GP and on the organization of the practice.

The emotional impact on the GP

The experience which left the biggest impression on me involved a father going through a psychotic crisis. He was threatening to take this tiny baby away with him. The mother tried to grab the child back, in the living room, and I uh..

. I contacted the Mental Health Service and waited for help. (GP7)

It is the GP's responsibility to do the initial examination during a psychotic episode. The GP's role in the actual treatment is limited, however. Usually, family members are the ones who seek help from the GP. The GP then responds by assessing the patient's mental state with an interview or information obtained from the family and his own observations upon arrival at the scene. In a crisis, GPs try to take the lead and restore order, but since they have limited experience with psychotic crises, they often feel powerless and depend on a quick response by the Mental Health Service team. The case reports discussed in the focus groups evoked a great amount of recognition of the problems and clearly demonstrated the need for emotional support. Most GPs feel alone, particularly when facing an acute crisis.

What the GPs experience and feel during a psychotic crisis involving a specific patient may have a lasting effect on the GPs' future attitudes towards that patient when caring for him or her in the chronic phase of the illness.

And when the patient doesn't want to be referred, you can only stand back and watch; and if he also refuses medication, you can only hope that things stay calm... (GP17)

Besides the feelings of powerlessness, anxiety also plays a role. GPs worry that patients with disturbed aggression management will become violent. They fear for their own personal safety, for disturbances in the GP surgery, and for frightening other patients. One GP mentioned that his anxiety was a result of feeling pulled into the psychotic thoughts of the patient. The GP's expertise GPs find themselves able to recognize a psychosis. However, with a new psychosis it can take some time before Female 0-5 Locum the clinical picture is correctly interpreted. GPs do not apply specific DSM categories, since they regard diagnosing according to these categories the psychiatrist's responsibility.

All GPs in this study refer young patients with a psychosis to a psychiatrist, while at the same time, they are willing to manage themselves older patients whose outlook is limited, and who will benefit from supportive and palliative care.

Most GPs expressed the view that they have a limited knowledge of pharmacotherapy. Starting a patient with schizophrenia on antipsychotic medication is considered to be the psychiatrist's responsibility. The GP's practice is usually involved in restarting medication or continuing prescription. For example, if experience with a previous antipsychotic drug has been positive, the GP will prescribe the same medication. In case of a newly diagnosed psychotic patient, six out of the 19 GPs will start the patient on antipsychotic medication themselves, whereas other GPs are inclined to refer the patient to specialized care immediately. GPs who initiate pharmacotherapy themselves hope to stabilize the patient, so that he or she is open to communication and is able to agree to the referral to a specialist. The GP knows the context and background of most of his patients and maintains the patient's medical file. When problems occur, the GP is the first to respond, and he often functions as the final safety net. However, GPs are accustomed to working independently, and they generally do not have the opportunity to discuss more difficult patients with a team.

In the chronic phase, the practice assistant takes care of repeat prescriptions and the GP only becomes involved by request. Three GPs mentioned that they make use of repeat prescription requests to invite the patient for monitoring. To build an effective doctor-patient relationship, the GP chooses to maintain a neutral but interested attitude. Most GPs do not actively follow patients with a chronic psychosis. Only a few offer the occasional follow-up appointment or ask the patient to come in when he or she forgets to pick up a new prescription.

Patient related factors

The patient's age and his prognosis play an important role in the care provided by GPs. Young people are always referred to the psychiatric specialist. People with a stable social context are referred less often than those without one. GPs with an affinity for chronic psychiatry feel ambivalent about their duties towards schizophrenic patients who refuse treatment and who have been rejected by society. The GP is a family physician, and all GPs consider it their responsibility to provide support and care for all the members of the patient's family. The family of a schizophrenic patient experiences stress and visits their GP more often [13,14]. Several GPs commented that, with certain patients, they invested considerable energy in caring for the patient's family during the acute psychotic phase. This concerned situations involving the family where the GP was trying to restore the balance in the family. Furthermore, contact with the family is important during the initial interviews, making appointments to discuss therapy compliance, and explaining the early recognition of symptoms indicating relapse.

The organization of the general practice

The GP operates without protection and bears full responsibility. House calls and office appointments are planned in the short term, and the days pass according to a fixed schedule. A crisis, however, happens without warning and is very time consuming. This upsets the practice routine, necessitating overtime hours.

A psychotic crisis is very time consuming and disturbs surgery hours. You all know what a full Monday schedule brings about.... (GP6)

To be able to manage a psychotic crisis at home, GPs find it essential that a doctor-family relationship exists which allows reasonably reliable agreements to be made. It is equally important that the situation is surveyable and that the Mental Health Service is available to assist. In hindsight, two GPs judged the responsibility of dealing with a psychotic crisis and the time required for it to be considerable. A social-psychiatric nurse is available to some of the GPs in their practices for counselling patients and to act as a consultant for the GP, but this nurse usually has no experience of caring for patients with psychotic disorders.

During the evening and at night, emergencies are covered by GPs working from a centralised on-call centre. These on-call GPs can ask for assistance of a social-psychiatric nurse from the Mental Health Service if necessary.

Collaborating with psychiatric specialists

This topic led to heated discussions, in which feelings of satisfaction, frustration, and powerlessness were expressed. Positive experiences were recounted involving nurses from the Mental Health Service who were willing and ready to assist and cooperate with the GP in solving problems. The GPs highly valued consultations with specialists and achieving shared care. Frustration following an inaccurate assessment by mental health care services is long felt by the GP who calls on acute psychiatric services, as well as feelings of being misunderstood. GPs do not feel their work is truly valued by the mental health care workers. They mentioned examples in which they felt excluded from the care of a patient. However, one GP was quite satisfied with an emergency plan developed by the psychiatrist in close consultation with the patient, in which the GP was designated as the caregiver to be first contacted in case of warning signs.

If necessary, I can fall back on the psychiatrist directly, but often I can handle things on my own with these patients. (GP6)

If the consultant and the GP are known to each other personally, and they are aware of each other's capabilities and skills with respect to the care of the patient, a foundation for a productive collaboration develops. Some GPs say that they would like to be more involved in the continuing care of chronic psychiatric patients as long as they can fall back on secondary health care resources when there is a crisis.

Discussion

Continuing care that is focused on the patient and his environment is the fundament of general practice. By using a systematic and structured approach, GPs provide care for patients with chronic physical diseases. Case management consists of the following elements: monitoring, assessing the physical and mental functional status of the patient, paying attention to the consequences for the family, patient (and family) education and contributing to specific, shared care with consultants.

Our study shows that the GPs refer all younger patients with a first episode psychosis, but they do not apply a proactive and structured approach when caring for patients with a chronic recurring psychosis, which is recommended in the English guideline for schizophrenia [6].

GPs experience a difference between intervening during an acute episode and caring for a chronic patient. An acute psychotic crisis is stressful and can sometimes be threatening. Often the GP feels that he cannot resolve the crisis and is dependent on the readiness of the Mental Health Service to respond. Also, GPs often find themselves in a position of solitary uncertainty when they offer to help during a psychotic crisis. The tension that these crises cause, may lead to some GPs avoiding these types of patients' altogether.

In the chronic phase, however, GPs do find satisfaction in offering patients a familiar and easy access to care. Physical complaints are often used as a means of inquiring about psychosocial circumstances, but GPs do not give systematic, structured attention to the physical and psychosocial aspects of this chronic disease. Patients with schizophrenia have a higher risk of developing somatic co-morbidities. In addition, these patients have more difficulty than other patients in obtaining access to the health services for their somatic complaints [15]. This means that the GP has to be extra vigilant regarding the appearance and existence of such signs and symptoms.

Monitoring patients with schizophrenia, while paying attention to physical health and individual self-care may improve the state of health of these patients. Some GPs experience a lack of specific skills necessary to treat these patients. This finding is in agreement with the findings of other research [16].

Having sufficient professional knowledge at one's disposal does not guarantee good patient care. The physician's assets also play a role [17]. His emotions are partial determinants for how the task is performed. Anxiety, for example, can have a negative effect.

In our opinion the following conditions will be helpful for the provision of good care of psychotic patients: having compassion for this type of patient, being able to handle feelings of powerlessness, not feeling rejected too quickly, and not expecting gratitude.

An important requirement for the provision of care for these patients is a well-defined collaboration with secondary health care services. Being able to rely on a rapid response from the Mental Health Service in a crisis situation increases the GP's perception of being able to solve problems in a satisfactory manner [18]. Patient care during the chronic phase requires both parties to understand and value each other's methods and to put this knowledge to good use. GPs sometimes feel undervalued by the psychiatrists; there is a need for greater acknowledgement of the valuable and complementary role in the treatment of chronic psychoses [16]. While on the other hand, GPs have only modest interest in psychiatric diagnostic classification systems [19].

Development of GP's interest in providing care for psychotic patients could be stimulated in several ways. In the United Kingdom the National Health Service (NHS) introduced mental health indicators in the new contract with GPs as an incentive to apply a more systematic approach to care, including the use of protocols and referral guidelines [6,20].

We assume that meeting the needs GPs have, could be helpful to increase their involvement in developing a primary care guideline with specific task descriptions in the complex multidisciplinary care for psychotic patients. One of these tasks is the early detection of the first episode psychosis [20,21]. In Birmingham the Early Detection In Untreated Psychosis Trial had been designed to evaluate the effectiveness of education interventions targeted GPs on the early detection of young patients with a first episode psychosis [22].

Study limitations and strengths

All the participating GPs regarded the meetings as positive. It enabled them to share their experience on this topic without being formally assessed. The audio tapes show that the GPs expressed themselves freely and their emotions appeared sincere. Our study included those GPs who were willing to spend time on this topic. Nonrespondents were probably GPs who are not interested in care for psychotic patients. Therefore, our findings do not represent the attitudes of all GPs in The Netherlands. A quantitative sequel in a representative sample of GPs is necessary to determine the impact of these variables.

The strength of this study is the qualitative method that really captured uncensored opinions and emotions of GPs, resulting from actual experiences in this field.

Conclusion

GPs do not apply a systematic approach to psychotic patients, but respond on requests of the patient and his family. They interpret their tasks differently, depending on personal affinities, experiences and the quality of the collaboration with the local Mental Health Service. These conclusions are the result of a qualitative study of experienced GPs and are compatible with other studies [23][24][25].

On the basis of these results, we propose a questionnaire for a quantitative study should be developed, which will allow the appropriate weighting factor to be allocated to the different variables. This will enable us to assess the actual needs of GPs with respect to the care for psychotic patients and to determine which interventions will contribute to further development of their competence, as well as interesting GPs in appropriating a primary care protocol.

Table 1 :
1Questions discussed in the focus groupsWhat experiences do you have with psychotic patients, and how do you feel about providing care for these patients? How do you cope with a first and a recurring psychosis? Pharmacotherapy, do you feel confident with it? Have you developed a specific policy in counselling/supporting chronic psychotic patients? Who takes the initiative in making contact? What kind of support and collaboration with the members of the family is there? Do you feel competent in providing care for psychotic patients? If not, what sort of training do you need? How do you feel about collaborating with the Mental Health Service? How much satisfaction do you gain from providing care for psychotic patients?Patient presentation
When I have been asked to intervene because the patient's
behaviour makes the situation unbearable, I usually find the
patient in an embarrassing condition in which my abilities as a
GP are very restricted. (PG2)

Of course I get scared.... with menacing people. A man once came to my practice with very strange complaints. He was very intimidating without actually becoming violent, yes, threatening and incomprehensible behaviour... (GP6)Three GPs find great satisfaction in caring for patients with schizophrenia, particularly during peaceful periods when the patient is stable. This satisfaction also depends on how knowledgeable the patient is about his disease, how easy it is to talk to him.Look, if he has something to do during the day, and he receives reasonable care, and the situation doesn't get out of hand, then I enjoy it too: when a certain amount of continuity is achieved, then I enjoy my job.(GP3)

Table 2 :
2The participantsFocus group 1
Nr.
Sexe
Years of experience
Location

1
Female
20-25
Suburban area
2
Male
15-20
Suburban area
3
Male
5-10
City
4
Female
5-10
Suburban area
5
Male
20-25
City

Focus group 2

6
Male
20-25
City
7
Female
20-25
City
8
Female
5-10
City
9
Male
10-15
City
10
Female
10-15
Rural area
11
Male
> 25
Rural area
12
Male
20-25
City
13
Male
20-25
City

Focus group 3

14
Male
20-25
City
15
Female
5-10
City
16
Female
15-20
City
17
Female
20-25
City
18
Male
5-10
City
19

Three of the GPs expressed the desire to learn strategies for communicating with psychotic patients: 'how do I connect with these people, how do I tell someone that he or she is not rational, and what should my approach be?'You have built a relationship with the patient, and if you can
make use of that, then you should; you shouldn't refrain from
treatment because then you run the risk of delay. You have to
minimize delay as much as possible, so just start... (GP3)

Communication problems are inherent to schizophrenia, this is
an important aspect of the disease: how do I communicate with
these people...? If they are really confused, then you have to
take a different approach........ interview them differently from
one who is coherent. (GP7)

The GP's professional approach
General practice offers people an easy and non-stigmatis-
ing access to health care.

It is a matter of sensitivity, and being there for them. I think
this is the most important thing that you can be for the chronic
psychiatric patient: that they can come to you and that they
know that you know everything that has happened, and that
they don't have to explain everything....... that they can trust
you. (GP9)

Patients who are not in treatment and whom I worry about......... and at whom nobody else bats an eyelid, what should I do with them............. (GP14)The GPs do not know what to do with patients who refuse
every form of treatment. When the patient has an aggres-
sive attitude, the doctor may decide that he is unable to
handle the patient. There was a consensus among partici-
pants on the need for close monitoring of aggressive psy-
chotic patients by the Mental Health Service.

The patient's family
As GP you are also the family doctor and I think that is a strong
trump because you are very much involved with the family. You
give them support and advice on how to deal which leads to an
indirect coaching of the patient. (GP1)

(page number not for citation purposes)
Publish with Bio Med Central and every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours -you keep the copyright Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentral
(page number not for citation purposes) MO and JS have written the final manuscript, which all authors read and approved.
AcknowledgementsWe would like to thank the general practitioners who participated in this study. This qualitative study has been funded by the Mental Health Stimulating Project from the Ministry of National Health.Competing interestsThe author(s) declare that they have no competing interests.Authors' contributionsMO initiated and organized the study, assisted by JS. MO and JS analysed the transcripts. After reading the first draft of the manuscript all authors provided critical comments.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/8/37/prepub
Excess mortality of schizophrenia. A meta-analysis. S Brown, Brown S: Excess mortality of schizophrenia. A meta-analysis.

. Br J Psychiatry. 171Br J Psychiatry 1997, 171:502-508.

Schizophrenia and increased risks of cardiovascular disease. C H Hennekens, A R Hennekens, D Hollar, D E Casey, Am Heart J. 150Hennekens CH, Hennekens AR, Hollar D, Casey DE: Schizophre- nia and increased risks of cardiovascular disease. Am Heart J 2005, 150:1115-1121.

The primary care of patients with schizophrenia: a search for good practice. T Burns, T Kendrick, Br J Gen Pract. 47Burns T, Kendrick T: The primary care of patients with schizo- phrenia: a search for good practice. Br J Gen Pract 1997, 47:515-520.

Do guidelines for severe mental illness promote physical health and well-being?. L Citrome, D Yeomans, J Psychopharmacol. 19Citrome L, Yeomans D: Do guidelines for severe mental illness promote physical health and well-being? J Psychopharmacol 2005, 19:102-109.

The NICE schizophrenia guidelines: the challenge of implementation. P Rowlands, Br J Psychiatry. 10Rowlands P: The NICE schizophrenia guidelines: the challenge of implementation. Br J Psychiatry 2004, 10:403-412.

National Institute for Clinical Excellence: Schizophrenia: full national clinical guidelines on core interventions in primary and secondary care. London: NICENational Institute for Clinical Excellence: Schizophrenia: full national clinical guidelines on core interventions in primary and secondary care. London: NICE; 2002.

De rol van de huisarts inzake geestelijke gezondheidszorg (GP's role in mental health care) Nijmegen Centre for quality of care research. Centre Wok, For Quality, Of Care, Research, University Medical Centre St RadboutWOK, Centre for Quality of Care Research: De rol van de huisarts inzake geestelijke gezondheidszorg (GP's role in mental health care) Nijmegen Centre for quality of care research, University Medical Centre St Radbout; 2002.

Physical health care of patients with schizophrenia in primary care: a comparative study. L Roberts, A Roalfe, S Wilson, H Lester, Fam Pract. 24Roberts L, Roalfe A, Wilson S, Lester H: Physical health care of patients with schizophrenia in primary care: a comparative study. Fam Pract 2007, 24:34-40.

Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. C Pope, N Mays, BMJ. 3116996Pope C, Mays N: Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ 1995, 311(6996):42-45.

Introducing focus groups. J Kitzinger, BMJ. 311Kitzinger J: Introducing focus groups. BMJ 1995, 311:299-302.

K Malterud, Qualitative research: standards, challenges, and guidelines. 358Malterud K: Qualitative research: standards, challenges, and guidelines. Lancet 2001, 358:483-488.

Qualitative data analysis in applied policy research. J Ritchie, L Spencer, Bryman A, Burgess R. Analysing Qualitative DataLondon: RoutledgeRitchie J, Spencer L: Qualitative data analysis in applied policy research. Edited by: Bryman A, Burgess R. Analysing Qualitative Data, London: Routledge; 1994.

Ulstein I: Relatives' distress and patients' symptoms and behaviours: a prospective study of patients with schizophrenia and their relatives. B Boye, H Bentsen, Acta Psychiatr Scand. 104Boye B, Bentsen H, Ulstein I: Relatives' distress and patients' symptoms and behaviours: a prospective study of patients with schizophrenia and their relatives. Acta Psychiatr Scand 2001, 104:42-50.

Experience of caregiving: relatives of people experiencing a first episode of psychosis. L Tennakoon, D Fannon, V Doku, S O'ceallaigh, W Soni, M Santamaria, E Kuipers, T Sharma, Br J Psychiatry. 177Tennakoon L, Fannon D, Doku V, O'Ceallaigh S, Soni W, Santamaria M, Kuipers E, Sharma T: Experience of caregiving: relatives of people experiencing a first episode of psychosis. Br J Psychiatry 2000, 177:529-533.

Sohoran H: Patients' and health professionals' view on primary c are for people with serious mental illness: focus group study. H Lester, J Q Tritter, BMJ. 330Lester H, Tritter JQ, Sohoran H: Patients' and health profession- als' view on primary c are for people with serious mental ill- ness: focus group study. BMJ 2005, 330:1122-1136.

Attitudes and roles of general practitioners in the treatment of schizophrenia compared with community mental health staff and patients. V J Carr, T J Lewin, R E Barnard, J M Walton, J L Allen, P M Constable, J L Chapman, Soc Psychiatry Psychiatr Epidemiol. 39Carr VJ, Lewin TJ, Barnard RE, Walton JM, Allen JL, Constable PM, Chapman JL: Attitudes and roles of general practitioners in the treatment of schizophrenia compared with community mental health staff and patients. Soc Psychiatry Psychiatr Epidemiol 2004, 39:78-84.

Satisfaction with primary care: the perspectives of people with schizophrenia. H Lester, J Q Tritter, E England, Fam Pract. 20Lester H, Tritter JQ, England E: Satisfaction with primary care: the perspectives of people with schizophrenia. Fam Pract 2003, 20:508-513.

How do general practitioners manage subjects with early schizophrenia and collaborate with mental health professionals?. H Verdoux, A Cougnard, S Grolleau, R Besson, F Delcroix, Soc Psychiatry Psychiatr Epidemiol. 40Verdoux H, Cougnard A, Grolleau S, Besson R, Delcroix F: How do general practitioners manage subjects with early schizo- phrenia and collaborate with mental health professionals? Soc Psychiatry Psychiatr Epidemiol 2005, 40:892-898.

Patients with a psychiatric disorder in general practice: determinants of general practitioners' psychological diagnosis. Pfm Verhaak, F G Schellevis, J Nuijen, A C Volers, Gen Hosp Psych. 28Verhaak PFM, Schellevis FG, Nuijen J, Volers AC: Patients with a psychiatric disorder in general practice: determinants of general practitioners' psychological diagnosis. Gen Hosp Psych 2006, 28:125-132.

Early intervention for first episode psychosis. D Shiers, H Lester, BMJ. 328Shiers D, Lester H: Early intervention for first episode psycho- sis. BMJ 2004, 328:1451-1452.

Management of first-episode psychosis. E Spencer, M Birchwood, D Mcgovern, Br J Psychiatry. 7Spencer E, Birchwood M, McGovern D: Management of first-epi- sode psychosis. Br J Psychiatry 2001, 7:133-140.

Design of the BiRmingham Early Detection in UntREated psychosis Trial (REDIRECT): a cluster randomised controlled trial of general practitioner education in detection of first episode psychosis. L Tait, H Lester, M Birchwood, N Freemantle, S Wilson, BMC Health Services Research. 519Tait L, Lester H, Birchwood M, Freemantle N, Wilson S: Design of the BiRmingham Early Detection in UntREated psychosis Trial (REDIRECT): a cluster randomised controlled trial of general practitioner education in detection of first episode psychosis. BMC Health Services Research 2005, 5:19.

Care of schizophrenia in general practice: the general practitioner and the patient. I Nazareth, M King, S Davies, Br J Gen Pract. 45Nazareth I, King M, Davies S: Care of schizophrenia in general practice: the general practitioner and the patient. Br J Gen Pract 1995, 45:343-347.

Service provision for people with schizophrenia. Role of the general practitioner. F H Lang, E C Johnstone, D G Murray, Br J Psychiatry. 171Lang FH, Johnstone EC, Murray DG: Service provision for people with schizophrenia. Role of the general practitioner. Br J Psy- chiatry 1997, 171:165-68.

General practitioners and schizophrenia: results from a Swiss survey. A E Simon, C Lauber, K Ludewig, H Braun-Scharm, D S Umbricht, Br J Psychiatry. 187Simon AE, Lauber C, Ludewig K, Braun-Scharm H, Umbricht DS: General practitioners and schizophrenia: results from a Swiss survey. Br J Psychiatry 2005, 187:274-81.