Search

OBJECTIVES The aim of this study was to compare two different approaches to the measurement of quality in general practice: data derived from routine NHS data sets and results from an index derived from patient-collected data. METHODS A secondary analysis of existing data sets and a cross-sectional survey were carried out in Lothian, Coventry, Oxfordshire and west London. The subjects comprised randomly selected and consenting practices, and a sample of patients within these practices. A National Health Service Practice Performance Index (NHSPPI) was constructed from 16 routinely available NHS performance indicators. The Consultation Quality Index (CQI) combines the Patient Enablement Instrument (PEI) with a measure of how well the patient knew the doctor, and with observed consultation length. RESULTS Scores for 12 of the 16 indicators varied significantly across the four regions. Mean practice NHSPPI score overall was 21.6 (SD 4.3), which varied significantly across regions. NHSPPI was predicted by practice list size, weighted deprivation index and proportion of other language patients in the practice, although their effects could not be separated. Overall there was no correlation between NHSPPI and CQI, although the prescribing component of the index was positively correlated to mean consultation length and negatively correlated with how well patients knew their doctors. CONCLUSIONS Good quality care as assessed by patients on completion of their consultation is independent of good quality care as assessed by best available measures of practice performance. We suggest that the CQI and the NHSPPI are at least as ready for use as other measures of performance in general practice.

This essay is a personal review of a research journey extending over 50 years during which time the understanding of medical practice has changed out of all recognition and the quality and standing of the discipline of general practice has improved substantially. Three main bodies of work are reviewed and set against the reasons why they were undertaken. The first, on the pathology of the appendix and the management of possible appendicitis, was carried out almost entirely in the hospital setting. The second, about the prescribing of antibiotics for respiratory illnesses, and the third, about the determinants of good consulting practice, were carried out in general practice. The essay concludes with a reflection on the relevance of the work to some contemporary academic and health service issues. Although the work was carried out in the UK in the context of its National Health Service (NHS), the conclusions are widely generalizable and have contributed to health service and academic developments in many other countries.

OBJECTIVES We aimed to compare a new primary care outcome measure-the Patient Enablement Instrument (PEI)-against two established satisfaction measures [the Medical Interview Satisfaction Scale (MISS) and the Consultation Satisfaction Questionnaire (CSQ)]. Specifically, we sought (i) to test whether enablement and satisfaction are related or separate concepts; and (ii) to assess whether the internal consistency of the PEI might be enhanced by the inclusion of items from the satisfaction instruments. METHODS Questionnaire forms containing the three instruments in a variety of combinations were distributed to a total of 818 patients attending for routine surgery consultations in three urban general practices of varying socio-economic mix. The main outcome measures were: scores on the PEI; scores on the CSQ, the MISS and their individual components; rank correlations between scores on the PEI and scores on the CSQ, the MISS and their component subscales; and Cronbach's alpha coefficient for the PEI. RESULTS Overall mean scores, expressed as percentages of maximum scores attainable, were 44.1% for the PEI, 76.9% for the CSQ and 77.6% for the MISS. Rank correlations between PEI scores and scores for the complete CSQ and MISS instruments were 0.48 (P < 0.01) and 0.47 (P < 0.01), respectively. Correlations of PEI scores with individual component scores on the CSQ were generally lower and ranged from 0.14 to 0.53; correlations of PEI scored with MISS component scores were also generally lower and ranged from 0.21 to 0.53. Internal consistency of the PEI items (assessed by Cronbach's alpha coefficient) was lowered when items from the CSQ or MISS were added. CONCLUSIONS The study shows that 'enablement' is a primary care outcome measure which is related to but is different from general satisfaction.

Although patient satisfaction research has looked at the aspects of care which patients are satisfied with and at which patients are satisfied with their care, few studies have looked at which patients are satisfied with which aspects of care. A retrospective analysis of data collected from 1599 patients attending 43 GPs was undertaken to examine the way that different patient characteristics influenced responses to a 31 item survey completed at the surgery after a consultation. Information on perceived distress [as measured by the Nottingham Health Profile (NHP)] was collected from patients prior to the consultation and further information about the patient and the consultation was recorded by the doctor after the consultation. Levels of satisfaction were high, with only seven of 31 items producing more than 5% of negative responses. These seven items covered whether the waiting time was too long, whether the doctor was relaxed, whether the doctor was in a hurry, whether there was anything else the patient would have liked to talk about had there been more time, whether the doctor had said or done anything to reduce the patient's worries, whether the doctor gave the feeling that the patient's opinions were important and whether there was anything about the consultation which disappointed the patient. Age, waiting time prior to the consultation, consultation length and positive scores on the six NHP dimensions of distress were all significantly associated with responses to one or more of these seven items. Patients experiencing pain and those with emotional distress were dissatisfied with different aspects of the consultation.(ABSTRACT TRUNCATED AT 250 WORDS)

A systematic review examining the efficacy of antibiotics in acute respiratory illness concluded that antibiotics are of little benefit. However, that review was based on analysis of only six randomized controlled trials, one of which was excluded because its analysis included patients with multiple episodes of illness; treatment group, either antibiotic or placebo, might have confounded the likelihood of suffering a subsequent episode of illness.This previously excluded randomized controlled trial of 301 patients with symptoms of minor respiratory illness was re-analysed to examine the efficacy of antibiotic versus placebo in terms of resolution of symptoms, most particularly cough.Antibiotic had no impact on the resolution of symptoms of cough at 1 and 2 weeks, respectively; adjusted odds ratio 1.2 [95% confidence interval (CI) 0.7--2.1] and 0.8 (95% CI 0.4--1.6). In those 220 (73%) individuals who suffered a cough, 48 (44%) and 19 (17%) of patients taking placebo were still coughing after 1 and 2 weeks, respectively.It appears that an antibiotic is likely to have, at best, a marginal impact on resolution of symptoms for most patients with minor respiratory illness in the community.

This paper is an attempt to evaluate the cost implications of decisions made by general practitioners during consultations. Prices were attached to the cost generating decisions of 85 general practitioners in South East Scotland who participated in a 12-month study of their workload. When the price attached to each referral decision was one out-patient attendance, 56 of the 85 general practitioners' costs per consultation were within 15% of the average cost, and 76 were within 25% of the average. However, when the price attached to referral activity was adjusted upwards (to allow for the inclusion of further hospital care), variations between doctors became more pronounced and the decision to refer replaced prescribing as the most important element of variable cost. No important relationships were discovered which linked cost generating activities with characteristics of the doctor or the practice. Implications for fund-holding are discussed.

Background The core values of general practice include holism and patient-centredness. None of the measures of quality of care in general practice presently capture the expression of these values at routine consultations. Objectives The aim of the present study was to construct a 'consultation quality index' (CQI) which reflects the core values of general practice, using as proxies 'consultation length' and how well patients 'know the doctor' as process measures and 'patient enablement' as an outcome measure. Methods The CQI was constructed from data collected from 23 799 adult English-speaking patients consulting 221 doctors in four demographically contrasting areas of the UK during 2 weeks of March/April 1998. A total of 171 doctors who entered 50 qualifying consultations were allocated scores for the three component variables, and a total CQI was calculated. Results CQI scores were in the range 4-18. Validity was examined by looking at high and low scorers in greater detail and by searching for correlates with case mix, patient age and gender, and the deprivation scores of the practices concerned. Particular attention was paid to how registrars and doctors new to their practices scored. The scores of different doctors in the same practice were also noted. The results had strong face validity and were independent of case mix and deprivation. Reliability was gauged by examining similar work from a previous study which had collected information on consultation length and enablement over three time periods. High CQI scores were associated with smaller overall practice list sizes. Conclusions We have outlined possible uses for the CQI as part of the packages assessing quality of care by doctors and practices. The measure may also have a part to play in recognizing poorly performing doctors. We suggest how CQI scores could contribute to an incentive scheme to reward good consulting practice. Further work is in hand to compare doctors' CQI scores with scores based on performance indicators constructed from routine NHS data on prescribing and preventive medicine.

The paper describes two ways in which the Nottingham Health Profile (NHP) may be useful in evaluating general practice: it can provide useful and relevant information about the needs of patients, and can also be used to evaluate outcome by examining the relationship between changes in perceived health status before and 4 weeks after a consultation in relation to care received during that consultation. Findings are based on a sample of 1979 consulters who completed the Nottingham Health Profile prior to consultation and 732 consulters aged 16 years who also completed a Nottingham Health Profile 4 weeks after consultation. Comparisons are made according to the age, sex and illness status of the consulters, length of consultation and psychosocial care received. As a measure of need, significant differences were found in the health profile according to age, sex and illness status, length of consultation and doctors perception of the presence of relevant psychosocial issues. The only variable which was significantly related to short-term outcome was reported presence of a long term illness relevant to the consultation. The NHP is shown to have shortcomings as a measure of outcome for a cross-section of general practice consulters; it is, however, useful in demonstrating how processes of care relate to need in general practice.

This paper describes a preliminary study which collected information on the work of 18 general practitioners during a total of 52 days, and also recorded their feelings of pressure and stress from hour to hour throughout each day. The instruments used to record information on day-to-day activities and to measure self-perceived pressure, stress and arousal are described. The reliability and validity of the methods used are discussed, and some suggestions made for future development. A few preliminary findings are presented.