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John Sanford Berkeley spent 13 years in general practice in Fort William before joining the leprosy mission in south India. He learnt hand surgery and developed a leprosy service in Bhutan. After public health training, he became …

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.

Objectives: To find out how a consulting process measure (consultation duration) and one aspect of immediate outcome (patient enablement) are related to personal/relational continuity (how well the patient knows the doctor) in a geographically and professionally diverse sample of general practices.Methods: A cross-sectional multi-practice questionnaire study set in a random sample of practices in four participating districts in Britain. The participants were 221 GPs in 53 practices consulted by 25,994 patients over a two-week period in March and April 1998.Results: “Knowing the doctor well” was significantly associated with better patient enablement but “seeing the regular doctor today” was not significantly associated. Patients in practices which encouraged them to see the same doctor or which operated a strict personal list system were not more enabled than those in other practices of similar size.Conclusions: This confirms that nature and quality of the patient-doctor relationship is more important tha...

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.

Objective: To compare quality of care between 1990 and 1992 in patients with self diagnosed joint pain. Design: Questionnaire and record based study. Subjects: Patients identified at consecutive consultations during two weeks in 1990, 1991, and 1992. Setting: Six practice groups in pilot fundholding scheme in Scotland. Main outcome measures: Length of consultation; numbers referred or investigated or prescribed drugs; responses to questions about enablement and satisfaction. Results: About 15% of patients consulted with joint pain each year. 25% (316) of them had social problems in 1990 and 37% (370) in 1992, about a fifth wanted to discuss their social problems. Social problems were associated with a raised general health questionnaire score. The mean length of consultation for patients with pain was 7.6 min in 1990 and 7.7 min in 1992. Patients wishing to discuss social problems received longer consultations (8.5 min 1990; 10.4 min 1992); but other patients with social problems received shorter consultations (7.4 min; 7.2 min). The level of prescribing was stable but the proportion of patients having investigations or attending hospital fell significantly from 1990 to 1992 (31% to 24%; 31% to 13% respectively). Fewer patients responded “much better” to six questions about enablement in 1992 than in 1990. Enablement was better after longer than shorter consultations for patients with social problems. Conclusions: Quality of care for patients with pain has been broadly maintained in terms of consultation times. The effects of lower rates of investigation and referral need to be investigated further.

In 1999 Shah1 and others said that the Royal College of General Practitioners should advocate longer consultations in general practice as a matter of policy. The college set up a working group chaired by A P Hungin, and a systematic review of literature on consultation length in general practice was commissioned. The working group agreed that the available evidence would be hard to interpret without discussion of the changing context within which consultations now take place. For many years general practitioners and those who have surveyed patients' opinions in the United Kingdom have complained about short consultation time, despite a steady increase in actual mean length. Recently Mechanic pointed out that this is also true in the United States.2 Is there any justification for a further increase in mean time allocated per consultation in general practice? We report on the outcome of extensive debate among a group of general practitioners with an interest in the process of care, with reference to the interim findings of the commissioned systematic review and our personal databases. The review identified 14 relevant papers. #### Summary points Longer consultations are associated with a range of better patient outcomes Modern consultations in general practice deal with patients with more serious and chronic conditions Increasing patient participation means more complex interaction, which demands extra time Difficulties with access and with loss of continuity add to perceived stress and poor performance and lead to further pressure on time Longer consultations should be a professional priority, combined with increased use of technology and more flexible practice management to maximise interpersonal continuity Research on implementation is needed The systematic review consistently showed that doctors with longer consultation times prescribe less and offer more advice on lifestyle and other health promoting activities. Longer consultations have been significantly associated with better recognition and …

OBJECTIVE--To compare prescribing patterns between a group of fundholding practices and a group of non-fundholding practices in north east Scotland using a method which provides more accurate statements about volumes prescribed than standard NHS statistics. DESIGN--The pharmacy practice division of the National Health Service in Scotland provided data for selected British National Formulary sections over two years. Each prescription issued was converted using the World Health Organisation "defined daily dose" mechanism. SETTING--Six fundholding groups (nine practices) in Grampian and Tayside regions and six non-fundholding practices in Grampian. RESULTS--During the past two years both fundholding and control practices reduced the volume of their prescribing for the classes of drug analysed. The unit costs of drugs in some classes, however, rose substantially, contributing to higher costs per patient. The unit costs rose more in the control practices (24%) than in the fundholding practices (11% in Tayside, 16% in Grampian). CONCLUSION--The use of defined daily doses helped identify cost and volume trends in specific areas of prescribing in fundholding and control practices. The basis on which funds are set needs improving, and defined daily doses may prove useful for setting volume targets within drug classes for all practices, whether fundholding or not.

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.

We welcome the excellent paper by Mead and colleagues on the characteristics and utility of the concept of enablement.1 Their paper raises two themes, one on the meaning of enablement, and the second on whether its use as a quality measure would be practical and fair. The most interesting issue in the first theme arises from the observation that patients from ethnic minority groups report higher enablement while possibly receiving care that might otherwise be expected to produce the opposite effect (in particular, having shorter consultations). In our papers on the same subject,2,3 we not only found that ethnic minority groups reported higher enablement, but also that the difference was even greater when the consultation took place in the patient's own language.3 This is compatible with Mead et al 's suggestion that ethnic minority patients are more likely to have their possibly different expectations of health care met than are native UK patients,1 but also suggests that these needs are most likely to be met when the cultural context of doctor and patient are well matched. But the situation may well be even more complex. In a small student study in west London, Hindi and Urdu speaking patients appeared to have different understandings of individual items in the patient enablement instrument (PEI), and also showed different levels of respect towards their GPs (S Khan and GK Freeman, unpublished data, 2004). We completely agree with Mead et al that more qualitative work is needed to help …

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.

Objectives: To measure quality of care at general practice consultations in diverse geographical areas, and to determine the principal correlates associated with enablement as an outcome measure. Design: Cross sectional multipractice questionnaire based study. Setting: Random sample of practices in four participating regions: Lothian, Coventry, Oxfordshire, and west London. Participants: 25 994 adults attending 53 practices over two weeks in March and April 1998. Main outcome measures: Patient enablement, duration of consultation, how well patients know their doctor, and the size of the practice list. Results: A hierarchy of needs or reasons for consultation was created. Similar overall enablement scores were achieved for most casemix presentations (mean 3.1, 95% confidence interval 3.1 to 3.1). Mean duration of consultation for all patients was 8.0 minutes (8.0 to 8.1); however, duration of consultation increased for patients with psychological problems or where psychological and social problems coexisted (mean 9.1, 9.0 to 9.2). The 2195 patients who spoke languages other than English at home were analysed separately as they had generally higher enablement scores (mean 4.5, 4.3 to 4.7) than those patients who spoke English only despite having shorter consultations (mean 7.1 (6.9 to 7.3) minutes. At individual consultations, enablement score was most closely correlated with duration of consultation and knowing the doctor well. Individual doctors had a wide range of mean enablement scores (1.1-5.3) and mean durations of consultation (3.8-14.4 minutes). Doctors9 ability to enable was linked to the duration of their consultation and the percentage of their patients who knew them well and was inversely related to the size of their practice. At practice level, mean enablement scores ranged from 2.3 to 4.4 and duration of consultation ranged from 4.9 to 12.2 minutes. Correlations between ranks at practice level were not significant. Conclusions: It may be time to reward doctors who have longer consultations, provide greater continuity of care, and both enable more patients and enable patients more. Key messages 38% of practices approached on a random basis in four areas of the United Kingdom collected data for 2 weeks showing the feasibility of surveying the content and outcome of routine consultations in general practice At consultation level, enablement correlates best with the duration of consultations and how well the patient knows the doctor These correlates apply at doctor level as well—more enabling doctors work in smaller practices than less enabling doctors Case mix does not seem to be a determinant of enablement scores, but patients with more complex problems require longer consultations to achieve equal enablement Patterns of duration of consultation and enablement in patients who speak languages other than English are different and require further study

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.

EDITOR—Over 40 years ago, I studied the clinical pathology of the appendix and the epidemiology of appendicectomy. I would like to comment on four complementary issues.1 Firstly, around 1960 the 4/1000 death rate ranged from 1/2600 for uncomplicated appendicitis in young adults, to 1/9 for patients older than 50 with a perforated appendix. Death rates for male patients were double those for female patients. Deaths from a normal appendicectomy were 1/5000 in young …

Editor—Like many others will have been, I was astonished at the assertion in Benjamin and Patel's leader that mortality from negative appendicectomy (1.5%) exceeded that of appendicectomy for acute appendicitis (0.2%).1 It is clear from reading their source document, that this is a seriously misleading statistic, the figure of 1.5% representing the mortality of comorbidity rather than that of the appendicectomy itself.2 In a study of all 805 deaths from appendicitis or appendicectomy in Scotland (population 5 million) over 10 years to 1963, mortality from appendicectomy for appendicitis was 0.62%, and that from negative appendicectomy was 0.06%. Seventy one of the 605 patients (11.7%) for whom clinical records could be studied had previously been treated non-operatively for suspected appendicitis, and 55 of them died from gangrenous or perforated appendicitis.3 For patients aged 12-29, in whom diagnostic difficulty is greatest, mortality from appendicectomy for appendicitis and for negative appendicectomy was 0.16% and 0.02%; the death rate from missed appendicitis—difficult to calculate exactly—was at least 0.04%. Attempting to project these results to the then competing management strategies I described as conservative (operating on around 60% of patients admitted with possible appendicitis) and radical (operating on 80% of such admissions) for patients in the age group 12-29,4 I estimated that avoidable mortality (death from missed appendicitis plus that from negative appendicectomy) from the two approaches was virtually identical at 1.13 and 1.07 patients per 10 000 admissions—figures which then represented 0.6 avoidable deaths per year in Scotland. It is hard to believe that all the advances described by Benjamin and Patel since then can have done all that much to improve these statistics. Two other observations are relevant. Firstly, appendicectomy but not appendicitis runs in families. Secondly, conservative surgeons become radical surgeons when dealing with medical and nursing colleagues and their families when they present with possible appendicitis. In this field at least, surgery—like general practice—combines the skills of a behavioural with those of a biomedical science. Jones ends his review of the contemporary management of suspected acute appendicitis by saying that we can be sure that emphasis on technology at the expense of clinical evaluation will diminish, rather than improve, the quality of care for patients with acute abdominal pain—a truth that surely has much wider applications.5

To examine the association between different consulting styles in general practice (defined according to the average length of doctor-patient contact time in surgery consultations) and the process of care for those patients presenting with new episodes of respiratory illness, 1787 consultations conducted by 85 general practitioner principals in Lothian from November 1987 to May 1988 were analysed. Short as against long consultations resulted in less attention being given to psychosocial issues that the doctor recognised as relevant. When psychosocial problems were dealt with prescribing of antibiotics decreased. In this volunteer sample of doctors the process of care seemed to reflect decisions as to how time was allocated rather than inherently different patterns of clinical behavior. Organisational and contractual changes will shift the mix of financial and professional incentives for general practitioners in ways that could lead to doctors reallocating their time toward shorter consultations; such a reallocation could have important implications for patient care.