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This study describes the implementation, in North Macedonia, of a &ldquo, tool&rdquo, initially devised in Scotland, to generate community and stakeholder discussion about the places in which they live and notably a place&rsquo, s capacity to generate health wellbeing and greater equity among citizens. In this study, the &ldquo, place standard tool&rdquo, (PST) is viewed from the perspective of creating places which can deliver a triple win of health and wellbeing, equity, and environmental sustainability. Skopje, North Macedonia&rsquo, s capital, inevitably differs economically, culturally, and politically from Scotland, thus providing an opportunity to augment existing knowledge on adaptability of the tool in shaping agendas for policy and action. Тhe PST was tested through seminars with selected focus groups and an online questionnaire. Over 350 respondents were included. Information on priorities enabled the distillation of suggestions for improvement and was shared with the Mayor and municipal administration. Skopje citizens valued an approach which solicited their views in a meaningful way. Specific concerns were expressed relating to heavy traffic and related air and noise pollution, and care and maintenance of places and care services. Responses varied by geographic location. Application of the PST increased knowledge and confidence levels among citizens and enthusiasm for active involvement in decision making. Effective implementation relies heavily on: good governance and top-level support, excellent organization and good timing, careful training of interviewers and focus group moderators, and on prior knowledge of the participants/respondents.

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 …

As part of this special issue on cloud computing, guest editors Ivan Arce and Anup Ghosh put together a roundtable discussion so readers can hear about cloud computing security from those who are on the front lines, providing services and looking at the real-world threats and requirements from the market.

This article is a contribution to the current debate about the future of general practice. Present rhetoric emphasising under-resourcing is disappointingly one-dimensional and is hindering exploration of alternative solutions. Workload is a major problem. Demand and expectations have risen substantially and an ageing population has brought increasing comorbidity. Early discharge and the devolution of more follow-up care to the community have also added to the responsibilities carried by primary care teams. GPs are reporting high levels of stress; morale and job satisfaction are lower than they should be. Retention of doctors is suboptimal and recruitment worryingly low. The administrative burden associated with the Quality and Outcomes Framework (QOF) is burdensome and often to no good purpose. Many patients report outstanding care from individual GPs and from practices generally. However, not all care is good, and there is noticeable public disenchantment on a number of fronts. Patients report real difficulty accessing GPs …

This paper outlines the 4D time-lapse monitoring of Chirag Field through 3D seismic surveys acquired in 1995 (before the 1997 startup of production) and 2002. It highlights the processing challenges of two surveys with different acquisition parameters, provides a brief outline of the rock properties, and, finally, summarizes the interpretation results that provide important surveillance data for this billion-barrel field.

At Azeri-Chirag-Gunashli (ACG), seismic activities have focused on static and dynamic imaging of the reservoir to reduce risk for appraisal and development drilling. Imaging and reservoir characterization constrain the “static” reservoir model, and 4D reservoir monitoring constrains the “dynamic” reservoir model. Over the last several years we have successfully tested and implemented prestack depth migration, 4-C OBS acquisition and processing, and towed-streamer 4D in various parts of ACG. Results from these technologies are being used to shape the longer-term (20+ years) seismic strategy of the development—in particular, how 4D seismic surveillance should be implemented across ACG.

The growth in SEG membership outside the United States is strong and rapidly approaching 50% of the total membership. This is due in part to the Global Membership category, which in 2002 added 649 new members to the SEG roster. So far in 2003 another 280 Global Members have joined. Apache Oil Corporation is sponsoring the dues of the first 1000 Global Members (entitled to all the rights of a regular membership except for voting privileges and hard copy delivery of the journals).

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...

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.

[][1] I have been a part of the College for 45 of its 60 years. What has it meant for me? On my first visit to Princes Gate, I was introduced to Robin Pinsent and immediately invited to join the morning meeting of the extremely friendly and committed Research Committee. The agenda — basically the Oral Contraceptive study, the late-running results of the last National Morbidity Study and the plans for the next one — was much the same. When I joined the Committee a decade later. So was the camaraderie. Princes Gate was full of London doctors rushing in, changing the world, and rushing out. Those from abroad came for the day (or night); read the papers in the leather sofas, chatted to Margaret Hammond in the library, passed the time of day with James Wood, … [1]: /embed/graphic-1.gif

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 …

The authors describe how their participation in a doctoral-level career counseling practicum has influenced their perceptions of the relationship between career and personal counseling, attitudes toward career services, and career interventions skills.