Physiotherapists' perceptions on using a multidimensional clinical reasoning form during psychologically informed training for low back pain.

PURPOSE: Building clinical reasoning skills is important to effectively implement psychologically informed practice. We developed a multidimensional clinical reasoning form (CRF) to be used by physiotherapists in a psychologically informed practice training programme for low back pain. In this paper we describe the development of the CRF, how the CRF was used in the training, and present an evaluation of physiotherapists' perceptions of the CRF. METHODS: Qualitative semi-structured interviews were conducted with ten physiotherapists purposively sampled in primary care. Data were gathered through pre, and post training focus group interviews and a secondary analysis of individual physiotherapist interviews conducted after the training. Thematic analysis was used to analyse the data and capture the emergent themes. RESULTS: Two main themes emerged before the training: (1) the CRF 'needs formal training' and (2) 'lacked instruction'. Three main themes emerged after the training (1) it provided 'a helpful framework for multidimensional clinical reasoning' (2) the CRF, and accompanying operational definitions, helped physiotherapists 'elicit information, with 'question prompts' helpful in facilitating patient disclosure (3) 'Utility' - although the CRF was not formally used by the physiotherapists it provided a conceptual reasoning framework to work from with more challenging patients. CONCLUSION: The CRF was not designed to be used in isolation by clinicians without training. However, when used as a training adjunct it appears to be valued by physiotherapists to help develop their critical thinking and better characterise patients' presentations in order to personalise care from a bio-psychosocial perspective.

Analysis of communication styles underpinning clinical decision-making in cancer multidisciplinary team meetings.

Introduction: In cancer care, multidisciplinary team (MDT) meetings are the gold standard. While they are trying to maximize productivity on the back of the steadily increasing workload, growing cancer incidence, financial constraints, and staff shortages, concerns have been raised with regards to the quality of team output, as reported by Cancer Research UK in 2017: "Sometimes we discuss up to 70 patients. This is after a whole day of clinics, and we do not finish until after 19.00. Would you want to be number 70?". This study aimed to explore systematically some of the dynamics of group interaction and teamwork in MDT meetings. Materials and methods: This was a prospective observational study conducted across three MDTs/university hospitals in the United Kingdom. We video-recorded 30 weekly meetings where 822 patient cases were reviewed. A cross-section of the recordings was transcribed using the Jefferson notation system and analyzed using frequency counts (quantitative) and some principles of conversation analysis (qualitative). Results: We found that, across teams, surgeons were the most frequent initiators and responders of interactional sequences, speaking on average 47% of the time during case discussions. Cancer nurse specialists and coordinators were the least frequent initiators, with the former speaking 4% of the time and the latter speaking 1% of the time. We also found that the meetings had high levels of interactivity, with an initiator-responder ratio of 1:1.63, meaning that for every sequence of interactions initiated, the initiator received more than a single response. Lastly, we found that verbal dysfluencies (laughter, interruptions, and incomplete sentences) were more common in the second half of meetings, where a 45% increase in their frequency was observed. Discussion: Our findings highlight the importance of teamwork in planning MDT meetings, particularly with regard to Cancer Research UK in 2017 cognitive load/fatigue and decision-making, the hierarchy of clinical expertise, and the increased integration of patients' psychosocial information into MDT discussion and their perspectives. Utilizing a micro-level methodology, we highlight identifiable patterns of interaction among participants in MDT meetings and how these can be used to inform the optimization of teamwork.

A critical look at ideas, concerns and expectations in clinical communication.

BACKGROUND: For medical students and doctors, capturing the patient's perspective is critical if the consultation is to be meaningful for both parties. Medical students are taught the import of this in their communication skills training aided by inquiring into the patient's ideas, concerns and expectations (ICE) during the consultation. Ensuring the effectiveness of those inquiries can be a challenge for different reasons. Yet apart from a handful of papers on the subject, there is little guidance on the efficacy of ICE as a communication technique and specifically how to successfully blend questions about ICE within the interaction between doctor and patient. PROPOSAL: This paper takes a closer look at this communication technique and explores some of the interactional features of inquiries into ICE. First, the background to ICE and its emergence within the field of medical education is considered. Next the argument considers some of the contextual and pedagogical issues that inquiries into ICE gives rise to. The discussion then goes on to explore some conceptual underpinnings drawing on findings from Conversation Analysis, which provide some direction in approaching questions about what the patient thinks. Finally, the implications of the argument presented are considered in relation to the teaching and assessment of medical students with a short proposal for next steps. CONCLUSION: Capturing the patient's perspective through an exploration of their ideas, concerns and expectations remains a valuable approach in communication skills training in medical education. It is important, however, that ICE type inquiries are used carefully and responsively if they are to be used to improve communication with patients.

Physiotherapists' Approaches to Patients' Concerns in Back Pain Consultations Following a Psychologically Informed Training Program.

Guidelines advocate a combined physical and psychological approach to managing non-specific chronic low back pain (NSCLBP), referred to as psychologically informed practice (PIP). PIP is underpinned by patient-centered principles and skilled communication. Evidence suggests that a physiotherapist-focused style of communication prevails in physiotherapy. There is a recognized need for observational research to identify specific communication practices in physiotherapy interactions. This observational study explored the interactional negotiation of agenda setting following a PIP training intervention, by identifying and describing how physiotherapists solicit and respond to the agenda of concerns that patients with NSCLBP bring to primary care initial encounters. The research setting was primary care. Nineteen initial physiotherapy consultations were video-recorded, transcribed, and analyzed using conversation analysis, a qualitative observational method. These data revealed a patient-focused style of communication where trained physiotherapists demonstrated a collaborative and responsive style of verbal and nonverbal communication to solicit, explore, and validate patients' concerns.

Degrees of Multidisciplinarity Underpinning Care Planning for Patients with Cancer in Weekly Multidisciplinary Team Meetings: Conversation Analysis.

PURPOSE: Despite an increase in research on multidisciplinary team (MDT) meetings, the implementation of MDT-driven decision-making, ie, its fidelity, remains unstudied. We report fidelity using an observational protocol measuring degree to which MDTs in their weekly meetings in the UK adhere to 1) the stages of group decision-making as per the 'Orientation-Discussion-Decision-Implementation' framework, and 2) cancer guidelines on the composition and characteristics of their weekly meetings produced by the UK's Department of Health, UK's National Cancer Action Team, Cancer Research UK, World Health Organization, and The Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales. PATIENTS AND METHODS: This is a prospective cross-sectional observational study of MDT meetings in the UK. Breast, colorectal, and gynecological cancer MDTs across three hospitals in the UK were video recorded over 12 weekly meetings, respectively, encompassing 822 case-reviews. A cross-section of 24 case-reviews was analysed with the main outcomes being adherence to the 'Orientation-Discussion-Decision-Implementation' framework, and the cancer guidelines. RESULTS: Eight percent of case-reviews in the MDT meetings involved all five core disciplines including surgeons, oncologists, radiologists, histopathologists, and specialist cancer nurses, and 38% included four. The majority of case-reviews (54%) were between two (25%) or three (29%) disciplines only. Surgeons (83%) and oncologists (8%) most consistently engaged in all stages of decision-making. While all patients put forward for MDT meeting were actually reviewed, 4% of them either bypassed the orientation (case presentation), and 8% did not articulate the final decision to the entire team. CONCLUSION: We found that, despite being a set policy, cancer case-reviews in MDT meetings are not entirely MDT-driven, with more than half of the case-reviews not adhering to the cancer guidelines, and just over 10% not adhering to the group decision-making framework. The findings are in line with the UK recommendation on streamlining MDT meetings and could help decide how to re-organise the meetings to be most efficient. Implications are discussed in relation to quality and safety of care.

How do physiotherapists solicit and explore patients' concerns in back pain consultations: a conversation analytic approach.

Background: Guidelines advocate that non-specific chronic low back pain (NSCLBP) be considered within a multi-dimensional bio-psychosocial (BPS) framework. This BPS approach advocates incorporating the patient's perspective as part of the treatment process. 'Agenda setting' has been introduced as the key to understanding patients' concerns in medical encounters; however, this has received little attention in physiotherapy. This study explored how physiotherapists solicit and respond to the agenda of concerns that patients with NSCLBP bring to initial encounters. Method: The research setting was primary care. Twenty initial physiotherapy consultations were video-recorded, transcribed and analyzed using conversation analysis, a qualitative observational method. Both verbal and non-verbal features of the interaction were considered. Results: This data highlights a spectrum of communication styles ranging from more physiotherapist-focused, where the physiotherapists did not attend to patients' concerns, to a more patient-focused style, which provided greater opportunities for patients to voice their concerns. On occasions, patients were willing to pursue their own agenda when their concern was initially overlooked. Conclusion: This study provides empirical evidence on communication patterns in physiotherapy practice. A more collaborative style of communication with a shared conversational agenda provided patients with the conversational space to describe their concerns more fully.

Maximizing the acquisition of core communication skills at the start of medical training.

BACKGROUND: Clinical communication teaching for medical undergraduates may involve real patient contact alongside simulated patient (SP) contact. However, there is still comparatively little known about the experience of learning with real patients and how that may impact on the SP encounter. AIM: To explore the impact of real patient contact on the experience of communication skills training and SP contact for first-year medical undergraduate students. METHODS: As part of the 6-year MBBS undergraduate medical degree at Imperial College London, students are obliged to undertake communication skills training, which involves teaching with simulated and real patients. In 2017 (toward the end of formal teaching), a small sample of Year 1 medical students, who had taken part in extra-curricular teaching with real patients were recruited for the study to compare their performance with a control group in a SP encounter. The performance of both groups was analyzed alongside follow-up focus group data from a sample of the study group. RESULTS: Quantitative analysis revealed there was no significant difference in communication skills during a scored SP interview between students with real patient contact and those without. Focus group data, however, revealed valuable insights into the experience of learning with real patients. Students reported a marked increase in their confidence and ability to naturalize their communication skills as a result of real patient contact. Students also reported that skills gained through real patient contact may not always transfer easily to the SP setting. CONCLUSION: Real patient contact is an invaluable component of communication training for undergraduate medical students. For successful implementation, there needs to be a clear curricular purpose at pedagogical, practical and organizational levels. Students' experience of real patient contact can provide an informed foundation upon which to implement other modes of teaching.

The perspectives of physiotherapists on managing nonspecific low back pain following a training programme in cognitive functional therapy: A qualitative study.

BACKGROUND: It has long been acknowledged that nonspecific chronic low back pain (NSCLBP) is associated with a complex combination of biopsychosocial (BPS) factors, and recent guidelines advocate that the management of back pain should reflect this multidimensional complexity. Cognitive functional therapy (CFT) is a behaviourally oriented intervention that targets patients' individual BPS profiles. Although the efficacy of CFT has been demonstrated in primary care, little evidence exists about the training requirements of this approach. METHODS: Qualitative semistructured interviews were conducted with 10 physiotherapists working in primary care, who had undergone a formal training programme in CFT. A purposive sampling method was employed to seek the broadest perspectives. Thematic analysis was used to analyse the interview transcripts and capture the emergent themes. RESULTS: Five main themes emerged: (i) the learning challenge; (ii) self-reported changes in confidence; (iii) self-reported changes in communication practice; (iv) self-reported changes in attitudes and understanding; (v) the physiotherapists felt that CFT was more effective than their usual approach for NSCLBP but identified barriers to successful implementation, which included a lack of time and difficulties in engaging patients with strong biomedical beliefs. CONCLUSIONS: The study suggested that training in CFT has the capacity to produce self-reported changes in physiotherapists' attitudes, confidence and practice. The provision of such training has implications in terms of time and costs; however, this this may be warranted, given the physiotherapists' strong allegiance to the approach compared with their usual practice.

Perceptions of physiotherapists towards the management of non-specific chronic low back pain from a biopsychosocial perspective: A qualitative study.

BACKGROUND: Physiotherapists have been urged to embrace a patient-oriented biopsychosocial (BPS) framework for the management of non-specific chronic low back pain (NSCLBP). However, recent evidence suggests that providing broader BPS interventions demonstrates small differences in pain or disability compared to usual care. Little is known about how to integrate a BPS model into physiotherapy practice and the challenges it presents. OBJECTIVE: To explore the perceptions of physiotherapists' in primary care in England adopting a BPS approach to managing NSCLBP patients. METHOD: Qualitative semi-structured interviews were conducted with ten physiotherapists working in primary care. A purposive sampling method was employed to seek the broadest perspectives. Thematic analysis was used to analyse the interview transcripts and capture the emergent themes. RESULTS: Three main themes emerged: (1) physiotherapists recognised the multi-dimensional nature of NSCLBP and the need to manage the condition from a BPS perspective, (2) addressing psychological factors was viewed as challenging due to a lack of training and guidance, (3) engaging patients to self-manage their NSCLBP was seen as a key objective. CONCLUSION: Although employing a BPS approach is recognised by physiotherapists in the management of NSCLBP, this study highlights the problems of implementing evidence based guidelines recommending that psychological factors be addressed but providing limited support for this. It also supports the need to allocate more time to explore these domains in distressed individuals. Engaging patients to self-manage was seen as a key objective, which was not a straightforward process, requiring careful negotiation.

Does the delivery of diagnostic news affect the likelihood of whether or not patients ask questions about the results? A conversation analytical study.

BACKGROUND: Asymmetries in knowledge and competence in the medical encounter often mean that doctor-patient communication can be compromised. This study explores this issue and examines whether the likelihood of patient question asking is increased following the delivery of diagnostic test results. It also examines whether that likelihood is related to the way in which the test results are delivered. OBJECTIVE: To examine when and how patients initiate questions following diagnostic news announcements. METHODS: We audio-recorded oncology consultations (n = 47) consisting of both first consultations and follow-up consultations with patients with different types of cancer, at a leading UK teaching hospital. From the primary sample, we identified 30 consultations based on a basic count of the frequency of patient questions and their positioning in relation to diagnostic announcements. This subset of 30 consultations consisted of a mix of first and follow-up consultations. RESULTS: Our data demonstrate how the design and delivery of diagnostic news announcements can either discourage or provide the opportunity for a patient-initiated question in the next turn of talk. We identified two types of announcement. Q+ generally provided for a patient-initiated question as a relevant next turn following the news announcement, whereas Q- did not. Q+ was sometimes followed up with the explanation of test results, which appeared to encourage further patient questions. CONCLUSION: The design and delivery of diagnostic news announcements can make a patient-initiated question more or less appropriate, in the next turn of talk. In addition, showing and explaining test results can encourage further opportunities for patients' questions.

Peer tutoring in clinical communication teaching: the experience of 1st year students and their peer tutors.

This article was migrated. The article was marked as recommended. This study explored the impact of peer tutoring in Clinical Communication teaching as it was expressed in the views of Year 1 students and their Peer Tutors at Imperial College London. Methods: a mixed methods approach was used combining questionnaires and focus groups. Quantitative findings were analysed using SPSS v23 and qualitative findings were analysed using Framework Methodology. Results: the findings suggest a very positive experience for both Year 1 students and their Peer Tutors with the former reporting feeling supported to practice and improve on their Clinical Communication Skills in a collaborative environment, being taught and learning from peers who would share their past educational experiences. No significant differences were found between students taught by Peer Tutors and those taught by Course Tutors. Peer Tutors on the other hand, reported an equally positive experience, which gave them an insight into teaching, improved their leadership and feedback skills, enhanced their confidence and helped them reflect on their own Clinical Communication skills. Conclusion: peer tutoring has many advantages as an educational method in medical education and Clinical Communication teaching and should be promoted in medical curricula.

Wearable technologies in osteoarthritis: a qualitative study of clinicians' preferences.

OBJECTIVE: This study investigates clinicians' views of health-related wearable technologies in the context of supporting osteoarthritis (OA) long-term management. Clinicians' preferences are critical in identifying realistic implementation strategies for such technologies. DESIGN: Qualitative study incorporating an inductive thematic analysis applied to identify key themes from clinicians' responses. PARTICIPANTS: Clinicians, including 4 general practitioners, 4 physiotherapists and 5 orthopaedic surgeons were interviewed. SETTING: The study was conducted in a University setting. RESULTS: Participants all agreed wearable technologies could positively complement their role and enhance their relationship with patients. Perceived benefits of wearable technologies included monitoring patients' progress, treatment evaluation, monitoring compliance and informing clinical decision-making. The device should be designed to provide objective data of patients' locomotion capability in an easy and timely fashion via a simple interface. Data should be available to both clinicians and patients to provide them with the motivation to achieve clinical goals and allow them to take ownership of their treatment. The use of technology was also seen as a way to more effectively plan treatment and manage patients' contact time saving time and cost. CONCLUSIONS: Findings support the use of wearable technologies to enhance current OA management and suggest clinical uses. Adoption of technologies could have implications on the effectiveness of treatment provided overcoming current barriers, in particular compliance with treatment.

Surgical decision making in a teaching hospital: a linguistic analysis.

BACKGROUND: The aim of the study was to gain insight in the involvement of non-operating surgeons in intraoperative surgical decision making at a teaching hospital. The decision to proceed to clip and cut the cystic duct during laparoscopic cholecystectomy was investigated through direct observation of team work. METHOD: Eleven laparoscopic cholecystectomies performed by consultant surgeons and specialty trainees at a London teaching hospital were audio and video recorded. Talk among the surgical team was transcribed and subjected to linguistic analysis, in conjunction with observational analysis of the video material, sequentially marking the unfolding operation. RESULTS: Two components of decision making were identified, participation and rationalization. Participation refers to the degree to which agreement was sought within the surgical team prior to clipping the cystic duct. Rationalization refers to the degree to which the evidential grounds for clipping and cutting were verbalized. CONCLUSION: The decision to clip and cut the cystic duct was jointly made by members of the surgical team, rather than a solitary surgeon in the majority of cases, involving verbal explication of clinical reasoning and verbal agreement. The extent of joint decision making appears to have been mitigated by two factors: trainee's level of training and duration of the case.

Learning about maternal death and grief in the profession: a pilot qualitative study.

INTRODUCTION: The aim of this study was to explore the impact of maternal death on maternity professionals, and their related professional and personal needs. MATERIAL AND METHODS: A qualitative study comprising semi-structured interviews in a UK inner-city academic maternity unit with over 5000 deliveries annually. Purposive sampling was utilized and semi-structured face-to-face interviews were performed with 14 healthcare professionals: four midwives, five doctors in training grades (trainees) and five consultant obstetricians. Identification of key themes was derived by textual analysis. RESULTS: Five main themes were identified: professional culture, organizational culture and external expectation; personal blame and debriefing; professional training; shaping the training; support and counseling. Maternal death has a major impact on professionals' feelings of grief, guilt and shame, which they are reluctant to talk about. Maternity professionals expressed a desire for training to prepare themselves to respond effectively in the event of maternal death. There was ambiguity about "debriefing" within a changing institutional culture. CONCLUSIONS: Maternal death is a devastating consequence of pregnancy. If these findings are replicated by interviewing a greater number and breadth of maternity professionals, then healthcare institutions need to develop appropriate training to prepare and help staff, which should improve the support they can give to the bereaved and to each other.

Patients' experiences of an initial consultation in oncology: knowing and not knowing.

OBJECTIVES: The aim of this paper was to explore how patients experience an initial oncology consultation. This study was part of a larger mixed methods research project designed to address the issue of improving communication and enhancing patient satisfaction with oncology consultations. DESIGN: Interpretive phenomenological analysis was used to interpret the participants' meanings of their experiences in their initial consultation. It is an idiographic approach that focuses in depth on a small set of cases in order to explore how individuals make sense of a similar experience. This retains the complexity and diversity of experiences. METHODS: In the larger study, semi-structured interviews were carried out with 36 patients as soon as possible after a consultation in oncology to explore their experiences. Five cases were selected for this study on the basis of homogeneity; they had all undergone some prior investigations of their illness, and this was their first consultation in oncology; they all provided rich accounts relating to how they had experienced the consultation. RESULTS: Patients' experiences of being given their diagnosis differed both between participants and within the same participant. Various defences seemed to be used in order to protect them from fully engaging with the knowledge they were given. Their accounts of what they wished to know in the consultation could be affected by a desire to protect themselves and/or family members from distress and by the practical need to know that may vary over time. CONCLUSION: The complexity of patients' needs and preferences regarding information means that the doctor's role in communicating that information in a patient-centred way is difficult. The findings are discussed in relation to open awareness theory as to how the emotional context of the consultation process affects information needs. Doctors need strategies to elicit information from patients about their needs from the consultation. This needs to be done at the start of consultations and throughout investigations and treatment, as needs may change over time. Statement of contribution What is already known on this subject? Patients' desire to know information is sometimes tempered with by a desire to avoid distress to themselves. Patients do not always understand or make accurate sense of what they have been told. Receiving a diagnosis of cancer is distressing for patients. What does this study add? Doctors need strategies to elicit information from patients about their needs for each consultation. This needs to be done consistently throughout the patient journey as needs may change over time. Patients control what they do or do not do with information but do not openly share this with the doctor. Our interpretations of the interviews stray beyond the conscious accounts of the consultations and draw on (unconscious) absences that may also be of significance in making sense of overall experience. The complexity of patients' needs and preferences regarding information means that the doctors' role is very difficult. Patients have a right to know but not a duty to know their diagnosis and prognosis.

Limited impact on patient experience of access of a pay for performance scheme in England in the first year.

BACKGROUND: Improvement of access to general practice is a priority in England. In 2006/07 an annual national survey of patient experience of access was introduced, with financial incentives to practices based on the findings of the survey among their own patients. OBJECTIVES: To describe changes in patient experience of access over the first two years of the survey and incentive scheme, and identify respondent and practice characteristics associated with patient experience of access. DESIGN AND METHODS: The study included 222 general practices in the east of England, which had completed the access survey in 2006/07 and 2007/08. We compared proportions of patients reporting satisfaction with different aspects of access in each year. In explanatory regression models, we investigated the associations between improvement of reported access and respondent and practice characteristics. RESULTS: There were some small improvements in reported access between the two surveys, although satisfaction with opening hours declined marginally. The explanatory analysis showed that larger practices, a higher proportion of respondents from ethnic minority groups, and higher deprivation were associated with patient reports of worse access. These variables and practice response rates did not explain the amount of change between the two years. CONCLUSIONS: The launch of the incentive scheme was not followed by convincing improvements in patient experience of access. Practices with deprived populations or with a high proportion of ethnic minority survey respondents are perceived as offering worse access, were not more likely to achieve improvements, and additional support should be considered to help these practices.

Management of smokers motivated to quit: a qualitative study of smokers and GPs.

BACKGROUND: The National Institute for Health and Clinical Excellence (NICE) guidelines state that GPs should manage smokers motivated to quit by offering referral to Stop Smoking Services (SSS) and that nicotine addiction treatment (NAT) should be offered only to those who decline referral. OBJECTIVE: To explore how smokers motivated to quit are managed in the GP consultation, specifically how treatment and referral are negotiated from the perspectives of both parties. METHODS: Twenty patients, identified in a consultation with their GP as motivated to quit smoking, and 10 participating GPs were interviewed. Interviews were recorded, transcribed, coded and analysed using the framework approach. RESULTS: Three strategies (treatment and follow-up by the GP, referral to SSS without treatment and immediate treatment with referral for follow-up) were evidenced in patient and GP accounts. Most patients were satisfied with their management and how this was negotiated, but some expressed surprise or dissatisfaction with lack of immediate treatment and questioned the need for referral to SSS. GPs welcomed the availability of SSS but some felt it important that they themselves also continued to support a quit attempt. Several saw advantages in offering NAT at the time the patient was motivated to stop. CONCLUSIONS: Smokers appear less convinced than GPs about the value of referral to SSS, although these differences may be resolved through negotiation. An alternative strategy to that proposed by NICE, which may be more acceptable to some smokers, is immediate treatment with subsequent support from SSS.

Do the Quality and Outcomes Framework patient experience indicators reward practices that offer improved access?

BACKGROUND: The Quality and Outcomes Framework (QOF) includes indicators for patient experience, but there has been little research on whether the indicators identify practices that deliver good patient access. AIM: To determine whether practices that achieved high QOF patient experience points in 2005/2006 or 2006/2007 also delivered good patient access. DESIGN OF STUDY: Use of publicly available data to investigate two hypotheses: practices with more positive access survey findings in 2006/2007 will be more likely to have achieved maximum QOF patient experience points in the same year; and practices with maximum QOF patient experience points in 2005/2006 will have higher access survey findings in 2006/2007. SETTING: Two-hundred and twenty-four East Midlands general practices. METHOD: For hypothesis one, binary logistic regression was used, with achievement of maximum QOF points as the dependent variable, and access survey findings, responder variables, and practice variables as independent variables. For hypothesis two, general linear models were used, with access survey findings as the independent variables, and achievement of maximum QOF points and the responder and practice variables as dependent variables. RESULTS: The findings did not support the first hypothesis. For the second hypothesis, achievement of maximum QOF points was only significantly associated with patient satisfaction with opening hours (positive correlation). QOF points were not associated with any other aspect of access. CONCLUSION: The QOF patient experience indicators do not reward practices that offer good patient access. A standard patient survey with financial incentive may be more effective in identifying and rewarding practices that offer better access, including opportunity to book appointments with a particular doctor.