Developing a 'consultation quality index' (CQI) for use in general practice.

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.

Quality at general practice consultations: cross sectional survey.

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). Doctors' 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.

Reducing consultations for symptoms of cystitis using a health education leaflet.

This study aims to evaluate the effects of a health education leaflet on the number of general practice consultations for the symptoms of cystitis. Seventy women with symptoms of cystitis were recruited into two groups, only one group received health education leaflets. Twenty-nine per cent of patients who received leaflets re-consulted within 40 weeks from presentation compared with 66% of patients who did not receive leaflets (P < 0.005).

A comparison of a Patient Enablement Instrument (PEI) against two established satisfaction scales as an outcome measure of primary care consultations.

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.

A comparison of three methods of setting prescribing budgets, using data derived from defined daily dose analyses of historic patterns of use.

BACKGROUND: Prescribing matters (particularly budget setting and research into prescribing variation between doctors) have been handicapped by the absence of credible measures of the volume of drugs prescribed. AIM: To use the defined daily dose (DDD) method to study variation in the volume and cost of drugs prescribed across the seven main British National Formulary (BNF) chapters with a view to comparing different methods of setting prescribing budgets. METHOD: Study of one year of prescribing statistics from all 129 general practices in Lothian, covering 808,059 patients: analyses of prescribing statistics for 1995 to define volume and cost/volume of prescribing for one year for 10 groups of practices defined by the age and deprivation status of their patients, for seven BNF chapters; creation of prescribing budgets for 1996 for each individual practice based on the use of target volume and cost statistics; comparison of 1996 DDD-based budgets with those set using the conventional historical approach; and comparison of DDD-based budgets with budgets set using a capitation-based formula derived from local cost/patient information. RESULTS: The volume of drugs prescribed was affected by the age structure of the practices in BNF Chapters 1 (gastrointestinal), 2 (cardiovascular), and 6 (endocrine), and by deprivation structure for BNF Chapters 3 (respiratory) and 4 (central nervous system). Costs per DDD in the major BNF chapters were largely independent of age, deprivation structure, or fundholding status. Capitation and DDD-based budgets were similar to each other, but both differed substantially from historic budgets. One practice in seven gained or lost more than 100,000 Pounds per annum using DDD or capitation budgets compared with historic budgets. The DDD-based budget, but not the capitation-based budget, can be used to set volume-specific prescribing targets. CONCLUSIONS: DDD-based and capitation-based prescribing budgets can be set using a simple explanatory model and generalizable methods. In this study, both differed substantially from historic budgets. DDD budgets could be created to accommodate new prescribing strategies and raised or lowered to reflect local intentions to alter overall prescribing volume or cost targets. We recommend that future work on setting budgets and researching prescribing variations should be based on DDD statistics.

Measuring quality in general practice. Pilot study of a needs, process and outcome measure.

1. As part of the Scottish Shadow Fundholding Evaluation (1990-92), quality of care was assessed in 6 practices with 49 general practitioners using a pre-consultation health needs questionnaire, consultation length as a process measure (previously shown to be a proxy measure for quality) and a post-consultation satisfaction/outcome measure which contained a subset of six questions assessing whether patients felt enabled by their consultation. This report describes secondary analysis of the available dataset undertaken to explore whether the approach used to evaluate quality of care for patients with specific clinical problems could be extended to the generality of general practice consultations. 2. Chapters 1 and 2 of the report describe earlier work developing both the concepts and instruments used in the Shadow Evaluation, and general findings already reported. The reliability and the construct validity of the measure of enablement are examined and found to be satisfactory. 3. Strong correlations between more time at consultations and more enablement for more patients are found at population level for patients with psychological problems, with social problems and with physical problems. More complex problems require more time to achieve equal benefit. 4. Mean consultation length and mean enablement score correlate well with each other and can be used as summary statistics of quality. Where trends require explanation or exploration, other measures of the use of time and the level of benefit gained are more helpful; both sets of analyses can be derived from the same datasets (Chapter 3). 5. Analyses at practice level show that practices which spend more time at consultations enable patients more whatever the nature of problems presented. The rank orders of time spent at consultation and of enablement are highly correlated (Chapter 4). 6. Analyses at doctor level show that doctors who spend more time at consultations enable patients more and that those who spend less time enable patients less. The numbers of patients available for study were not sufficient to explore this association within subgroups of clinical presentations. As in previous studies, we found that doctors who take longer time are likely to be more patient centred, and those who take less time are likely to be less patient centred. Case-mix varies between doctors, but seems to be independent of whether a doctor is more or less patient centred (Chapter 5). 7. The methods developed in this study give useful insights into the definition and delivery of quality of care in general practice (Chapter 6). The measures now need to be tested in different clinical, cultural and organizational settings and results compared with those found using routinely available NHS data on prescribing and achievement of other clinical and management targets (Chapter 7).

Addressing the credibility gap in general practice research: better theory; more feeling; less strategy.

A substantial international network of general practice researchers has grown up over the past 30 years, and the literature of the discipline is now extensive and diverse. Nevertheless, there is considerable ambivalence within the profession about what research can offer, where its weight should be being put and how best the opportunities its insights create can be taken advantage of. The sometimes disappointingly low credibility of research and researchers needs to be addressed. The issues of the adequacy of underlying 'theory' and of ownership of research agendas may contain the basis of a way forward.

Care of patients with selected health problems in fundholding practices in Scotland in 1990 and 1992: needs, process and outcome.

BACKGROUND: At the time of the introduction of fundholding, a number of potential benefits and concerns about fundholding were debated. AIM: A study was undertaken to compare process and outcome of care in patients with different levels of physical, social and psychological need in 1990 and 1992 in six fundholding groups in Scotland. METHOD: Patients aged 16 years and over consulting with a range of marker conditions in 1990 and 1992 completed a pre-consultation health status questionnaire asking about physical, social and psychological problems, and a postconsultation satisfaction/enablement questionnaire asking about their ability to cope, and understand their illness. Main outcome measures were consultation length and satisfaction/enablement score. RESULTS: Of patients attending in the study period, 39% consulted for one or more marker condition. The proportion of patients reporting social problems rose between 1990 and 1992 for 11 out of 12 conditions. Overall, consultation lengths remained constant. Patients wanting to discuss social problems had significantly longer consultations than those reporting no social problems or problems they did not wish to discuss. The proportion of patients expressing enablement dropped for eight conditions and rose for four between 1990 and 1992. The decrease in the proportion expressing enablement remained after controlling for the rise in the percentage reporting social problems. Patients who had social problems they did not wish to discuss but a general health questionnaire score of five or more were the group reporting lowest enablement. Significantly more patients with pain, skin problems and digestive problems reported social problems and significantly fewer of them reported enablement in 1992 compared with 1990. Patients with diabetes, angina, chronic bronchitis and problems seeing fared relatively well over the study period. Some patients with psychosocial problems fared poorly (they had relatively short consultations and were unlikely to express an ability to cope/understand their illness). CONCLUSION: The issue of whether benefits to some patient groups from recent health service changes may be matched by disadvantage to other groups, for example those with clinical problems with no financial incentive to provide pro-active care or with psychosocial difficulties, is discussed.

Use of videotaped consultations in summative assessment of trainees in general practice.

BACKGROUND: There are many different methods by which trainees may be assessed summatively. AIM: The objective of the study was to determine if videotaped consultations could be used to identify reliably those general practitioner trainees who have not yet reached acceptable levels of competence. METHOD: Videotapes of 10 trainees carrying out normal consultations were assessed by 20 assessors for acceptable competence using a rating scale specifically developed for the purpose. RESULTS: A principal components analysis showed a strong correlation among the items in the rating scale used, indicating that a single underlying factor accounted for 76% of the overall scores. Agreement between assessors on the scoring of individual consultations was limited. There was much greater consistency with regard to the decision on overall competence, examined for the first consultation. A non-competent trainee would have a 95% probability of being identified by the process as described using two assessors for each videotape. The assessors had reached firm judgements on each trainee by the time four consultations had been viewed. CONCLUSION: The workload involved in producing and analysing the tapes is discussed. Considerations of patient consent are addressed. It is concluded that the use of videotaped consultations appears to offer a feasible and reliable method of summative assessment of general practitioner trainees.

Research in general practice: international problems--international solutions.

Although research in primary care has a higher profile than ever before, its impact on professional practice and on government planning often seems less than it should be. In the first part of the paper, the different research agendas of governments, health departments, professional associations and colleges, and of universities are explored. In the second part of the paper a research project which attempts to define and measure quality of care given to patients with a 'marker' health problem (arthritic pain) is developed from the stage of asking questions to interpreting findings. In the third part of the paper, a number of conflicts between research agendas, styles of research, and needs and expectations of different 'purchasers' and 'providers' are explored using the themes and the details of the earlier parts of the paper as illustration, and a model is constructed to help explain why research, practice and policy making often live less easily together than is good for each. The importance of creating a supportive climate for research, of providing adequate infrastructure, and of making appropriate training available is emphasized.

Evaluating care of patients reporting pain in fundholding practices.

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.

General practice fundholding: observations on prescribing patterns and costs using the defined daily dose method.

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.

Summative assessment: a pilot project in the west of Scotland.

In the autumn of 1991 the Committee in General Practice of the west of Scotland region appointed a working party to investigate the possibility of developing a credible, valid and reliable programme of summative assessment for general practitioner trainees. The working group formulated a four-part package consisting of a multiple true-false paper, a trainee audit project, the trainers' judgement, and analysis of videotaped consultations. The reasons for the use of this selection of methods are discussed. It is suggested that a summative assessment process for trainees should make use of the trainers' considerable knowledge of the trainee, have an external component, be criterion referenced, have an element of continuous assessment, and involve direct assessment of clinical competence. A pilot study of assessment of clinical competence using videotapes of routine trainee consultations by 25 volunteer general practitioner assessors is described. A rating instrument for use in differentiating the competent from the not yet competent trainee is discussed. The working group and the group of videotape assessors came to the provisional conclusion that the use of videotaped consultations may be a valid and feasible method of assessing the competence of general practitioner trainees as part of a balanced summative assessment programme.

The universities' research assessment exercise 1992: a second opinion.

We compared assessments of university departments of general practice by the heads of department with those of The UK University Funding Council. There was little difference between them. The departmental heads' assessment was quicker and cheaper. Current means of assessing academic departments may need to be reconsidered.

The need for another look at the patient in general practice satisfaction surveys.

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)

The chief scientist reports ... Evaluation of the Scottish shadow fund-holding project: first results.

This paper reports preliminary findings from the action research evaluation of the Scottish shadow fund-holding project. Fifty doctors looking after 84,000 patients in six groups negotiated and managed a paper fund for six months, and then a real fund for six months. First analyses of quantitative data suggest that the numbers of prescriptions written, investigations done and referrals made remained stable over the period of study. The length of time spent at consultations varied apparently independently of holding a fund. Patient satisfaction with actions taken by doctors and their feelings of benefit from consultations were high throughout the study, but a consistent and significant shift from very satisfied to satisfied categories was noted in all practices for most variables surveyed during the course of 1990-91. Analyses to explain this are continuing. Qualitative study identified benefits in terms of a greater understanding of the costs of activities, and new working patterns between hospital, general practice and administrative staff have led to progressive work in contracting for quality of patient care. At the same time, the lack of sophistication of fund setting needs to be addressed; equity issues will become relevant as fund-holding reaches a larger proportion of practices. The pressures on those taking leading roles in administration are high, and this is confirmed by parallel quantitative work. Further information is becoming available on both prescribing and the care of selected 'marker' conditions, and these will be the subject of further reports.

The chief scientist reports ... The Scottish general practice shadow fund-holding project--outline of an evaluation.

After the agreement in January 1989 between the Minister of Health at the Scottish Office, Mr Michael Forsyth, and six groups of General Practitioners (GPs) in the Grampian and Tayside Regions of Scotland to embark on a 'shadow fund-holding' project, the Government agreed to promote an independent evaluation of the scheme. As a result, the Department of General Practice at Edinburgh University was invited to present plans to evaluate the working of and results of the scheme. Consultations with the Minister and Health Department officials, the general practices concerned, and staff of the two Health Boards involved took place during the first three months of 1990, and an outline protocol for the evaluation was approved and funded through the Chief Scientist Organisation for a three-year period from April 1990. It was agreed by all involved that piecemeal publications of results during the period of the research would be inappropriate, but with other attempts to evaluate fund-holding now being reported elsewhere in the UK, it has been agreed that an outline of issues being explored and the methods being used would be in the general interest. This paper first outlines the principal areas in which the evaluation is being focused, then describes the general methods being used, and finally comments on some of the problems encountered with the evaluation. The project should be seen as a descriptive beginning to what may well be a period of around a decade needed to appreciate the full implications of any major change in the organisation of health service provision.

Changes resulting from increasing appointment length: practical and theoretical issues.

The experience of one urban teaching practice in changing its appointment length from 7.5 to 10.0 minutes is described. Observed benefits to patients attending routine surgeries included an increased consultation time (mean 8.6 minutes before, 9.1 minutes after) and reduced waiting time (mean 19.1 minutes compared with 14.6 minutes). Overall, workload was unchanged but improving the 'fit' between supply and demand was associated with loss of flexibility--a greater number of extra patients required to be seen, apparently because fewer appointments were available at the start of each day. Waiting and consultation times in teaching surgeries and trainee surgeries (booked throughout at 10.0 minute intervals) were unchanged in response to the new arrangements. The changes introduced were well received by medical and reception staff although their response was not formally measured. Planning the organization of an appointment system requires several distinct decisions to be made. The preferred or actual average length of consultations has to be decided and booking arrangements designed to enable this to take place without the doctors persistently running over time. The number of appointments per week required to meet anticipated demand has to be calculated on the basis of list size and expected annual consultation rate. However, an exact fit between supply and demand will lead to congestion of the system and it appears that flexibility in the form of an overprovision of appointments to projected demand of about 120% should be built in. Sufficient vacant slots must be provided at the start of each day to allow sufficient flexibility to avoid excessive numbers of patients having to be accommodated.(ABSTRACT TRUNCATED AT 250 WORDS)