Nadia Llanwarne

Relationship Between Clinical Quality and Patient Experience: Analysis of Data From the English Quality and Outcomes Framework and the National GP Patient Survey

PURPOSE Clinical quality and patient experience are both widely used to evaluate the quality of health care, but the relationship between these 2 domains remains uncertain. The aim of this study was to examine this relationship using data from 2 established measures of quality in primary care in England. METHODS Practice-level analyses (N = 7,759 practices in England) were conducted on measures of patient experience from the national General Practice Patient Survey (GPPS), and measures of clinical quality from the national pay-for-performance scheme (Quality and Outcomes Framework). Spearman’s rank correlation and multiple linear regression were used on practice-level estimates. RESULTS Although all the correlations between clinical quality summary scores and patient survey scores are positive, and most are statistically significant, the strength of the associations was weak, with the highest correlation coefficient reaching 0.18, and more than one-half were 0.11 or less. Correlations with clinical quality were highest for patient-reported access scores (telephone access 0.16, availability of urgent appointments 0.15, ability to book ahead 0.18, ability to see preferred doctor 0.17) and overall satisfaction (0.15). CONCLUSION Although there are associations between clinical quality and measures of patient experience, the 2 domains of care quality remain predominantly distinct. The strongest correlations are observed between practice clinical quality and practice access, with very low correlations between clinical quality and interpersonal aspects of care. The quality of clinical care and the quality of interpersonal care should be considered separately to give an overall assessment of medical care.

Rating Communication in GP Consultations: The Association Between Ratings Made by Patients and Trained Clinical Raters

Patient evaluations of physician communication are widely used, but we know little about how these relate to professionally agreed norms of communication quality. We report an investigation into the association between patient assessments of communication quality and an observer-rated measure of communication competence. Consent was obtained to video record consultations with Family Practitioners in England, following which patients rated the physician’s communication skills. A sample of consultation videos was subsequently evaluated by trained clinical raters using an instrument derived from the Calgary-Cambridge guide to the medical interview. Consultations scored highly for communication by clinical raters were also scored highly by patients. However, when clinical raters judged communication to be of lower quality, patient scores ranged from “poor” to “very good.” Some patients may be inhibited from rating poor communication negatively. Patient evaluations can be useful for measuring relative performance of physicians’ communication skills, but absolute scores should be interpreted with caution.

Quality improvement in general practice

Quality improvement describes the process of improving patients’ safety, experiences and health outcomes by systematically addressing individual and organisational processes. This is aimed at creating a ‘self-improving NHS’, in which individual clinicians are empowered to make changes toward a more efficient, safe and cost-effective healthcare system that is readily able to respond to patients’ needs. Improvement science is increasingly recognised as a central component to healthcare, and with general practice taking on added responsibility for the healthcare budget, it is essential that our training addresses aspects of healthcare organisation and improvements. This article offers a summary for AITs and GPs to further their understanding of improvement science. It provides some useful methods to facilitate the delivery of change in the GP surgery.

Prescribing for ADHD in primary care

Attention deficit hyperactivity disorder (ADHD) is the name given to a condition characterised by inattention, hyperactivity, and impulsivity. Although there are many historical descriptions of these behaviours in children,1 definitions of ADHD as a disease emerged in the 1980s, when the practice of classifying mental disorders became popular and the DSM-III and ICD-9 diagnostic systems shifted the scientific focus on mental illness from aetiological debates to finding practical and reliable disease descriptions. The term ADHD, drawn from the DSM-III, was initially used only in North America. In Europe, the term ‘hyperkinetic disorder’ was used and was initially reserved only for the most severe cases. The broader definition afforded by the DSM eventually led to a corresponding rise in diagnosis rates in Europe, although they were still dwarfed by the much higher rates seen in the US. This historic diversion in practice has been partly explained by differing diagnostic criteria, but also by the power of the pharmaceutical industry, advocacy groups, and the internet.2 A comprehensive 2015 meta-analysis included 175 ADHD prevalence studies and suggested an overall pooled estimate of 7.2%, although few included studies were from outside of Europe and North America.3 Prescribing rates are naturally closely linked to prevalence and have also received much attention. A 2016 study explored prescribing patterns of ADHD drugs in children in the UK using primary care records, finding a dramatic increase in use from 1992 until around 2008, with stable levels of use since then.4 Indeed, ADHD drug use in children aged <16 years increased a staggering 34-fold overall in that 16-year period. The steadying of prevalence in …

The evaluation of physicians’ communication skills from multiple perspectives

PURPOSE To examine how family physicians’, patients’, and trained clinical raters’ assessments of physician-patient communication compare by analysis of individual appointments. METHODS Analysis of survey data from patients attending face-to-face appointments with 45 family physicians at 13 practices in England. Immediately post-appointment, patients and physicians independently completed a questionnaire including 7 items assessing communication quality. A sample of videotaped appointments was assessed by trained clinical raters, using the same 7 communication items. Patient, physician, and rater communication scores were compared using correlation coefficients. RESULTS Included were 503 physician-patient pairs; of those, 55 appointments were also evaluated by trained clinical raters. Physicians scored themselves, on average, lower than patients (mean physician score 74.5; mean patient score 94.4); 63.4% (319) of patient-reported scores were the maximum of 100. The mean of rater scores from 55 appointments was 57.3. There was a near-zero correlation coefficient between physician-reported and patient-reported communication scores (0.009, P = .854), and between physician-reported and trained rater-reported communication scores (−0.006, P = .69). There was a moderate and statistically significant association, however, between patient and trained-rater scores (0.35, P = .042). CONCLUSIONS The lack of correlation between physician scores and those of others indicates that physicians’ perceptions of good communication during their appointments may differ from those of external peer raters and patients. Physicians may not be aware of how patients experience their communication practices; peer assessment of communication skills is an important approach in identifying areas for improvement.

A short journey of immersion in Italian general practice

What an enriching experience this fortnight in Rome has been. I have spent time observing general practice clinics, visits to housebound patients, internal medicine consultations, and the practice of an alternative, holistic approach to the management of common ailments. I worked with Dr E, a GP who completed her training last December and who works as the Italian equivalent of a ‘portfolio GP’. Local GPs employ Dr E to look after their housebound patients. She is also involved in teaching on the GP training programme in Rome and works privately from home, practising what she calls ‘lifestyle medicine’. This is an alternative, holistic approach comprising Goshinken and meditation. Dr E put me in touch with the delightfully welcoming Dr G, a GP in Rome for 35 years, and I spent a considerable chunk of my exchange in clinics with Dr G and his wife Dr M. They have two consulting studios, just 200 yards apart. Both are tucked away in residential apartment blocks. One is comprised of two rooms: a waiting room with a reception desk in the corner and a consulting room. The other is more spacious, enabling Dr G and his wife to consult at the same time from two consulting rooms linked by a long corridor to the waiting room, a bathroom and, at the end of the corridor, a small reception room with the secretary’s desk. This is very different from the spacious and multistaffed health centres to which I have become accustomed in the UK. Single-handed practices located in residential blocks are the norm in Rome. In this respect, Dr G and his wife, who have worked together for several decades, are actually unusual. They employ just two members of staff, a secretary at each practice. The first few consultations I observed felt, apart from the intellectual effort required to follow the consultation in Italian, remarkably familiar: back pain, renal stones, an ongoing cough, and a sick note request. The room set-up, however, was different: the doctor sat majestically behind an old oak desk, surrounded by numerous drug boxes enthusiastically donated during daily visits from pharmaceutical ‘reps’. I heard several conversations about the therapeutic superiority of branded over generic medicines. Dr E confirmed my suspicions of a widespread belief in such therapeutic superiority in Italy. Apparently, the healthcare organisations are trying to dispel such myths, but deepseated convictions are hard to shift. I wonder what the Care Quality Commission would make of the cluttered shelves and crowded desk space I witnessed. The communication style in consultations seemed more forthright and didactic than that of contemporary English general practice. Was it the desk arrangement that created this impression? Or was it the Italian manner, more outspoken than the English attempt at awkward diplomacy? Or simply that both Dr G and Dr M knew all their patients so well? ‘You must have the camera test; it has been 4 years since the last one!’ Dr M exclaimed to a 65-year-old patient presenting with epigastric pain and expressing fear at the prospect of a further gastroscopy. Both doctors clearly demonstrated a fine relationship with their patients. Consultations were peppered with informal discussions about family members and personal achievements, and the patients spontaneously voiced their affection for the doctors: ‘He has been my GP since I was nine’, a 43-year-old policeman with knee pain proudly announced. With both doctors working full-time, worries about relational continuity did not feature. Dr M has a list of 1500 patients, Dr G of 1000 patients. He cannot take on more patients because of his additional responsibilities as an occupational physician in local hospitals, supermarkets and schools. The government pays the doctors a monthly sum to run their practice, which is dependent on the number of patients registered. There are some small additional payments for activities such as the influenza vaccination programme. Last year, Dr G and Dr M administered over 500 vaccinations. In the absence of nurses, procedures such as ECGs, spirometry and vaccines are carried out by the doctors. I asked Dr E about ‘patient-centred care’ and ‘shared decisionmaking’, of which I had seen little evidence in consultations. Dr E smiled and said, ‘We are starting to think about it but it is not