BMJ 1999;319:738-743 ( 18 September )

General Practice

Quality at general practice consultations: cross sectional survey

John G R Howie, professor, a David J Heaney, research fellow, a Margaret Maxwell, research fellow, a Jeremy J Walker, research fellow, a George K Freeman, professor, b Harbinder Rai, research assistant. b

a Department of Community Health Sciences-General Practice, University of Edinburgh, Edinburgh EH8 9DX, b Department of Primary Health Care and General Practice, Imperial College School of Medicine, Chelsea and Westminster Hospital, London SW10 9NH

Correspondence to: J G R Howie John.Howie{at}ed.ac.uk

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.


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




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Rapid Responses:

Read all Rapid Responses

Time may not lead to quality
Daniel Kremer
bmj.com, 3 Oct 1999 [Full text]
Is enablement enough?
Laura E H Booth
bmj.com, 7 Oct 1999 [Full text]
Re: Time may not lead to quality
David Heaney
bmj.com, 20 Nov 1999 [Full text]
Re: Is enablement enough?
David Heaney
bmj.com, 20 Nov 1999 [Full text]
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