Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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More information please
- Mark Pasola (28 June 2002)
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Is the high referral rate of NHS direct a cause for concern?
- john sharvill (1 July 2002)
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Performance anxiety
- T Elwyn Davies (2 July 2002)
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lies
- douglas salmon (4 July 2002)
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Was there really variation among scenarios?
- Adam Jacobs (9 July 2002)
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Only to be expected
- Andrew J Cave (9 July 2002)
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Continuity of care ignored
- Peter C. Arnold (23 July 2002)
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Mark Pasola, General Practitioner Borough Green Medical Practice, Quarry Hill Road, Borough Green, Kent TN15 8RQ
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This is interesting work. May we please know the details of the checklist of essential actions against which the various services were judged? |
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john sharvill, GP Deal Kent Ct14 7 AU
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The main aim of this research appears to have been that Walk in centres are safe. However the main conclusions should include that NHS direct refers on 80% of its calls after a considerable time in getting through and then 14 minutes in consultation.Does this not need some explanation? John Sharvill |
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T Elwyn Davies, GP Principal Cheddar Medical Centre, Roynon Way, Cheddar, BS27 3NZ
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EDITOR - In their comparison of quality in different primary care settings, Grant et al offer a cautious comentary on their study design and reach the fairly modest conclusion that walk-in centres provide adequate and safe care when matched to general practice. They emphasise their findings do not imply care in general practice is inferior to walk-in centres and point out that performance on checklists may not reflect competence as a clinician. All of this being so, the decision to head the 'This week in the BMJ' digest 'Walk-in centres outperform GPs' seems somewhat curious. Check lists are a means of imposing simplified structures on highly complex settings. They measure adherence to the agreed simplification. It should surprise no one that walk-in centres, which rely on the explicit use of protocols to simplify health care, should perform better on checklists than general practice, which may well be subject to quite different influences. Whether one system is ultimately 'outperforming' the other is a matter for continuing research, but is certainly not answered by this paper, which in its use of standardised patients cannot address key determinants of quality such as patient satisfaction, the furtherance of good relations between carer and patient, and the crucial issue of whether a patient actually gets better. Dr Elwyn Davies
Competing interests: practising GP |
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douglas salmon, partner Birmingham B20 3 HE
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this study involved the recruiting and training of individuals with the deliberate and pre-meditated intent of lying to healthcare workers, about fictional symptoms, within the context of a medical consultation. Is lying to doctors ethical ? |
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Adam Jacobs, Director Dianthus Medical Limited, London SW19 3TZ
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Grant et al tell us that there was considerable variation among the clinical scenarios they used to compare walk-in centres with general practice and NHS direct. They conclude that walk-in centres were better than general practice for postcoital contraception and asthma, but not for sinusitis, headache, or chest pain. Unfortunately, they do not present the necessary statistical results to support that conclusion. If we are to believe that the difference between walk-in centres and general practice depends on the clinical scenario, then we need to see the results of the interaction test between setting and scenario in the statistical model that Grant et al used. We are told that they included the interaction term in the model, but are not given the results. Were the interactions significant? If so, it would be helpful to be told P values and confidence intervals for the between- scenario differences in the between-setting difference. If the interactions were not significant, then the apparent effect of scenario on the between-setting difference could just be due to chance. |
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Andrew J Cave, Research Director, Dept of Family Medicine University of Alberta Edmonton, T6G 2G3
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I was surprised by the obvious bias in this article by Grant etal.The authors are astute enough to limit their conclusions to "the range of conditions under study" I dont think there was much of a range. All the conditions assessed are classic walk in conditions...note also they are "conditions" not patients. I doubt the Walkin clinics would have done so well with real standardised patients. For example Mrs Smith who presents with CHF, deteriorating renal function , failing sight, diabetes ,deafness and no social support. I think general practice would have come into its own . Walkin clinics can of course do quicky stuff well or they would be out of business. The authors might as well have compared the management of these "cases" by obstetricians if they want walkin clinics to look good. What is interesting is that the GPs did do a complete job on the cases with the lowest referrals. They made less work for others and avoided unecessary costs for the system. It seems to me that the choice of cases set up General Practice to do relatively badly by limiting them to the easy stuff walkin clinics can handle. The conclusion might be ....Walkin clinics do a limited range of easy things adequately but refer more than is needed. |
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Peter C. Arnold, Former GP Sydney, Australia 2027
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My concern about this paper is its focus on what I call ?incidental medicine?. I refer to the focus of consultations on the incident which leads to the patient?s presenting for medical advice, and to these types of consultations often being incidental to significant aspects of the patient?s underlying state of health. As a patient, I value continuity of care as the most important aspect of primary care. I want to know that I can see the same doctor over time, and that, in an emergency, I will be attended to by someone I know and who knows me. It would appear that Grant et al did not consider continuity of care to be a ?quality? feature worth studying. The tragedy of primary care in many western countries is that, for the convenience of doctors and administrators, it is being replaced by incidental medicine. Continuity of care has been downgraded or ignored as an index of the quality of primary care. |
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