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Rapid Responses: Rapid Responses published:
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Questionable measures of quality
- Sarah Nicholls, Matthew Hankins, statistician; Helen Smith, Chair of Primary Care (7 July 2006)
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when interpersonal skills and technical care collide
- Anne E Thompson (14 July 2006)
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Sarah Nicholls, Specialist Registrar in Public Health Brighton and Sussex Medical School, Division of Primary Care and Public Health, Brighton, BN1 9PH, Matthew Hankins, statistician; Helen Smith, Chair of Primary Care
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Rao et al (1) report that the General Practice Assessment Survey (GPAS) subscales are highly inter-correlated, yet not correlated with records-based measures of clinical quality. We wish to add two observations to the debate. Firstly, the authors repeat the assertion that the GPAS has been “extensively tested for validity” when in fact neither of the cited articles (2, 3) contains any validation data whatsoever. Indeed the second of these articles (3) concluded that the GPAS should be validated “against external criteria”. We can find no evidence of external validation. It therefore remains unclear whether the GPAS really does measure satisfaction. Secondly we take issue with the focus on only three clinical quality outcomes (monitoring and controlling hypertension and uptake of influenza vaccination) as representative of the wide range of care delivered to the elderly in primary care. Furthermore we suspect that the lack of correlation between influenza vaccination rates and monitoring or control of hypertension may be due to the former being more a measure of practice organisation rather than clinical quality. This study raises fascinating questions for patients, healthcare professionals and policy makers alike. 1 Rao M, Clarke A, Sanderson C, Hammersley R. Patients’ own assessments of quality of primary care compared with objective records based measures of technical quality of care: cross sectional study. BMJ 2006;333:19-22. 2 Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DH, Lieberman N, et al. The primary care assessment survey: tests of data quality and measurement performance. Med Care 1998;36: 728-39. 3 Ramsay J, Campbell JL, Schroter S, Green J, Roland M. The general practice assessment survey (GPAS): tests of data quality and measurement properties. Fam Pract 2000;17: 372-9 Competing interests: None declared |
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Anne E Thompson, Consultant Child & Adolescent Psychiatry Lincolnshire Partnership NHS Trust, Child & Family Services,10/11 Lindum Ter., Lincoln, LN2 5RT
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Dear Editor Rao et al found that older patients’ assessments of the technical quality of the care they received from general practitioners were not closely related to case note measures of good clinical care. Patients’ assessments of the technical aspects of their clinical care were however strongly correlated with their assessments of their doctors’ interpersonal skills, trust and communication skills [1]. In a speciality such as child and adolescent psychiatry, where many of the interventions are psychological therapies, I suggest that good quality technical care may in fact include aspects of a doctor’s professional style such as good interpersonal skills and good communication. The need to develop a high level of skill in engaging and communicating with children, adolescents and parents is one of the technical skills which must be developed in higher specialist training in child & adolescent psychiatry [2]. There is evidence that “therapist factors” contribute to the effectiveness of all psychological therapies and may be more influential on patient outcome than the style and content of a specific therapeutic approach [3]. Enabling patients to feel listened to, accepted and understood may therefore be both an interpersonal skill and a technical skill in psychological medicine. The importance of this aspect of clinical care to our patients was highlighted in Lincolnshire Partnership NHS Trust’s survey of children aged 9 to 18 using child & adolescent mental health services (CAMHS) over a 2 week period in 2004. The Experience of Service Questionnaire [4] collects patient opinions about 5 dimensions of patient experience (access, environment, outcomes, organisation of care and humanity of care) using a 12 item questionnaire and free text comments from patients. When we categorised the comments written by patients into the five dimensions of patient experience we found that humanity of care was commented on as frequently as satisfaction with outcome (72 and 73 comments each) and much more commonly than aspects of access (3 comments), environment (23 comments) or organisation of care (6 comments). If patient choice truly begins to drive service development in CAMHS, our young patients’ preference for empathic attentive doctors should also secure them treatment with technically effective specialists. Yours sincerely Dr Anne Thompson MB BS MRCP (UK) MRCPsych Consultant Child & Adolescent Psychiatrist References 1. Rao M, Clarke A, Sanderson C, Hammersley R. Patients’ own assessments of quality of primary care compared with objective records based measures of technical quality of care: cross sectional study. BMJ 2006; 333:19-22. 2. Royal College of Psychiatrists Higher Specialist Training Committee. Child & Adolescent Psychiatry Specialist Advisory Committee Advisory Papers. London: Royal College of Psychiatrists, 1999. 3. Chatoor I, Krupnick J. The role of non-specific factors in treatment outcome of psychotherapy studies. Eur Child Adol Psych 2001; 10 Suppl 1: 119-25. 4. http://www.healthcarecommission.org.uk/_db/_documents/04017624.pdf Competing interests: None declared |
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