Quality, core values and the general practice consultation: issues of definition, measurement and delivery

Howie JGR, Heaney D and Maxwell M. Quality, and core values and the general practice consultation: issues of definition, measurement and delivery. Family Practice 2004; 21: 458–468. Doctors working in any branch of medicine aim to provide and to improve quality on a continuous basis. Teaching and research are intended to underpin these processes. Quality measurement attempts to check that these aims are being met. In the UK, for general practice, within-profession initiatives served the public adequately until well into the 1980s, as testified by the founding of the College of General Practitioners in 1952, the establishment of Departments of General Practice throughout the 1960s and 1970s, and the ‘GP Charter’ of 1966—all of which were responses to the ground-breaking exposure of the state of UK general practice of the early NHS years in the Collings Report of 1950.1 The discipline's ill-considered rejection of the government's ‘good practice allowance’ initiative in 1985 marked its failure to recognize the growing wish of public and government for more explicit quality accountability and the guaranteeing of minimum standards of care and competence. The ‘imposed’ 1990 Contract and the series of initiatives around clinical governance which have followed have been a direct consequence. The creation of NICE (the National Institute for Clinical Excellence), of clinical guidelines, of the National Service Frameworks (initially for cardiovascular disease, cancer and mental health), and moves to establish a workable basis for re-accreditation have all highlighted the real difficulty in finding ways of conceptualizing and measuring quality of care in ways which capture the full range of issues that matter to patients and can be applied in day to day practice. Campbell and Roland2 have proposed a categorization for conceptualizing and measuring quality which describes access and effectiveness as its two principal components, and subdivides effectiveness into clinical effectiveness and interpersonal effectiveness (efficiency and equity are added as separate issues). That categorization has similarities to, but important differences from, the division of effectiveness into technical and interpersonal effectiveness originally proposed by Donabedian.3 This essay argues, amongst other things, that the importance of inter-personal effectiveness—the more difficult component to define and measure—is, because of the difficulty in operationalizing it, in danger of being lost under the weight of material on the biomedical component of clinical effectiveness. This essay first describes the evolution of thinking within the discipline of general practice about its ‘core values’. It then discusses the definition and measurement of two of these ‘core values’ (‘patient-centredness’ and ‘holism’) in more detail. Next, it traces the development of the Consultation Quality Index (CQI), an opportunistically developed instrument designed to capture and measure a range of quality issues (most successfully at doctor level) at the interface between clinical/technical and interpersonal effectiveness, and suggests a number of ways in which it might be applied. Finally, the essay discusses how current and future work might strengthen the CQI and help ensure that the importance of inter-personal care will not be lost from the ‘quality agenda’ in general practice. The work of Michael Balint4 in the 1950s brought prominence to the importance of defining patient and doctor (as well as illness) factors in constructing and analysing general practice consultations, and his influence was strongly apparent in the seminal book, The Future General Practitioner,5 which underpinned so much of both undergraduate and postgraduate teaching in and about general practice from the 1970s on. About the same time, the new leaders of academic departments of general practice in universities were staking out the boundaries of their much-contested territory. McWhinney6 first described four criteria that an academic or independent discipline had to meet, namely having (i) a unique field of action; (ii) its own skills; (iii) the ability to support research; and (iv) control over its own postgraduate training. Richardson7 also identified four criteria, omitting McWhinney's ‘control over postgraduate training’ and adding instead the possession of an ‘identifiable philosophy’. McWhinney's ‘skills’ included the ability to elucidate undifferentiated clinical problems, and his attitudes included an overriding interest in people before their diseases, emphasizing, as Balint had done before, the part played by the doctor's personality in the dynamics of the doctor–patient relationship. Richardson's ‘skills’ included recognition not only of the pathology of the illness but also of the psychology and sociology of the patient. His ‘philosophy’ emphasized personal and continuing responsibility, and a balancing of values and judgements. In 1974, the Leeuwenhorst Group8 listed in its definition of the role of the GP, the integration of physical, psychological and social factors in considerations about health and illness, and referred to continuing management and the ability to gather information and make relationships at a considered pace over time. The term ‘patient-centred’ first appeared in the early pages of The Future General Practitioner, presented as an approach which encompasses ‘the patient's total experience of illness’, and it has come to represent the defining philosophy of general practice, emphasizing the importance of taking patient beliefs and characteristics into consideration when making clinical decisions. Given the (correct) implication that such issues and influences have been under-represented in the traditional teaching and training in medical schools by recent generations of hospital specialists, it is not surprising that this philosophy has in recent years underpinned much of both undergraduate teaching and postgraduate training in the setting of general practice. (Paradoxically, claiming that the patient-centred approach is a defining characteristic of general practice has harmed the development of partnership between those who practice in the community and those who work in hospital, patient-centredness having come to be seen as the obverse of having special clinical knowledge, the implication being that GPs are ‘people’ doctors whereas hospital doctors are not.) When Kuhn9 wrote his classic treatise The Structure of Scientific Revolutions, it was McWhinney10 who first extended its logic to medical practice, arguing that for medicine, its ‘paradigm shift’ would be away from disease-centred biomedicine and into a more patient-centred alternative. His team in London Ontario published a ground-breaking series of papers on ‘the patient-centred clinical approach’,11–13 and Moira Stewart,14 whose work is referred to in more detail below, became the most influential writer on this theme for the next two decades. From these early writings, two ‘core value’ themes emerge. 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is to define the that are working and the values that will the This essay has the of the evolution of ‘core values’ in general practice, on two that have been as of defining namely and has how difficult it is to define and measure these and has identified these from working in the have then described own work out in over two decades. the from that work has been the development of the an instrument the to quality of care at in general practice and to research its in the issues in this have on and at other on it that is a of only a of the in at the other it is apparent that doctors more and those that are are also those who are more to have and to patients who is both for more and for doctors as the of their the of the most doctors the of the the CQI as being at its most as a measure of doctors and as an instrument for on the of are other of doctors patients who not and this is in from and the is more marked when these patients a doctor their own at the Given that ‘the to be of the important of it is surprising that of has so research as in teaching not because most such have on The CQI is of an number of designed or to quality of care at general practice of the such as the and are of patient of the of and of General and the both of which have been from being health to Campbell have that quality in general practice has two and that effectiveness into clinical effectiveness and effectiveness of personal that two of effectiveness to an important as inter-personal the and management of clinical division of effectiveness into technical effectiveness and inter-personal effectiveness. team has the of as a of the quality of a it has to be to the of doctors or to clinical of of the in as a new and recent work has a between a of described as and but only a between the same and patient that the CQI is a of from both the clinical and inter-personal and of the of the issues which and have identified as important to is the more of the two core values this has and the CQI to 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to represent the ‘core values’ of the discipline of general practice. 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