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1.  Identifying predictors of high quality care in English general practice: observational study 
BMJ : British Medical Journal  2001;323(7316):784.
Objectives
To assess variation in the quality of care in general practice and identify factors associated with high quality care.
Design
Observational study.
Setting
Stratified random sample of 60 general practices in six areas of England.
Outcome measures
Quality of management of chronic disease (angina, asthma in adults, and type 2 diabetes) and preventive care (rates of uptake for immunisation and cervical smear), access to care, continuity of care, and interpersonal care (general practice assessment survey). Multiple logistic regression with multilevel modelling was used to relate each of the outcome variables to practice size, routine booking interval for consultations, socioeconomic deprivation, and team climate.
Results
Quality of clinical care varied substantially, and access to care, continuity of care, and interpersonal care varied moderately. Scores for asthma, diabetes, and angina were 67%, 21%, and 17% higher in practices with 10 minute booking intervals for consultations compared with practices with five minute booking intervals. Diabetes care was better in larger practices and in practices where staff reported better team climate. Access to care was better in small practices. Preventive care was worse in practices located in socioeconomically deprived areas. Scores for satisfaction, continuity of care, and access to care were higher in practices where staff reported better team climate.
Conclusions
Longer consultation times are essential for providing high quality clinical care. Good teamworking is a key part of providing high quality care across a range of areas and may need specific support if quality of care is to be improved. Additional support is needed to provide preventive care to deprived populations. No single type of practice has a monopoly on high quality care: different types of practice may have different strengths.
What is already known on this topicQuality of care varies in virtually all aspects of medicine that have been studiedMost studies look at quality of care from a single perspective or for a single conditionWhat this study addsQuality of care varies for both clinical care and assessments by patients of access and interpersonal carePractices with longer booking intervals provide better management of chronic disease; preventive care is less good in practices in deprived areasNo single type of practice has a monopoly on high quality care—small practices provide better access but poorer diabetes careGood team climate reported by staff is associated with a range of aspects of high quality care
PMCID: PMC57358  PMID: 11588082
2.  Specialist outreach clinics in general practice: what do they offer? 
BACKGROUND: Specialist outreach clinics in general practice, in which hospital-based specialists hold outpatient clinics in general practitioners' (GPs) surgeries, are one example of a shift in services from secondary to primary care. AIM: To describe specialist outreach clinics held in fundholding general practices in two specialties from the perspective of patients, GPs, and consultants, and to estimate the comparative costs of these outreach clinics and equivalent hospital outpatient clinics. METHOD: Data were collected from single outreach sessions in fundholding practices and single outpatient clinics held by three dermatologists and three orthopaedic surgeons. Patients attending the outreach and outpatient clinics, GPs from practices in which the outreach clinics were held, and the consultants all completed questionnaires. Managers in general practice and hospital finance departments supplied data for the estimation of costs. RESULTS: Initial patient questionnaires were completed by 83 (86%) outreach patients and 81 (75%) outpatients. The specialist outreach clinics sampled provided few opportunities for increased interaction between specialists and GPs. Specialists were concerned about the travelling time resulting from their involvement in outreach clinics. Waiting times for first appointments were shorter in some outreach clinics than in outpatient clinics. However, patients were less concerned about the location of their consultation with the specialist than they were about the interpersonal aspects of the consultation. There was some evidence of a difference in casemix between the dermatology patients seen at outreach and those seen at outpatient clinics, which confounded the comparison of total costs associated with the two types of clinic. However, when treatment and overhead costs were excluded, the marginal cost per patient was greater in outreach clinics than in hospital clinics for both specialties studied. CONCLUSION: The study suggests that a cautious approach should be taken to further development of outreach clinics in the two specialties studied because the benefits of outreach clinics to patients, GPs and consultants may be modest, and their higher cost means that they are unlikely to be cost-effective.
PMCID: PMC1313104  PMID: 9406489

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