The pattern of silent time in the clinical consultation: an observational multichannel video study.

OBJECTIVE: To describe silent time in the clinical consultation: who initiates and terminates it and at what stage most silence occurs. METHODS: We conducted an analysis of 127 multichannel video recordings of consultations by 12 GPs; filmed using the ALFA (Aggregation of Log Files for Analysis) open-source toolkit. The start and end of silence was manually coded using an observational data capture tool. We report who initiates and terminates silence, describe the proportion of the consultation, what happens within it and the distribution of silent periods by quartile of the consultation. RESULTS: We found the median proportion of silence was 12.3% and interquartile range 14.3%. Silent periods (52.4%) were both initiated and terminated by the doctor. The majority of silent time (78.1%) is spent on computer-based activities and physical examination. Silent periods which do not involve physical examination mainly occur in the second half of the consultation and represent 70.6% of the total duration and 64.8% of the episodes of silence. CONCLUSIONS: The computer is a third party in the GP consultation and often requires silent time during doctor-computer interaction. Doctors' control and patients allow silence for the doctor to complete tasks often involving the computer and also for time out from the consultation. There is a clear pattern of when doctors need most to have silence and consultation models should be developed that reflect this need.

Improving the management of type 2 diabetes through large-scale general practice: the role of a data-driven and technology-enabled education programme.

A quality improvement (QI) scheme was launched in 2017, covering a large group of 25 general practices working with a deprived registered population. The aim was to improve the measurable quality of care in a population where type 2 diabetes (T2D) care had previously proved challenging. A complex set of QI interventions were co-designed by a team of primary care clinicians and educationalists and managers. These interventions included organisation-wide goal setting, using a data-driven approach, ensuring staff engagement, implementing an educational programme for pharmacists, facilitating web-based QI learning at-scale and using methods which ensured sustainability. This programme was used to optimise the management of T2D through improving the eight care processes and three treatment targets which form part of the annual national diabetes audit for patients with T2D. With the implemented improvement interventions, there was significant improvement in all care processes and all treatment targets for patients with diabetes. Achievement of all the eight care processes improved by 46.0% (p<0.001) while achievement of all three treatment targets improved by 13.5% (p<0.001). The QI programme provides an example of a data-driven large-scale multicomponent intervention delivered in primary care in ethnically diverse and socially deprived areas.

Using 'Active Signposting' to streamline general practitioner workload in two London-based practices.

General practice is at the forefront of the National Health Service, but is currently being overwhelmed by ever-increasing patient demand and financial constraints. Telephone consultations (TCs) have been used as a method to ease pressure on general practice. Many of these consultations are booked with general practioners (GPs), despite occasions when the patient could have either been signposted to self-help or offered an alternative service. This quality improvement project (QIP) aimed to evaluate the nature of TCs undertaken by GPs at our two practices; and whether the patients' needs could have adequately been met without the involvement of a GP. Consultations where this was the case were deemed 'possibly avoidable', and those where involvement with a GP was the best option have been termed 'essential'. A retrospective analysis was undertaken to establish a baseline figure for the proportion of possibly avoidable TCs in two practices. A new intervention was then introduced, with reception staff following a set of protocols when booking in patients. Patients who did not require a GP to deal with their query were actively signposted by reception staff to other allied healthcare professionals, non-medical staff or an alternative service at the time of booking their appointment. Two practices were involved in the study. After 2 Plan, Do, Study, Act (PDSA) cycles, the proportion of essential consultations taking place at both practices increased from 28.6% and 27.3% at baseline, to 82.6% and 71.4%, respectively. A lower number of possibly avoidable TCs equates to more time for essential TCs and greater value for money for the practice. Patient access to care is also improved, with patients directed to alternative and often quicker services which still meet their needs adequately. With the current system of primary care unable to cope with the demands it faces, interventions such as active signposting provide value for both GP practices and patients alike.

What drives quality improvement in chronic kidney disease (CKD) in primary care: process evaluation of the Quality Improvement in Chronic Kidney Disease (QICKD) trial.

OBJECTIVES: This study is a process evaluation of the Quality Improvement in Chronic Kidney Disease (QICKD) study, comparing audit-based education (ABE) and sending clinical guidelines and prompts (G&P) with usual practice, in improving systolic blood pressure control in primary care. This evaluation aimed to explore how far clinical staff in participating practices were aware of the intervention, and why change in practice might have taken place. SETTING: 4 primary care practices in England: 2 received ABE, and 2 G&P. We purposively selected 1 northern/southern/city and rural practice from each study arm (from a larger pool of 132 practices as part of the QICKD trial). PARTICIPANTS: The 4 study practices were purposively sampled, and focus groups conducted with staff from each. All staff members were invited to attend. INTERVENTIONS: Focus groups in each of 4 practices, at the mid-study point and at the end. 4 additional trial practices not originally selected for in-depth process evaluation took part in end of trial focus groups, to a total of 12 focus groups. These were recorded, transcribed and analysed using the framework approach. RESULTS: 5 themes emerged: (1) involvement in the study made participants more positive about the CKD register; (2) clinicians did not always explain to patients that they had CKD; (3) while practitioners improved their monitoring of CKD, many were sceptical that it improved care and were more motivated by pay-for-performance measures; (4) the impact of study interventions on practice was generally positive, particularly the interaction with specialists, included in ABE; (5) the study stimulated ideas for future clinical practice. CONCLUSIONS: Improving quality in CKD is complex. Lack of awareness of clinical guidelines and scepticism about their validity are barriers to change. While pay-for-performance incentives are the main driver for change, quality improvement interventions can have a complementary influence.

Physician Associate and General Practitioner Consultations: A Comparative Observational Video Study.

BACKGROUND: Physician associates, known internationally as physician assistants, are a mid-level practitioner, well established in the United States of America but new to the United Kingdom. A small number work in primary care under the supervision of general practitioners, where they most commonly see patients requesting same day appointments for new problems. As an adjunct to larger study, we investigated the quality of the patient consultation of physician associates in comparison to that of general practitioners. METHOD: We conducted a comparative observational study using video recordings of consultations by volunteer physician associates and general practitioners with consenting patients in single surgery sessions. Recordings were assessed by experienced general practitioners, blinded to the type of the consulting practitioner, using the Leicester Assessment Package. Assessors were asked to comment on the safety of the recorded consultations and to attempt to identify the type of practitioner. Ratings were compared across practitioner type, alongside the number of presenting complaints discussed in each consultation and the number of these which were acute, minor, or regarding a chronic condition. RESULTS: We assessed 62 consultations (41 general practitioner and 21 physician associates) from five general practitioners and four physician associates. All consultations were assessed as safe; but general practitioners were rated higher than PAs in all elements of consultation. The general practitioners were more likely than physician associates to see people with multiple presenting complaints (p<0.0001) and with chronic disease related complaints (p = 0.008). Assessors correctly identified general practitioner consultations but not physician associates. The Leicester Assessment Package had limited inter-rater and intra-rater reliability. CONCLUSIONS: The physician associate consultations were with a less complex patient group. They were judged as competent and safe, although general practitioner consultations, unsurprisingly, were rated as more competent. Physician associates offer a complementary addition to the medical workforce in general practice.