The relationship between income and performance indicators in general practice: a cross-sectional study.

OBJECTIVE: To explore the relationship between the income of general practitioners (GPs) and the performance characteristics of their practices. DESIGN: Cross-sectional survey. SETTING: All practices (n = 166) in an inner city health authority, two years before the introduction of the new GP contract in April 2004 were studied. MAIN OUTCOME MEASURES: True income per GP was unavailable to us. Instead, the proxy measure - superannuable pay - was calculated (gross eligible income per GP minus the national average sum for GP expenses). Practice staff funding figures were also obtained. These two financial indicators were compared with practice characteristics and performance indicators. RESULTS: Data were available from 151 out of 166 practices. Based on regression analysis, larger list sizes and higher practice staff budgets predicted 31% of the variation in GP income (standardized beta = 0.66, P < 0.001; beta = 0.19, P = 0.02; respectively). Higher staff budgets were independently associated with better cervical smear and two-year-old vaccination rates (standardized beta = 0.24, P < 0.01; beta = 0.18, P = 0.03; respectively). No association was demonstrated between performance indicators and income. CONCLUSION: Under the previous contract, GPs were able to maximize their income by taking on more patients, whereas achievement of performance targets had very little impact on overall income. The opportunity costs of pursuing higher-quality care might have outweighed the modest financial rewards attached to performance targets. Provided rewards for good-quality care are sufficiently high, the new GP contract is likely to tip the balance in favour of generating earnings by improving the quality of clinical care. To deliver this care, as measured by available performance indicators, our findings imply that a greater investment in practice staff will be needed.

A study of the relationship between patients' attitudes and doctors' prescribing.

Questionnaires were given to 139 appointment attenders and 141 open access attenders prior to consultations at one general practice. These enquired about patients' attitudes toward common illness and its treatment. Data on prescribing were obtained from the general practitioners after the consultation. The results suggested that two sets of attitudes were present in the sample: a preference for self care and a preference for drug treatment. They did not suggest that open access attenders were more in favour of drug treatment than appointment attenders. Although the issuing of prescriptions was broadly in line with patients' attitudes, the only attitudinal statement significantly associated with doctors' prescribing behaviour was one reflecting a preference for drug treatment. A logit analysis showed that the effect of patients' attitudes was apparent for open access attenders but not appointment attenders. The data lend support to the hypothesis that doctors are more aware of the pressure to prescribe than of the preference for self care.

A study of patients attending without appointments in an urban general practice.

OBJECTIVE: To ascertain which social and psychological characteristics are associated with patients attending surgeries without appointments. DESIGN: Prospective study of patients attending an urban centre group practice. SETTING: Urban health centre group practice with five doctors and 12,000 patients in an area of high (greater than 20%) unemployment and social deprivation. PATIENTS: All attenders at the open access surgery and one in four consecutive attenders by appointment, selected sequentially from the first three appointments, during 10 days in January 1989. Patients participating in the pilot study, reattending during the study period, or attending antenatal clinics were excluded. MAIN OUTCOME MEASURES: Patients' attitude to making appointments and reasons for attending, including perception of urgency, with respect to sociodemographic and psychosocial data obtained from a self completed questionnaire before the consultation. Doctors' diagnosis and perception of urgency obtained from a separate questionnaire. RESULTS: 86% (141/172) Of patients attending without appointments and 96% (139/145) with appointments responded to the questionnaire. The need for consultation was considered to be "very urgent" or "fairly urgent" in significantly more of the open access group than the appointments group (89%, 124/139 v 66%, 91/138; chi 2 = 27.04, df = 3; p less than 0.001), although the doctors did not share the same views. Significantly more patients had self limiting conditions of recent onset in the open access than in the appointments group (75%, 101/135 v 48%, 59/123: p less than 0.001). Overall, open access attendance was significantly linked with social support (39%, 48/124 v 26%, 32/123; p less than 0.05) and with marital separations or intentions to separate (10%, 9/87 v 0/92; 47%, 32/87 v 22%, 20/92 respectively; both p less than 0.001), but the doctors recorded significantly fewer psychological and social problems in these patients (p less than 0.05). Although almost half those in the appointments group considered that making appointments was inconvenient, more of those in the open access group agreed with this view (47%, 60/129 v 61%, 80/131). CONCLUSIONS: There was an important link between social support problems and a negative attitude to making appointments. In our previous experience encouraging patients to make appointments has been unsuccessful; practices serving areas with a high prevalence of social deprivation providing a mixed open access and appointments system may better serve patients' needs.