Improving the interface between primary and secondary care: a statement from the European Working Party on Quality in Family Practice (EQuiP).

A group from the European Working Party on Quality in Family Practice (EQuiP), working with over 20 European colleges of primary care, has assessed what, in their view, is needed to improve the quality of care at the interface between general practice and specialists. Experiences and ideas from a wide range of people were gathered through focused group discussions. From these it was clear that, for real improvement at the interface of care, changes are needed in the system of care and in the ways that doctors view their roles and their performance. All providers of care need to be able to see the care system from the patients' perspective if they are to help their patients make sense of and benefit from an increasingly complex system. This paper outlines the EQuiP recommendations on how cooperation between general practitioners and specialists might be improved. This includes strategic perspectives and both targets for improvement and methods for teaching, training and development that are all independent of country and health care system. The 10 targets for development identified by the group are: leadership, initial shared care approaches, task division, mutual guidelines, patient perspective, informatics, education, team building, quality monitoring systems, and cost effectiveness. Working towards these targets could provide an effective approach to improving the cooperation between the interfaces of care. Getting effective leadership is a necessary first step as implementation of such a strategy will involve significant change. Responsibility lies primarily with the medical profession.

[Practice patterns, physicians' characteristics and patient-evaluated quality of general practice in Norway]. / Praksisform, legekarakteristika og pasientvurdert kvalitet i norsk allmennpraksis.

BACKGROUND: Norwegian general practice is a conglomerate of organisational forms. Studies of quality differences between types of practice have not been published. There is scant knowledge of how physician characteristics may influence patients' experience of the quality of care. MATERIALS AND METHODS: In this study of patient experiences with quality in primary care, we received answers to a questionnaire from more than 1,600 patients who had made office visits to 61 GPs working in 44 different practices. The patients expressed their opinion of the quality of medical-technical performance, doctor-patient relationship, information and support, accessibility and the organisation of general practice. Using multilevel analysis we compared solo-practices with group practices, and conventional types of practices with list-patient practices. RESULTS: No significant differences in patient experienced quality were found for different practices with traditional organisation. List-patient practices scored lower on quality than conventional practices, especially on accessibility and organisation. There were no significant differences in patient evaluation related to the doctor's gender. GPs with more than ten years in a practice were rated lower on quality than GPs with ten or fewer years of experience. INTERPRETATION: The way general practice is organised and the number of years the GP has worked in the same practice appear to influence how patients experience the quality of primary health care.

[Quality of general practice as experienced by patients]. / Pasientopplevd kvalitet i allmennpraksis.

BACKGROUND: The aim of the study was to explore the impact of feedback to general practitioners regarding patient evaluation of the quality of services rendered. MATERIAL AND METHODS: 1,614 patients in 41 general practices assessed the quality of care they had received during the last 12 months. The results for each practice were compared to the mean quality level of all the practices, and returned to the practice. This report was followed by a questionnaire to the GPs asking for their opinion of such feedback. Six of the GPs were also interviewed by telephone. RESULTS: The GPs welcomed patient quality evaluations and comparisons. However, they doubted that the feedback would lead to any action taken, as they had neither the time nor the energy to make changes in clinical performance or organisational structure. They questioned quality assessment by patients being an objective measure of quality. The GPs were willing to discuss the results in peer groups, but were reluctant to share the information with staff or patients. INTERPRETATION: The present study does not indicate that feedback given in the form of reports at practice level regarding patient assessed quality is an effective method for quality improvement.

[Communication between general practitioners and hospital interns at emergency admissions]. / Kommunikasjon mellom primaerleger og turnusleger i sykehus ved akuttinnleggelser.

Communication between general practitioners and hospital interns serves as basis for the first in-hospital treatment of emergency admitted patients. The purpose of this study is to describe how this communication currently functions in Norway. The study was carried out by personal and focus group interviews with general practitioners and hospital interns, and questionnaire responses from 532 doctors. Both general practitioners (93%) and hospital interns (84%) claim that the general practitioner's information is usually valuable for the initial hospital treatment. 89% of the general practitioners and 65% of the interns (p < 0.01) responded affirmatively to general statements characterising the existing communication as good. However, 58% of the interns are of the opinion that there are many unnecessary referrals to the hospitals, and 47% respond that the general practitioners often refer a patient in order to get rid of a problem they should have been able to handle themselves. The interns single out simple problems with the referral letters, such as illegible handwriting, and left-out or unsorted information. This critical view can in part be explained by the sense of isolation, lack of autonomy and high work load that interns experience in their obligatory hospital year. We recommended that interns are invited to participate when hospital doctors and general practitioners meet.

[The first telephone call at emergency admissions--the role of nurses]. / Den første telefonsamtalen ved akuttinnleggelser--sykepleiernes rolle.

The article focuses on whom in the hospital the general practitioners first inform when referring emergency patients. The study is based on interviews with general practitioners and hospital interns, and questionnaires answered by 532 doctors, selected from hospital areas where the primary doctor on call usually is an intern. Three fourths of the respondents state that the general practitioner when referring patients usually gives the clinical information directly by phone to an intern. The remaining state that general practitioners normally inform a hospital nurse about emergency admissions. The quality of communication, and the respect developed between general practitioners and interns is perceived as being better when there is a direct communication between the general practitioner and the hospital doctor, bypassing the nurse. The interns respect the admission decisions of the general practitioners to a significantly larger degree, and claim that necessary information about the patient is easier to obtain when they routinely communicate with the general practitioners. In our opinion, the present study gives reason to recommend a direct telephone contact between the referring general practitioner and the hospital intern as part of emergency admissions.

[Interpretation of questionnaires. An translation method problem]. / Oversettelse av spørreskjema. Et oversett metodeproblem.

For use in a different cultural background, translated questionnaires need to be validated in the new context. International guidelines are needed for such validation, as precision in translation is an important methodological issue. The article consists in a review of the issue and recommended guidelines for the translation and validation of questionnaires, based on the authors' experience and international literature in the field. The authors participate in a European research programme (EU/BIOMED-Europep), set up to develop a questionnaire for exploring patients' priorities and their evaluations of important aspects of general practice.

[The good general practice--Norwegian patients' evaluation and priorities]. / Den gode allmennpraksisen--norske pasientar sine vurderingar og prioriteringar.

Researchers from seven European countries are participating in a study where patients evaluate their experiences with regard to primary health care. The overall aim of this study is to develop a valid, reliable and user-friendly cross-cultural questionnaire, which will subsequently be used to gather patients' evaluations across Europe. This paper reports on the first step in this process, where Norwegian patients rate their experiences with regard to primary health care over the last six months. A total of 830 questionnaires were handed out by 12 practitioners located in different places in Norway. 431 (52%) answers were returned. Norwegian patients value first and foremost accessibility to the doctor and the practice, and then continuity of care, respect, confidentiality, competence and information in their encounters with the primary health service. These findings can be used by general practitioners in their quality improvement efforts.

[Significant medical quality concepts in a clinical context]. / Sentrale medisinske kvalitetsbegreper i en klinisk sammenheng.

For centuries, doctors have been working continuously on improving clinical practice, but there has not been the same focus on improving the organization of health care. Many doctors still believe that quality improvement only applies to medical practice. This is no longer so. Present day medical quality improvement includes both clinical practice and the health care system. The principles relating to quality systems describe the strategies and practical accomplishment of changes to improve the quality of care. These common principles should be applied to clinical practice, to how the systems work and to interpersonal relationships in health care. Norwegian medical quality assessment is encountering problems with language and definitions. A common understanding and use of standard terms is still lacking. This may be one reason why the medical profession is still unfamiliar with quality assessment as a method for the continuous improvement of health care. Using a clinical example, this article discusses the understanding and use of five important terms in quality assessment: quality, clinical guidelines, indicators, criteria, and standards.

[Which medical quality concepts should be used in Norway? Some significant quality concepts with definitions, synonyms and analogues English terms]. / Hvilke medisinske kvalitetsbegreper bør vi bruke i Norge? Noen sentrale kvalitetsbegreper, med definisjoner, synonymer og analoge engelske uttrykk.

The terminology for quality in medical practice is over-complex, confusing and often applied indiscriminately. Such terms are meant to contribute to the understanding of medical performance and to be used as tools for its improvement. In order to be able to understand each other and to perform quality assessment a set of comprehensible terms and concise definitions of those terms is needed. This article defines and discusses in alphabetical order some of the most important Norwegian medical quality terms, giving the corresponding expressions in English. The aim of the authors is to create a Norwegian reference for medical quality terminology, modified to conform with international literature. This is a continuous process, as are other areas of quality assessment, and for the present time we recommend that these definitions be used as standard terminology for Norwegian medical quality assessment.

[Trends and traditions in Scandinavian general medicine]. / Trender och traditioner i nordisk allmänmedicin.

Recent decades have witnessed radical changes both in the workload and in the job description of general practitioners (GPs) in the Nordic countries, and the trend continues. Owing to social changes, particularly the deterioration in health care economy, the GPs will in the future be required to deal with increasing numbers of patients as well as increasingly severe categories of diseases, previously treated at hospital departments and clinics. This will entail increased demands in terms both of the further education of GPs and of the equipment available to them. It will also entail improved and extended cooperation between GPs and consultants, both in matters of overall policy and in the management of individual cases.