Family Practice, 2014, Vol. 31, No. 1, 1–6 doi:10.1093/fampra/cmt079 Advance Access publication 9 December 2013
In retrospect—a reflection on a 50-year research journey John G R Howie* Emeritus professor of general practice, University of Edinburgh, 4 Ravelrig Park, Balerno, Edinburgh EH14 7DL, UK.
Received July 11 2013; revised November 4 2013; Accepted November 5 2013.
This essay is a personal review of a research journey extending over 50 years during which time the understanding of medical practice has changed out of all recognition and the quality and standing of the discipline of general practice has improved substantially. Three main bodies of work are reviewed and set against the reasons why they were undertaken. The first, on the pathology of the appendix and the management of possible appendicitis, was carried out almost entirely in the hospital setting. The second, about the prescribing of antibiotics for respiratory illnesses, and the third, about the determinants of good consulting practice, were carried out in general practice. The essay concludes with a reflection on the relevance of the work to some contemporary academic and health service issues. Although the work was carried out in the UK in the context of its National Health Service (NHS), the conclusions are widely generalizable and have contributed to health service and academic developments in many other countries. Keywords: Consultations, decision-making, general practice, prescribing, research, theory.
Introduction I was always a problem-centred and hypothesis-driven researcher, and my attempt to create a model of how clinical decisions are made was probably an inevitable component of my academic life.
I qualified in medicine in 1961, having always intended to become a GP. Elsewhere (1), I have described the twists of fate that eventually led me into my career as an academic in general practice. My starting point was the frustration I felt about both my school and University education with their emphases on rote learning to the exclusion of fostering understanding. As a clinical student, I soon realized that senior clinicians did not always practice what they taught and that they presented their views of correct practice without being up-front about the range of differing approaches taken by others. The management of uncertainty was a closed book. My principal research activities were encompassed in three distinct research programmes, one each mainly in Glasgow, Aberdeen and Edinburgh. They are described in turn. In my early years, I saw problems in rather black and white terms, and my early researches while based in pathology reflected that. As I moved into general practice, clinical experience brought different and richer colours to my researches. But wherever I was working,
Appendicitis and abdominal pain (Glasgow: c1961–66) I decided to study medicine only in my last year at school after having my appendix removed. So appendicitis was always a subject close to my heart. In my first job as a house surgeon, one of my seniors seemed to take particular delight in questioning my decisions to call him in or to wait for morning. I was often unconvinced by his judgements but impressed by the difficulties of separating right from wrong. Possible appendicitis was the commonest surgical emergency in the 1960s, and classical appendicitis was much less common than was appendicectomy. Naked-eye examination of appendices removed in theatre was highly subjective, and few clinical
© The Author 2013. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected].
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*Correspondence to John G R Howie, Emeritus professor of general practice, University of Edinburgh, 4 Ravelrig Park, Balerno, Edinburgh EH14 7DL, UK; E-mail: [email protected]
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to remove appendices from the children of medical colleagues and from nurses than from other population groups. While on a rotation through an immunology department, I was asked to explore the then current suggestion of a link between appendicectomy and the later development of malignancy, particularly in the bowel. Theoretically, this seemed plausible given that the analogue to the appendix in the hen is the driver of its immune mechanisms. My work was in two parts. First a careful deconstruction of the original article in Cancer showed a significant flaw in the matching of its control population (half the control patients—although matched for age—had died a decade before the test patients, taking them back in their younger years to before appendicectomy had become fashionable). Then a prospective study using the west of Scotland cancer register and controls from the Glasgow general practice I was about to join as a partner confirmed that cancer patients were no more likely to have had their appendices removed than were controls (10).
1966 After 4 years in pathology, I became a partner in a local practice in which I had been ‘moonlighting’ for the previous 2 years. Two episodes in my first 3 months were to have a lasting influence on my career as an academic in general practice. One November morning, I visited an elderly man living alone in a single room with outside toilet. He was clearly terminally ill, almost certainly with prostate cancer. The professor’s unit in the teaching hospital I had just left was on call but claimed to have no room for my patient. I was crudely bullied by his registrar about what tests I had done (not only did I know my patient’s mean corpuscular haemoglobin concentration but I also knew what it meant). I went straight to the hospital, confirmed a plenitude of empty beds and sent my patient in by ambulance. He died next day; I vowed to challenge and change the values and behaviour of teaching hospitals towards GPs and their patients. Two weeks later, I attended a Sunday postgraduate lecture with a hundred or more colleagues. We signed a register that brought us payment for attending; the lecturer gave his services free. We had coffee, went in to the lecture theatre and the lights were put out to show some fluorescent micrographs. When the lights went back on, more than half the doctors had left. The lecturer said simply ‘so this is what general practice is about’. My mission now had an added dimension.
Respiratory illness and antibiotic prescribing (Glasgow: 1966–70; Aberdeen: 1970–80; Edinburgh 1980–c1985) Now in full-time general practice and faced with my first winter respiratory tract infection (RTI) epidemic, uncertain whether to
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diagnoses were tested against pathological examination. Early in my originally intended single year in pathology, I started looking at the correlation between symptoms and pathology and decided to correlate each with recurrence of symptoms. The first ‘discovery’ was that the management of appendicitis and abdominal pain was anything but ‘evidence based’. There was no definition of where microscopic normality stopped and abnormality started. Early in my 2-year pathology-based study of all appendices removed in the Western Infirmary of Glasgow, I chanced on a beautiful slide showing large deposits of golden pigment (iron) in an appendix abscess. My mentor encouraged me to examine the specimen using a special iron stain. The picture was remarkable, with iron deposits everywhere. So I stained all my specimens for iron and correlated the findings with recent history of abdominal pain. The correlation was good—better for males than for females in whom the turnover of iron was no doubt faster. Crucially, this finding helped to remove the myth of ‘chronic appendicitis’ from consideration as a diagnostic entity. So began a series of epidemiological studies into the relation between abdominal pain and appendicitis. I developed a histological classification (2), published work on the use of stainable iron as a diagnostic technique (3), assessed the morbidity (short term and longer term) of removing and of not removing the appendix for patients presenting with abdominal pain (4,5) and analysed the mortality from appendicitis and appendicectomy based on all relevant patients in Scotland dying over a 10-year period (6). This mortality study was one of the pieces of research I enjoyed most. Using projections from the parallel work I was doing on classifying appendices histologically, I was able to show progressively worsening death rates as age and the severity of the inflammatory process increased. There was also a fascinating gender difference, death rates for males being double those for females at each age and pathology group. Finally, I analysed the outcomes in young females cared for in ‘conservative’ surgical units (operating in three out of five patients admitted) and in ‘radical’ surgical units (operating in four out of five), finding mortality rates equivalent but overall morbidity less and symptom relief better in units with the more radical approach to operative intervention (7). There were other interesting findings. With help from the ‘stainable iron’ discovery, ‘mesenteric adenitis’ was found to contain two subgroups. Patients with positive iron in their appendices (half of those concerned) had the same cure rate as patients with undisputed appendicitis, whereas those without iron had the same symptom recurrence rate as those having normal appendices removed (8). And—serendipitously anticipating the findings in my later work on antibiotic prescribing for general practice respiratory illnesses—there was evidence that non-clinical ‘patient’ and ‘doctor’ factors influenced clinical decision-making (9). In particular, I found that appendicectomy but not appendicitis runs in families. I was also able to show that surgeons were more likely
In retrospect—a reflection on a 50-year research journey
same conclusion.) Earlier, we had shown (in a rather small study) that being a high-antibiotic prescriber appeared to generate rather than prevent reconsultation, calling into doubt another common justification for prescribing antibiotics for minor indications (21). Now in Edinburgh, I wanted to complete the RTI story by showing that when doctors were stressed, the proportion of unnecessary antibiotics prescribed increased. The design of our subsequent ‘stress study’ did not allow us to link prescribing specifically to sore throats, but one analysis did show that running late (a major stressor) was associated with higher prescribing for RTIs and less attention to psychosocial comorbidity (22)—a quality issue we were to focus on in subsequent work.
The determinants of good general practice consultations (Edinburgh: 1980–c2006) Coming to Edinburgh marked the start of a fulfilling partnership first with Mike Porter (a medical sociologist) and then with others (in particular David Heaney and Margaret Maxwell in Edinburgh and George Freeman in London). Taking up the hypothesis referred to above that working under stress was harmful to the quality of consultations, we piloted a way of self-reporting stress and stressors. Our subsequent ‘stress study’ (23) also incorporated the fore-runner of our ‘enablement’ outcome measure (which we then developed with help from Jeremy Walker) (24). We collected some evidence that attitudes to care affected the way doctors consulted (with Jane Hopton) (25) and published the Royal College of General Practitioners Occasional Paper no 75 (26), which described in detail how our methods had been developed and presented the case for using consultation length as a proxy for quality of care at consultations (27). It was our good fortune that just as we were wondering how best to continue this work, the Scottish Government commissioned us to evaluate the 1990 NHS Shadow Fund-holding Project in the north-east of Scotland. We used our developing expertise with large consultation-based projects to produce a series of six articles that suggested, among other things, that there were both benefits and disbenefits associated with incentive-based contractual arrangements (28–33). Patients with incentivised conditions did well—but at the expense of those whose presenting problems were not incentivized, many of whom had significant psychosocial comorbidity that was less likely to be attended to effectively (33). We also confirmed the utility of ‘enablement’ as an outcome measure assessing the extent to which patients feel they understand their illnesses better and feel more able to cope with them, contrasting with ‘satisfaction’, which may mean no more than that expectations are fulfilled even although these may have been modest. Our work thus far had lacked information on continuity of care and on the ethnicity of patients and doctors, and in our next and most ambitious study that included these variables, we
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become an antibiotic prescriber or not and unable to find any helpful guidance in the literature, I was supported by Lederle pharmaceuticals to carry out arandomised controlled trial in our own and a neighbouring practice (with Angus Clark) during the winter of 1969/70 (fortunately for our trial an epidemic year). The results showed no advantage for antibiotic takers (11,12). I spent the next 30 years trying to explain why the findings have had so little impact! Moving to an academic position in Aberdeen, I was fortunate to have access to the recent north-east Scotland workload study designed by Ian Richardson. This showed wide variation between GPs in how they named illnesses and prescribed antibiotics (13). My next study tested the hypothesis that doctors (at least for RTI) often decide on treatment first and rationalize their decisions by adding an appropriate diagnostic label (14,15). I then confirmed the legitimacy of this conclusion with a simulated-patient interview study with 20 local GPs (16). Then followed two landmark studies; the first was the ‘sore throats’ study. We prepared booklets of pictures of red throats all with the same clinical histories. Extra contextual information was added randomly to half the pictures in each booklet so that each contained an equal number of neutral and ‘loaded’ situations. (The additional information included the patient living in a remote part of the practice; being ill on a Friday evening; a student due to sit an examination; a teacher going for a job interview; a mother struggling to cope with young twins; a child whose brother is in hospital with pneumonia; a family about to go abroad on holiday.) The booklets were sent to 1000 Royal College of General Practitioners members who were asked whether they would prescribe antibiotics in the circumstances described. The responses showed that decisions to prescribe antibiotics were often influenced by non-biomedical factors (17). The second study showed that children of psychotropictaking mothers were more likely to be prescribed antibiotics than were the children of non-psychotropic-taking mothers (18) and that the age curve for antibiotic use in the children was a mirror image of the curve for psychotropic use by their mothers. Given that by now the case for less rather than more prescribing for general practice RTIs had been made (particularly for the classic ‘sore throat’ presentation), the one issue still to be addressed was whether withholding antibiotics might increase the risk of streptococcal sequelae—particularly rheumatic fever and also glomerulonephritis and quinsy. With Jack Taylor, we undertook an imaginative piece of epidemiological work that discounted the likelihood that glomerulonephritis was linked to non-prescribing of antibiotics at presenting sore throat consultations (at least in Scotland and at this time), and we repeated the work for rheumatic fever with Bruce Foggo (then visiting from New Zealand) (19,20). (A matching study of patients with quinsy was started by another research fellow but never finished; Paul Little in Southampton later filling this gap and coming to the
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truths. Just as GPs can be unambiguously disease centred and effective when that is appropriate, so also can hospital physicians be highly patient centred when that is what is needed. Although I did not realize it at the time, my appendicitis portfolio had shown that, for example surgical decision-making is also influenced by non-biomedical determinants. My conclusion is that rather than being fundamentally different, general practice and hospital medicine are on a continuum and that practitioners of each routinely balance both social/behavioural and biomedical science influences in their decision-making. However, the relative weighting of these sciences applicable in the two different settings is sufficiently different for general practice to be rightly regarded as a discipline in its own right. Thus I see ‘general practice’ as a statement of location, and ‘general practitioners’ as the description of those who work in that location. Generalism is inherently different from specialism because of its breadth, and it has developed its own set of clinical skills to reflect its very different case-mix. Thus, I think it is better to describe general practice as an independent clinical discipline than as a specialty.
Reflection
The academic task
Fifty years ago, general practice was often portrayed as a career for those who had not succeeded in becoming specialists. It had only just attained its own College, and the first professor in the subject was about to be appointed in Edinburgh. Ian McWhinney (41) defined the criteria of a discipline as having a defined clinical territory, specific skills, the ability to support research and its own postgraduate training. Ian Richardson (42) added the need to have an identifiable philosophy. General practice has claimed ‘patient centredness’ (in contrast to disease centredness) as that philosophy. But is ‘patient centredness’ truly the property of general practice? And can it be claimed on its own to be the defining characteristic of the discipline?
The task of the medical academic includes teaching, research, clinical work and advocacy. For me, research is the pivotal activity. Ideally, it should attempt to develop basic understanding/theory in a particular sphere of interest. Mine was the determinants of good consulting practice. My second and third bodies of work were clearly directed to that end. By chance, it turned out that my first body of work on appendicitis fitted well with my later conclusions about the overlapping nature of generalism and specialism. Additionally, these bodies of work help explain why guideline—and target-driven—care is not always seen as appropriate, especially by those working in the setting of general practice. [Elsewhere, I have expanded on the thinking behind the creation of a descriptive/diagrammatic model of the determinants of good consulting practice (43).]
The identity of the discipline How did my researches help define the special identity of general practice and enable me to promote my discipline as a credible academic subject within medical schools? The work on prescribing antibiotics for respiratory illnesses and on the determinants of quality at consultations showed that decision-making in general practice is significantly influenced by issues of context and by the culture of and interactions between doctors and patients, all of which combine to modify the biomedical assumptions of conventional hospital clinical teaching. It has been tempting— and unhelpfully divisive—to claim that general practice owns the focus on patients and their beliefs and needs (patient centredness), whereas hospital medicine owns the territory of clinical competence. Both claims are over-simplifications of partial
Universities It is a feature of modern universities that acquiring research funding is the ultimate measure of academic success. The pressure is now on researchers to work in multidisciplinary research groups and to seek funding from major specialist funding organizations. This has led to the disappearance of small departments, including—in nearly all medical schools—departments of general practice, although the importance of the discipline’s contribution to teaching has grown hugely in recent years. In addition, the kind of researches into the nature of care in general practice (for example defining the determinants of quality of care at consultations) that I have focussed on during my
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worked with cohorts of doctors and patients in Lothian, west London, Oxford and Coventry. This study again produced a significant series of publications confirming that the doctors who enabled most were also those who spent longer with patients and offered better continuity of care (34). There were interesting and important findings about consultations where patients and doctors consulted in languages other than English (35). We proposed a measure of quality of care at consultations [the Consultation Quality Index (CQI)], which we had found identified some 2% of doctors with a variety of important health/ quality problems, but the team broke up after my retirement and we did not manage to test it prospectively (36). Three later articles contributed to the developing debate on the construction of measures of quality in general practice (37–39). A final publication (with Stewart Mercer) (40) included his ‘empathy’ measure and produced an improved measure (the CQI-2)—now best used without the ‘consultation length’ variable that has been outdated by the new methods of working, which have followed on from the UK Department of Health’s ‘Quality and Outcomes Framework’ initiative.
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In retrospect—a reflection on a 50-year research journey
own career is now harder than ever to fund through conventional streams. In the years ahead, our discipline is going to have to strive hard to maintain and promote its identity within the Institutions of Higher Education. Failure to keep a strong academic presence will lead inexorably to our losing the ability to influence decisions on health policy.
Acknowledgements
Clinical care
Declaration
It is a concern in all forms of clinical practice that governmentset targets and contract incentives have come to assume such prominence in medical care. To meet these pressures, general practices have become steadily larger, and continuity of care correspondingly poorer. The needs and wishes of patients—and indeed the values and preferences of many (if not most) clinicians are too often given secondary priority. Psychosocial issues are widely perceived to have been the main casualty (as our earlier work on fund holding demonstrated) and general practice medicine is the poorer for it. It is understandable that unacceptable variations in the care delivered for well-defined biomedical problems should have led to target-driven care in appropriate clinical situations, but for the larger part of the general practice task, needs and wishes of patients do not fit comfortably into a disease-centred template. Now with a good research-based understanding of the true nature of our discipline, it should be possible for practising clinicians to reclaim ownership of the political environment that determines the structure and delivery of general practice services. Alvin Feinstein, a distinguished American epidemiologist, wrote in The Lancet of 1970 ‘Until the methods of science are made satisfactory for all the important distinctions of human phenomena, our best approach to many problems in therapy will be to rely on the judgements of thoughtful people who are familiar with the total realities of human ailments’ (44). I hope the work I have described in this essay has helped to tease out how these judgements are made and how they can be better understood and used for the benefit of patient care.
Funding: none. Ethical approval: none. Conflict of interest: none.
Research is a compelling activity—exciting but often frustrating; hard work but eventually rewarding; when successful, fun and addictive. Having an interest in research should be an integral part of any medical career, but it needs a purpose, and it is most satisfying when it pursues a question of interest and importance to the researcher. The more difficult the problem being tackled, the more important it is to break it down into smaller parts. Well done, it will make a real difference to the care and well-being of patients.
References 1. Howie JGR. Patient-Centredness and the Politics of Change. A Day in the Life of Academic General Practice. London: The Nuffield Trust, 1999, pp. 7–24. 2. Howie JGR. Too few appendicectomies? Lancet 1964; i: 1240–42. 3. Howie JGR. The prussian-blue reaction in the diagnosis of previous appendicitis. J Pathol Bacteriol 1996; 91: 85–92. 4. Howie JGR. The morbidity of non-operative treatment of possible appendicitis. Scott Med J 1968; 13: 68–71. 5. Howie JGR. The morbidity of appendicectomy. Scott Med J 1968; 13: 72–7. 6. Howie JGR. Death from appendicitis and appendicectomy. Lancet 1966; ii: 1344–47. 7. Howie JGR. The place of appendicectomy in the treatment of young adult patients with possible appendicitis. Lancet 1968; i: 1365–7. 8. Howie JGR. Mesenteric adenitis. Br Med J 1969; ii: 449–50. 9. Howie JGR. Appendicectomy and family history. Br Med J 1979; 2: 1003. 10. Howie JGR, Timperley WR. Cancer and appendectomy. Cancer 1966; 19: 1138–42. 11. Howie JGR, Clark GA. Double-blind trial of early demethylchlortetracycline in minor respiratory illness in general practice. Lancet 1970; 2: 1099–102. 12. Fahey T, Howie J. Re-evaluation of a randomized controlled trial of antibiotics for minor respiratory illness in general practice. Fam Pract 2001; 18: 246–8. 13. Howie JGR, Richardson IM, Gill G, Durno D. Respiratory illness and antibiotic use in general practice. J R Coll Gen Pract 1971; 21: 657–63. 14. Howie JGR. Diagnosis–the Achilles heel? J R Coll Gen Pract 1972; 22: 310–5. 15. Howie JGR. A new look at respiratory illness in general practice. A reclassification of respiratory illness based on antibiotic prescribing. J R Coll Gen Pract 1973; 23: 895–904. 16. Howie JGR. Further observations on diagnosis and management of general practice respiratory illness using simulated patient consultations. Br Med J 1974; ii: 540–3. 17. Howie JGR. Clinical judgement and antibiotic use in general practice. Br Med J 1976; 2: 1061–4. 18. Howie JGR, Bigg AR. Family trends in psychotropic and antibiotic prescribing in general practice. Br Med J 1980; 280: 836–8.
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Conclusion
The researches described in this essay have depended on the support and contributions of many others. Their names are found as co-authors throughout the text and in the reference list attached. I am deeply grateful to what each has contributed. The reference list is almost entirely personal; each article contains its own references that give a fuller picture of how the journey has fitted into the work of others.
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32. Howie JGR, Heaney DJ, Maxwell M. Evaluating care of patients reporting pain in fundholding practices. BMJ 1994; 309: 705–10. 33. Howie JGR, Heaney DJ, Maxwell M. Care of patients with selected health problems in fundholding practices in Scotland in 1990 and 1992: needs, process and outcome. Br J Gen Pract 1995; 45: 121–6. 34. Howie JGR, Heaney DJ, Maxwell M, Walker JJ, Freeman GK, Rai H. Quality at general practice consultations: cross sectional survey. BMJ 1999; 319: 738–43. 35. Freeman GK, Rai H, Walker JJ, Howie JGR, Heaney DJ, Maxwell M. Non-English speakers consulting with the GP in their own language: a cross-sectional survey. Br J Gen Pract 2002; 52: 36–8. 36. Howie JGR, Heaney DJ, Maxwell M, Walker JJ, Freeman GK. Developing a ‘consultation quality index’ (CQI) for use in general practice. Fam Pract 2000; 17: 455–61. 37. Maxwell M, Heaney DJ, Howie JGR, Walker JJ, Freeman GK. Acceptability of methods and measures used to determine quality of general practice consultations: results of a focus group study and an acceptability questionnaire. Prim Health Care Res Dev 2002; 3: 29–41. 38. Heaney DJ, Walker JJ, Howie JGR et al. The development of a routine NHS data-based index of performance in general practice (NHSPPI). Fam Pract 2002; 19: 77–84. 39. Mercer SW, Howie JGR. CQI-2–a new measure of holistic interpersonal care in primary care consultations. Br J Gen Pract 2006; 56: 262–8. 40. Howie JGR, Heaney D, Maxwell M. Quality, core values and the general practice consultation: issues of definition, measurement and delivery. Fam Pract 2004; 21: 458–68. 41. McWhinney IR. General practice as an academic discipline. Reflections after a visit to the United States. Lancet 1966; 1: 419–23. 42. Richardson IM. The value of a university department of general practice. Br Med J 1975; 4: 740–2. 43. Howie JGR. Diagnosis in general practice and its implications for quality of care. J Health Serv Res Policy 2010; 15: 120–2. 44. Feinstein AR. The need for humanised science in evaluating medication. Lancet 1972; 2: 421–3.
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19. Taylor JL, Howie JGR. Antibiotics, sore throats and acute nephritis. J R Coll Gen Pract 1983; 33: 783–6. 20. Howie JGR, Foggo BA. Antibiotics, sore throats and rheumatic fever. J R Coll Gen Pract 1985; 35: 223–4. 21. Howie JGR, Hutchison KR. Antibiotics and respiratory illness in general practice: prescribing policy and work load. Br Med J 1978; 2: 1342. 22. Howie JGR, Porter AM, Forbes JF. Quality and the use of time in general practice: widening the discussion. BMJ 1989; 298: 1008–10. 23. Porter AM, Howie JGR, Levinson A. Measurement of stress as it affects the work of the general practitioner. Fam Pract 1985; 2: 136–46. 24. Howie JGR, Heaney DJ, Maxwell M, Walker JJ. A comparison of a Patient Enablement Instrument (PEI) against two established satisfaction scales as an outcome measure of primary care consultations. Fam Pract 1998; 15: 165–71. 25. Howie JGR, Hopton JL, Heaney DJ, Porter AM. Attitudes to medical care, the organization of work, and stress among general practitioners. Br J Gen Pract 1992; 42: 181–5. 26. Howie JGR, Heaney DJ, Maxwell M. Measuring quality in general practice. Roy Coll Gen Pract 1997; Occ Paper 75, 1–32. 27. Howie JGR, Porter AM, Heaney DJ, Hopton JL. Long to short consultation ratio: a proxy measure of quality of care for general practice. Br J Gen Pract 1991; 41: 48–54. 28. Howie JGR, Heaney DJ, Maxwell M, Porter AM, Hopton JL, Light CJ. The chief scientist reports. The Scottish general practice shadow fund-holding project–outline of an evaluation. Health Bull 1992; 50: 316–28. 29. Howie JGR, Heaney DJ, Maxwell M. Evaluation of the Scottish Shadow Fund Holding Project: First Results. Health Bull 1993; 51: 94–105. 30. Maxwell M, Heaney D, Howie JGR, Noble S. General practice fundholding: observations on prescribing patterns and costs using the defined daily dose method. BMJ 1993; 307: 1190–4. 31. Heaney DJ, Howie JGR, Maxwell M. The referral component of fundholding: Can both quantity and quality be assessed on routine data? Health Bull 1994; 52: 285–96.
Family Practice, 2014, Vol. 31, No. 1
In retrospect—a reflection on a 50-year research journey John G R Howie* Emeritus professor of general practice, University of Edinburgh, 4 Ravelrig Park, Balerno, Edinburgh EH14 7DL, UK.
Received July 11 2013; revised November 4 2013; Accepted November 5 2013.
This essay is a personal review of a research journey extending over 50 years during which time the understanding of medical practice has changed out of all recognition and the quality and standing of the discipline of general practice has improved substantially. Three main bodies of work are reviewed and set against the reasons why they were undertaken. The first, on the pathology of the appendix and the management of possible appendicitis, was carried out almost entirely in the hospital setting. The second, about the prescribing of antibiotics for respiratory illnesses, and the third, about the determinants of good consulting practice, were carried out in general practice. The essay concludes with a reflection on the relevance of the work to some contemporary academic and health service issues. Although the work was carried out in the UK in the context of its National Health Service (NHS), the conclusions are widely generalizable and have contributed to health service and academic developments in many other countries. Keywords: Consultations, decision-making, general practice, prescribing, research, theory.
Introduction I was always a problem-centred and hypothesis-driven researcher, and my attempt to create a model of how clinical decisions are made was probably an inevitable component of my academic life.
I qualified in medicine in 1961, having always intended to become a GP. Elsewhere (1), I have described the twists of fate that eventually led me into my career as an academic in general practice. My starting point was the frustration I felt about both my school and University education with their emphases on rote learning to the exclusion of fostering understanding. As a clinical student, I soon realized that senior clinicians did not always practice what they taught and that they presented their views of correct practice without being up-front about the range of differing approaches taken by others. The management of uncertainty was a closed book. My principal research activities were encompassed in three distinct research programmes, one each mainly in Glasgow, Aberdeen and Edinburgh. They are described in turn. In my early years, I saw problems in rather black and white terms, and my early researches while based in pathology reflected that. As I moved into general practice, clinical experience brought different and richer colours to my researches. But wherever I was working,
Appendicitis and abdominal pain (Glasgow: c1961–66) I decided to study medicine only in my last year at school after having my appendix removed. So appendicitis was always a subject close to my heart. In my first job as a house surgeon, one of my seniors seemed to take particular delight in questioning my decisions to call him in or to wait for morning. I was often unconvinced by his judgements but impressed by the difficulties of separating right from wrong. Possible appendicitis was the commonest surgical emergency in the 1960s, and classical appendicitis was much less common than was appendicectomy. Naked-eye examination of appendices removed in theatre was highly subjective, and few clinical
© The Author 2013. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected].
1
Downloaded from http://fampra.oxfordjournals.org/ at Kungl Tekniska Hogskolan Biblioteket on July 11, 2015
*Correspondence to John G R Howie, Emeritus professor of general practice, University of Edinburgh, 4 Ravelrig Park, Balerno, Edinburgh EH14 7DL, UK; E-mail: [email protected]
Family Practice, 2014, Vol. 31, No. 1
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to remove appendices from the children of medical colleagues and from nurses than from other population groups. While on a rotation through an immunology department, I was asked to explore the then current suggestion of a link between appendicectomy and the later development of malignancy, particularly in the bowel. Theoretically, this seemed plausible given that the analogue to the appendix in the hen is the driver of its immune mechanisms. My work was in two parts. First a careful deconstruction of the original article in Cancer showed a significant flaw in the matching of its control population (half the control patients—although matched for age—had died a decade before the test patients, taking them back in their younger years to before appendicectomy had become fashionable). Then a prospective study using the west of Scotland cancer register and controls from the Glasgow general practice I was about to join as a partner confirmed that cancer patients were no more likely to have had their appendices removed than were controls (10).
1966 After 4 years in pathology, I became a partner in a local practice in which I had been ‘moonlighting’ for the previous 2 years. Two episodes in my first 3 months were to have a lasting influence on my career as an academic in general practice. One November morning, I visited an elderly man living alone in a single room with outside toilet. He was clearly terminally ill, almost certainly with prostate cancer. The professor’s unit in the teaching hospital I had just left was on call but claimed to have no room for my patient. I was crudely bullied by his registrar about what tests I had done (not only did I know my patient’s mean corpuscular haemoglobin concentration but I also knew what it meant). I went straight to the hospital, confirmed a plenitude of empty beds and sent my patient in by ambulance. He died next day; I vowed to challenge and change the values and behaviour of teaching hospitals towards GPs and their patients. Two weeks later, I attended a Sunday postgraduate lecture with a hundred or more colleagues. We signed a register that brought us payment for attending; the lecturer gave his services free. We had coffee, went in to the lecture theatre and the lights were put out to show some fluorescent micrographs. When the lights went back on, more than half the doctors had left. The lecturer said simply ‘so this is what general practice is about’. My mission now had an added dimension.
Respiratory illness and antibiotic prescribing (Glasgow: 1966–70; Aberdeen: 1970–80; Edinburgh 1980–c1985) Now in full-time general practice and faced with my first winter respiratory tract infection (RTI) epidemic, uncertain whether to
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diagnoses were tested against pathological examination. Early in my originally intended single year in pathology, I started looking at the correlation between symptoms and pathology and decided to correlate each with recurrence of symptoms. The first ‘discovery’ was that the management of appendicitis and abdominal pain was anything but ‘evidence based’. There was no definition of where microscopic normality stopped and abnormality started. Early in my 2-year pathology-based study of all appendices removed in the Western Infirmary of Glasgow, I chanced on a beautiful slide showing large deposits of golden pigment (iron) in an appendix abscess. My mentor encouraged me to examine the specimen using a special iron stain. The picture was remarkable, with iron deposits everywhere. So I stained all my specimens for iron and correlated the findings with recent history of abdominal pain. The correlation was good—better for males than for females in whom the turnover of iron was no doubt faster. Crucially, this finding helped to remove the myth of ‘chronic appendicitis’ from consideration as a diagnostic entity. So began a series of epidemiological studies into the relation between abdominal pain and appendicitis. I developed a histological classification (2), published work on the use of stainable iron as a diagnostic technique (3), assessed the morbidity (short term and longer term) of removing and of not removing the appendix for patients presenting with abdominal pain (4,5) and analysed the mortality from appendicitis and appendicectomy based on all relevant patients in Scotland dying over a 10-year period (6). This mortality study was one of the pieces of research I enjoyed most. Using projections from the parallel work I was doing on classifying appendices histologically, I was able to show progressively worsening death rates as age and the severity of the inflammatory process increased. There was also a fascinating gender difference, death rates for males being double those for females at each age and pathology group. Finally, I analysed the outcomes in young females cared for in ‘conservative’ surgical units (operating in three out of five patients admitted) and in ‘radical’ surgical units (operating in four out of five), finding mortality rates equivalent but overall morbidity less and symptom relief better in units with the more radical approach to operative intervention (7). There were other interesting findings. With help from the ‘stainable iron’ discovery, ‘mesenteric adenitis’ was found to contain two subgroups. Patients with positive iron in their appendices (half of those concerned) had the same cure rate as patients with undisputed appendicitis, whereas those without iron had the same symptom recurrence rate as those having normal appendices removed (8). And—serendipitously anticipating the findings in my later work on antibiotic prescribing for general practice respiratory illnesses—there was evidence that non-clinical ‘patient’ and ‘doctor’ factors influenced clinical decision-making (9). In particular, I found that appendicectomy but not appendicitis runs in families. I was also able to show that surgeons were more likely
In retrospect—a reflection on a 50-year research journey
same conclusion.) Earlier, we had shown (in a rather small study) that being a high-antibiotic prescriber appeared to generate rather than prevent reconsultation, calling into doubt another common justification for prescribing antibiotics for minor indications (21). Now in Edinburgh, I wanted to complete the RTI story by showing that when doctors were stressed, the proportion of unnecessary antibiotics prescribed increased. The design of our subsequent ‘stress study’ did not allow us to link prescribing specifically to sore throats, but one analysis did show that running late (a major stressor) was associated with higher prescribing for RTIs and less attention to psychosocial comorbidity (22)—a quality issue we were to focus on in subsequent work.
The determinants of good general practice consultations (Edinburgh: 1980–c2006) Coming to Edinburgh marked the start of a fulfilling partnership first with Mike Porter (a medical sociologist) and then with others (in particular David Heaney and Margaret Maxwell in Edinburgh and George Freeman in London). Taking up the hypothesis referred to above that working under stress was harmful to the quality of consultations, we piloted a way of self-reporting stress and stressors. Our subsequent ‘stress study’ (23) also incorporated the fore-runner of our ‘enablement’ outcome measure (which we then developed with help from Jeremy Walker) (24). We collected some evidence that attitudes to care affected the way doctors consulted (with Jane Hopton) (25) and published the Royal College of General Practitioners Occasional Paper no 75 (26), which described in detail how our methods had been developed and presented the case for using consultation length as a proxy for quality of care at consultations (27). It was our good fortune that just as we were wondering how best to continue this work, the Scottish Government commissioned us to evaluate the 1990 NHS Shadow Fund-holding Project in the north-east of Scotland. We used our developing expertise with large consultation-based projects to produce a series of six articles that suggested, among other things, that there were both benefits and disbenefits associated with incentive-based contractual arrangements (28–33). Patients with incentivised conditions did well—but at the expense of those whose presenting problems were not incentivized, many of whom had significant psychosocial comorbidity that was less likely to be attended to effectively (33). We also confirmed the utility of ‘enablement’ as an outcome measure assessing the extent to which patients feel they understand their illnesses better and feel more able to cope with them, contrasting with ‘satisfaction’, which may mean no more than that expectations are fulfilled even although these may have been modest. Our work thus far had lacked information on continuity of care and on the ethnicity of patients and doctors, and in our next and most ambitious study that included these variables, we
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become an antibiotic prescriber or not and unable to find any helpful guidance in the literature, I was supported by Lederle pharmaceuticals to carry out arandomised controlled trial in our own and a neighbouring practice (with Angus Clark) during the winter of 1969/70 (fortunately for our trial an epidemic year). The results showed no advantage for antibiotic takers (11,12). I spent the next 30 years trying to explain why the findings have had so little impact! Moving to an academic position in Aberdeen, I was fortunate to have access to the recent north-east Scotland workload study designed by Ian Richardson. This showed wide variation between GPs in how they named illnesses and prescribed antibiotics (13). My next study tested the hypothesis that doctors (at least for RTI) often decide on treatment first and rationalize their decisions by adding an appropriate diagnostic label (14,15). I then confirmed the legitimacy of this conclusion with a simulated-patient interview study with 20 local GPs (16). Then followed two landmark studies; the first was the ‘sore throats’ study. We prepared booklets of pictures of red throats all with the same clinical histories. Extra contextual information was added randomly to half the pictures in each booklet so that each contained an equal number of neutral and ‘loaded’ situations. (The additional information included the patient living in a remote part of the practice; being ill on a Friday evening; a student due to sit an examination; a teacher going for a job interview; a mother struggling to cope with young twins; a child whose brother is in hospital with pneumonia; a family about to go abroad on holiday.) The booklets were sent to 1000 Royal College of General Practitioners members who were asked whether they would prescribe antibiotics in the circumstances described. The responses showed that decisions to prescribe antibiotics were often influenced by non-biomedical factors (17). The second study showed that children of psychotropictaking mothers were more likely to be prescribed antibiotics than were the children of non-psychotropic-taking mothers (18) and that the age curve for antibiotic use in the children was a mirror image of the curve for psychotropic use by their mothers. Given that by now the case for less rather than more prescribing for general practice RTIs had been made (particularly for the classic ‘sore throat’ presentation), the one issue still to be addressed was whether withholding antibiotics might increase the risk of streptococcal sequelae—particularly rheumatic fever and also glomerulonephritis and quinsy. With Jack Taylor, we undertook an imaginative piece of epidemiological work that discounted the likelihood that glomerulonephritis was linked to non-prescribing of antibiotics at presenting sore throat consultations (at least in Scotland and at this time), and we repeated the work for rheumatic fever with Bruce Foggo (then visiting from New Zealand) (19,20). (A matching study of patients with quinsy was started by another research fellow but never finished; Paul Little in Southampton later filling this gap and coming to the
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truths. Just as GPs can be unambiguously disease centred and effective when that is appropriate, so also can hospital physicians be highly patient centred when that is what is needed. Although I did not realize it at the time, my appendicitis portfolio had shown that, for example surgical decision-making is also influenced by non-biomedical determinants. My conclusion is that rather than being fundamentally different, general practice and hospital medicine are on a continuum and that practitioners of each routinely balance both social/behavioural and biomedical science influences in their decision-making. However, the relative weighting of these sciences applicable in the two different settings is sufficiently different for general practice to be rightly regarded as a discipline in its own right. Thus I see ‘general practice’ as a statement of location, and ‘general practitioners’ as the description of those who work in that location. Generalism is inherently different from specialism because of its breadth, and it has developed its own set of clinical skills to reflect its very different case-mix. Thus, I think it is better to describe general practice as an independent clinical discipline than as a specialty.
Reflection
The academic task
Fifty years ago, general practice was often portrayed as a career for those who had not succeeded in becoming specialists. It had only just attained its own College, and the first professor in the subject was about to be appointed in Edinburgh. Ian McWhinney (41) defined the criteria of a discipline as having a defined clinical territory, specific skills, the ability to support research and its own postgraduate training. Ian Richardson (42) added the need to have an identifiable philosophy. General practice has claimed ‘patient centredness’ (in contrast to disease centredness) as that philosophy. But is ‘patient centredness’ truly the property of general practice? And can it be claimed on its own to be the defining characteristic of the discipline?
The task of the medical academic includes teaching, research, clinical work and advocacy. For me, research is the pivotal activity. Ideally, it should attempt to develop basic understanding/theory in a particular sphere of interest. Mine was the determinants of good consulting practice. My second and third bodies of work were clearly directed to that end. By chance, it turned out that my first body of work on appendicitis fitted well with my later conclusions about the overlapping nature of generalism and specialism. Additionally, these bodies of work help explain why guideline—and target-driven—care is not always seen as appropriate, especially by those working in the setting of general practice. [Elsewhere, I have expanded on the thinking behind the creation of a descriptive/diagrammatic model of the determinants of good consulting practice (43).]
The identity of the discipline How did my researches help define the special identity of general practice and enable me to promote my discipline as a credible academic subject within medical schools? The work on prescribing antibiotics for respiratory illnesses and on the determinants of quality at consultations showed that decision-making in general practice is significantly influenced by issues of context and by the culture of and interactions between doctors and patients, all of which combine to modify the biomedical assumptions of conventional hospital clinical teaching. It has been tempting— and unhelpfully divisive—to claim that general practice owns the focus on patients and their beliefs and needs (patient centredness), whereas hospital medicine owns the territory of clinical competence. Both claims are over-simplifications of partial
Universities It is a feature of modern universities that acquiring research funding is the ultimate measure of academic success. The pressure is now on researchers to work in multidisciplinary research groups and to seek funding from major specialist funding organizations. This has led to the disappearance of small departments, including—in nearly all medical schools—departments of general practice, although the importance of the discipline’s contribution to teaching has grown hugely in recent years. In addition, the kind of researches into the nature of care in general practice (for example defining the determinants of quality of care at consultations) that I have focussed on during my
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worked with cohorts of doctors and patients in Lothian, west London, Oxford and Coventry. This study again produced a significant series of publications confirming that the doctors who enabled most were also those who spent longer with patients and offered better continuity of care (34). There were interesting and important findings about consultations where patients and doctors consulted in languages other than English (35). We proposed a measure of quality of care at consultations [the Consultation Quality Index (CQI)], which we had found identified some 2% of doctors with a variety of important health/ quality problems, but the team broke up after my retirement and we did not manage to test it prospectively (36). Three later articles contributed to the developing debate on the construction of measures of quality in general practice (37–39). A final publication (with Stewart Mercer) (40) included his ‘empathy’ measure and produced an improved measure (the CQI-2)—now best used without the ‘consultation length’ variable that has been outdated by the new methods of working, which have followed on from the UK Department of Health’s ‘Quality and Outcomes Framework’ initiative.
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In retrospect—a reflection on a 50-year research journey
own career is now harder than ever to fund through conventional streams. In the years ahead, our discipline is going to have to strive hard to maintain and promote its identity within the Institutions of Higher Education. Failure to keep a strong academic presence will lead inexorably to our losing the ability to influence decisions on health policy.
Acknowledgements
Clinical care
Declaration
It is a concern in all forms of clinical practice that governmentset targets and contract incentives have come to assume such prominence in medical care. To meet these pressures, general practices have become steadily larger, and continuity of care correspondingly poorer. The needs and wishes of patients—and indeed the values and preferences of many (if not most) clinicians are too often given secondary priority. Psychosocial issues are widely perceived to have been the main casualty (as our earlier work on fund holding demonstrated) and general practice medicine is the poorer for it. It is understandable that unacceptable variations in the care delivered for well-defined biomedical problems should have led to target-driven care in appropriate clinical situations, but for the larger part of the general practice task, needs and wishes of patients do not fit comfortably into a disease-centred template. Now with a good research-based understanding of the true nature of our discipline, it should be possible for practising clinicians to reclaim ownership of the political environment that determines the structure and delivery of general practice services. Alvin Feinstein, a distinguished American epidemiologist, wrote in The Lancet of 1970 ‘Until the methods of science are made satisfactory for all the important distinctions of human phenomena, our best approach to many problems in therapy will be to rely on the judgements of thoughtful people who are familiar with the total realities of human ailments’ (44). I hope the work I have described in this essay has helped to tease out how these judgements are made and how they can be better understood and used for the benefit of patient care.
Funding: none. Ethical approval: none. Conflict of interest: none.
Research is a compelling activity—exciting but often frustrating; hard work but eventually rewarding; when successful, fun and addictive. Having an interest in research should be an integral part of any medical career, but it needs a purpose, and it is most satisfying when it pursues a question of interest and importance to the researcher. The more difficult the problem being tackled, the more important it is to break it down into smaller parts. Well done, it will make a real difference to the care and well-being of patients.
References 1. Howie JGR. Patient-Centredness and the Politics of Change. A Day in the Life of Academic General Practice. London: The Nuffield Trust, 1999, pp. 7–24. 2. Howie JGR. Too few appendicectomies? Lancet 1964; i: 1240–42. 3. Howie JGR. The prussian-blue reaction in the diagnosis of previous appendicitis. J Pathol Bacteriol 1996; 91: 85–92. 4. Howie JGR. The morbidity of non-operative treatment of possible appendicitis. Scott Med J 1968; 13: 68–71. 5. Howie JGR. The morbidity of appendicectomy. Scott Med J 1968; 13: 72–7. 6. Howie JGR. Death from appendicitis and appendicectomy. Lancet 1966; ii: 1344–47. 7. Howie JGR. The place of appendicectomy in the treatment of young adult patients with possible appendicitis. Lancet 1968; i: 1365–7. 8. Howie JGR. Mesenteric adenitis. Br Med J 1969; ii: 449–50. 9. Howie JGR. Appendicectomy and family history. Br Med J 1979; 2: 1003. 10. Howie JGR, Timperley WR. Cancer and appendectomy. Cancer 1966; 19: 1138–42. 11. Howie JGR, Clark GA. Double-blind trial of early demethylchlortetracycline in minor respiratory illness in general practice. Lancet 1970; 2: 1099–102. 12. Fahey T, Howie J. Re-evaluation of a randomized controlled trial of antibiotics for minor respiratory illness in general practice. Fam Pract 2001; 18: 246–8. 13. Howie JGR, Richardson IM, Gill G, Durno D. Respiratory illness and antibiotic use in general practice. J R Coll Gen Pract 1971; 21: 657–63. 14. Howie JGR. Diagnosis–the Achilles heel? J R Coll Gen Pract 1972; 22: 310–5. 15. Howie JGR. A new look at respiratory illness in general practice. A reclassification of respiratory illness based on antibiotic prescribing. J R Coll Gen Pract 1973; 23: 895–904. 16. Howie JGR. Further observations on diagnosis and management of general practice respiratory illness using simulated patient consultations. Br Med J 1974; ii: 540–3. 17. Howie JGR. Clinical judgement and antibiotic use in general practice. Br Med J 1976; 2: 1061–4. 18. Howie JGR, Bigg AR. Family trends in psychotropic and antibiotic prescribing in general practice. Br Med J 1980; 280: 836–8.
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Conclusion
The researches described in this essay have depended on the support and contributions of many others. Their names are found as co-authors throughout the text and in the reference list attached. I am deeply grateful to what each has contributed. The reference list is almost entirely personal; each article contains its own references that give a fuller picture of how the journey has fitted into the work of others.
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32. Howie JGR, Heaney DJ, Maxwell M. Evaluating care of patients reporting pain in fundholding practices. BMJ 1994; 309: 705–10. 33. Howie JGR, Heaney DJ, Maxwell M. Care of patients with selected health problems in fundholding practices in Scotland in 1990 and 1992: needs, process and outcome. Br J Gen Pract 1995; 45: 121–6. 34. Howie JGR, Heaney DJ, Maxwell M, Walker JJ, Freeman GK, Rai H. Quality at general practice consultations: cross sectional survey. BMJ 1999; 319: 738–43. 35. Freeman GK, Rai H, Walker JJ, Howie JGR, Heaney DJ, Maxwell M. Non-English speakers consulting with the GP in their own language: a cross-sectional survey. Br J Gen Pract 2002; 52: 36–8. 36. Howie JGR, Heaney DJ, Maxwell M, Walker JJ, Freeman GK. Developing a ‘consultation quality index’ (CQI) for use in general practice. Fam Pract 2000; 17: 455–61. 37. Maxwell M, Heaney DJ, Howie JGR, Walker JJ, Freeman GK. Acceptability of methods and measures used to determine quality of general practice consultations: results of a focus group study and an acceptability questionnaire. Prim Health Care Res Dev 2002; 3: 29–41. 38. Heaney DJ, Walker JJ, Howie JGR et al. The development of a routine NHS data-based index of performance in general practice (NHSPPI). Fam Pract 2002; 19: 77–84. 39. Mercer SW, Howie JGR. CQI-2–a new measure of holistic interpersonal care in primary care consultations. Br J Gen Pract 2006; 56: 262–8. 40. Howie JGR, Heaney D, Maxwell M. Quality, core values and the general practice consultation: issues of definition, measurement and delivery. Fam Pract 2004; 21: 458–68. 41. McWhinney IR. General practice as an academic discipline. Reflections after a visit to the United States. Lancet 1966; 1: 419–23. 42. Richardson IM. The value of a university department of general practice. Br Med J 1975; 4: 740–2. 43. Howie JGR. Diagnosis in general practice and its implications for quality of care. J Health Serv Res Policy 2010; 15: 120–2. 44. Feinstein AR. The need for humanised science in evaluating medication. Lancet 1972; 2: 421–3.
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19. Taylor JL, Howie JGR. Antibiotics, sore throats and acute nephritis. J R Coll Gen Pract 1983; 33: 783–6. 20. Howie JGR, Foggo BA. Antibiotics, sore throats and rheumatic fever. J R Coll Gen Pract 1985; 35: 223–4. 21. Howie JGR, Hutchison KR. Antibiotics and respiratory illness in general practice: prescribing policy and work load. Br Med J 1978; 2: 1342. 22. Howie JGR, Porter AM, Forbes JF. Quality and the use of time in general practice: widening the discussion. BMJ 1989; 298: 1008–10. 23. Porter AM, Howie JGR, Levinson A. Measurement of stress as it affects the work of the general practitioner. Fam Pract 1985; 2: 136–46. 24. Howie JGR, Heaney DJ, Maxwell M, Walker JJ. A comparison of a Patient Enablement Instrument (PEI) against two established satisfaction scales as an outcome measure of primary care consultations. Fam Pract 1998; 15: 165–71. 25. Howie JGR, Hopton JL, Heaney DJ, Porter AM. Attitudes to medical care, the organization of work, and stress among general practitioners. Br J Gen Pract 1992; 42: 181–5. 26. Howie JGR, Heaney DJ, Maxwell M. Measuring quality in general practice. Roy Coll Gen Pract 1997; Occ Paper 75, 1–32. 27. Howie JGR, Porter AM, Heaney DJ, Hopton JL. Long to short consultation ratio: a proxy measure of quality of care for general practice. Br J Gen Pract 1991; 41: 48–54. 28. Howie JGR, Heaney DJ, Maxwell M, Porter AM, Hopton JL, Light CJ. The chief scientist reports. The Scottish general practice shadow fund-holding project–outline of an evaluation. Health Bull 1992; 50: 316–28. 29. Howie JGR, Heaney DJ, Maxwell M. Evaluation of the Scottish Shadow Fund Holding Project: First Results. Health Bull 1993; 51: 94–105. 30. Maxwell M, Heaney D, Howie JGR, Noble S. General practice fundholding: observations on prescribing patterns and costs using the defined daily dose method. BMJ 1993; 307: 1190–4. 31. Heaney DJ, Howie JGR, Maxwell M. The referral component of fundholding: Can both quantity and quality be assessed on routine data? Health Bull 1994; 52: 285–96.
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