BMJ

Health Promotion In The General Practice Consultation: A Minute Makes A Difference

Author(s): A. Wilson, P. McDonald, L. Hayes and J. Cooney
Source: BMJ: British Medical Journal, Vol. 304, No. 6821 (Jan. 25, 1992), pp. 227-230
Published by: BMJ
Stable URL: http://www.jstor.org/stable/29714332
Accessed: 08-05-2015 20:03 UTC
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GENERAL

Health
makes

PRACTICE

in the general

promotion
a difference

A Wilson,

P McDonald,

L Hayes,

J Cooney

Abstract

factors
see

Objective?To
ment
length
to

seven

from

10 minutes

per

would

appoint?
or less

increase

health

of

were

10 minute

six minutes

One

patients

to deliver

per patient).

increased

in Nottinghamshire.
practices
were
recruited.
general
practitioners
were
a booking
or more
rate of eight
an hour,
a wish
for longer consultations,
and

Setting?10

general

patients

to increase
plans
Main
outcome
tions;
cervical

of

blood

of

pressure,

consulta?
and

weight,

in the medical
of
record;
cytology
recording
advice
about
and
alcohol,
diet,
smoking,
exercise,
in the medical
immunisation
of the
record;
reporting
above

activities
in the

7-16 minutes
blood

pressure,
about

advice

in

frequent

health

these

and

of previous
health
was
sessions.
There

coverage
mental
sion

by
Patients

of smoking

of exercise,

sessions,
one
in which
recorded

and

the

or more
in

in the experi?
problems
in discus?
little change
or cervical

cytology

of time is a major
factor
in
Conclusions?Shortage
failure
to realise
their potential
general
practitioners'
in health
General
be
should
promotion.
practice
so that doctors
can run 10 minute
organised
appoint?
ment

Centre,

The

A Wilson,
MRCGP, lecturer
P McDonald,
BSC, research
assistant
L Hayes, ma, research
assistant
J Cooney,
assistant

has

Sciences

BMJ

volume

ing

of non-medical

developments,
common
the most

are
and

frequently

promotion

complaint

or

personnel.3
the
with

consultations
encounters

present
opportunities
at either
issues directed
the broader

needs

of

the

in primary
to raise
the present?
individual

as "all aspects
has been defined
of
promotion
status of
those activities
the health
that seek to improve
and the community."5
individuals
The main
contribu?
of

25 January

To

association.
the

for

date,
have

doctor

ences by individual doctors or be due to the relatively

small

number

of

activities

preventive

sampled.

Many doctors booking patients at less than 10minute

intervals

a desire

for longer appointments,

for
for health
greater
opportunities
a controlled
trial of 10 minute
report

express

including
We
promotion.14

to
for 16 such doctors.
aim was
The
appointments
discover
whether
other
such a change
among
things
would
increase
the amount
of secondary
and tertiary
in the consultation.
The
prevention
study measured
other
have

stress
outcomes,
including
been reported
elsewhere.15

in the doctors,

which

Subjects and methods

were

for participation

Criteria

or more

of eight

patients

an hour,
and plans

a current
a desire

rate
booking
to change
to

to increase
consultations,
longer
appoint?
ment
were
recruited
after a survey
length.
Participants
conducted
of Nottinghamshire
in
general
practitioners
1988, which

a 67%

achieved

rate.

response

Forty

eight

doctors fulfilled the entry criteria, and the first 16 of

these
was

to agree

to take part were

included.
in
of those
eligible

representative

booked

the general

1992

practitioner

is to discuss

lifestyle

eight

patients

This

sample
of age

terms

an

hour.

an hour,

one who

booked

10, and one who booked

10 who booked

patients
therefore

Median

12
was

length

appointment

six minutes.

booked
with
surgeries
appointments
were
to take place
intervals
timetabled
once a fortnight
on a designated
day and time for each
to extend
doctor.
all participants
Although
planned
Experimental
at 10 minute

their

consultation

average

little or as much
Two
patients.
far as possible
week.

patient.4
Health

tion

304

use

these

health
of

and

clinics

promotion

Leicester
Building,
Royal Infirmary, PO Box 65,
Leicester LE2 7LX.
BMJ 1992;304:227-30

care
in primary
and nation?

promotion

been
both
emphasised
internationally
2
In general
to
there is debate
about how
practice
on health
this service, with
increasing
emphasis

care
to:
Correspondence
Dr A Wilson,
Department
General Practice, Clinical

of health

importance

Despite
doctor

this
explain
studies
controlling
in single
practices

and have
produced
to screen?
in relation
results,
particularly
B
and
health
education.10
reflect
These
differ?
may
ing

nine,

ally.1
deliver

MSC, research

however,

experimental
been
based

who

NG7 2UH

rates of screening,
because
of
possibly
of
time.9 Many
availability
confounding
or interests
such as the personality
of the doctor
higher

(median 36-5 years), sex (81%male (n=13)), and list

size (median 2200). The sample included four doctors

sessions.

Introduction

Nottingham

is shortage
of time in the consulta?
shown
smaller
list sizes have been

the

activity.

of General
Department
The Medical
Practice,
School, Queen's Medical

factors
may,

is not

consultation

practice

an

and weight

diet,

and
more

6%
of over
average
more
often
reported
alcohol
and
consumption

increased

sessions.

discussion

of

significantly

were

education

and

Recording

consumption,

was

experimental
consultations

notes

medical

alcohol

8-25

7-04

and

sessions.

the

of

proportion
items
of
in

smoking,
immunisation

were

times
sessions

experimental
in the control

general

reasons

by patients.
consultation

Results?Mean
minutes

cytology.6
of the

inconsistent

appointment
length.
measures?Duration

recording

for specific
arrangements
as blood
or
pressure
recording
studies
that this
suggest
Empirical

such

explanation
Practices
with

tion.

Subjects?16
criteria
Entry

or make

apply
tests,

appoint?
control

with
compared
booked
doctors

in which
the same
surgeries
at their normal
rate (median

and

screening
cervical
potential
realised.79

consultations.

practice
trial

Design?Controlled
ments.
Consultations

extending
a half minutes

and

patient

in general

promotion

whether

a minute

consultation:

practice

The

time,

they

could

as

spend

time as they wished with individual

were
used,
and day of
the period
before

types of control
surgeries
for time of day
matched

first was

drawn

from

as
the
the

took place during

the trial phase,
trial, and the second
an experimental
in the alternate
session
weeks
when
was

not

included

scheduled.
in case

The
of

227

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any

first

control

contaminating

was

session
effect

of

the

longer
second
related
mix

on

bookings
to control

thus

events,

of

were

patients.
included

When

exit

and

entry

times.

doctor

herself.

individual

of
timing
contributed

to

at

were

the

the

noted

and

total

same

estimation

time

subsample
these procedures,

to verify
audiotaped
timing of consultations.
medical

record

assistants

other

although
A

was

36

sessions
including

by one of three
and entries
of the session

reviewed

at the end

consultation

compared
groups
ficant

with

were

compared
variables

Categorical

the

the

was

Agreement
was
also

and questionnaire
x statistic,
by Cohen's
between
agreement

record,

estimated
to measure

used

observers.16'7

Results
included
The
study
tions. Mean
consultation
the

in

sessions

in each

the

espisodes,
and second

or other

problems

was

problems,
the experimental
of "other"
proportion

between
The

in

higher
second

the

sessions

tively; p<0 01 for each pair). Patients

each

was

by using
activity
the medical
from
measured
and

on both

audiotape

the

The

of

episodes

previous

table
l?Duration
sessions

of consulta?
subsample
health
education

for
analysed
same definitions

record.

as for extraction
was
reliability
record
the medical

Interrater
from

extraction

analysis.

doctors

Participating

of consultation

in experimental

were

and

not

control

mental

sessions
less

The

medical

96*6%
mental

No of surgery sessions 91
No of consultations 1514
166
Mean No of patients per session
No (%)of consultations timed
1436(94-8)
7-04
Mean duration (min)
Median duration (min) 60
Lower quintile of duration
(min) 4-0
Upper quintile of duration
9-0
(min)

Second
control

96
1496
156
1421(95-0)
7-16
60

112
1461
13 0
1370(93-8)
8-25
7-0*

and experi?
control,
II shows
Table
that

items

of health

were

education

and

about

diet, weight,
exercise,
more
was
recorded
frequently
these differences
but
sessions,
The
significant.
taking a cervical

proportion
smear was

in
were

recorded.

Discus?

cervical

cytology

the

experimental

not

consistently
in which

of consultations
recorded

did

not

on breast
self examination
Data
type of surgery.
as this was recorded
so infrequently
included
rate of prescribing
did not differ
The
cases).

differ

by
are not

(total five
between

5-0

the
tions

in first

sessions

respectively).
the
showed
the patient
from
questionnaire
in the
towards
increased
health
trends
promotion

pressure
smear

Discussion about weight (nomeasurement

the patient's
and
95-7%,

11-0

sessions

Data
same

(57*1%,
control,

and 56-9%
55-7%,
second
and
control,

of

consulta?

experimental

in experimental and control sessions with health promotion activities recorded in notes
First
control session
(n=1478)

Cervical
Health education:

respectively).

(97-6%,

40

(percentages) of consultations

Procedures:
Recording of blood

second

control,

sessions

cases

100

*First control session v second control session: p=NS; first control session v
experimental session: p<0-001 (Mann-Whitney U test); second control
session v experimental session: p<0-001 (Mann-Whitney U test).

II?Numbers

in first

after

reviewed

of

about smoking,
of blood pressure
and advice
recording
were
and immunisation
alcohol
signifi?
consumption,
as
in the experimental
sessions,
cantly more
frequent
one or
was
in which
of consultations
the proportion
sion

Experimental

was

record
in 96-6%

consultation

more
First
control

table

respec?

in the three

As consultation
length
respectively).
than
times
length,
waiting
changed
appointment
for patients
decreased
17-0,
15*0, and 5-0
(medians
in first control,
second
and experi?
minutes
control,
mental
sessions).

data.

sociodemographic
tions
audiotaped

control

After

to classify

asked

the consulting
leaving
a question?
was
to complete
asked
patient
educa?
about
health
included
which
naire,
questions
of general
and discussion
tion, preventive
procedures
as basic
as well
health
health
and previous
problems,
"other."

control

in age, sex, or social class

types of surgery did not differ
that slightly
fewer
5-15 year olds
distribution
except
were
seen
in the experimental
sessions
7-7%,
(8-3%,
in first control,
second
and 4-9%
and experi?
control,

were

Doctors
in the appendix.
as "new,"
"new
problem
or

first

15*1% and 19-4% in

sessions (21 -8% compared with

and

no
new

the experimental

and health
education
examination,
prescribing,
to a protocol.
from this
Extracts
noted
according
are
to health
related
activities
promotion
protocol

longer
of

new

of

frequency

slightly

consulta?

aminute

(table
I). Comparison
showed
type of session

problems
sessions.

control

and 4471
over

time was
sessions

experimental
mix
patient

differences

299

on

problem,"
room each

by
were

of differences

significance

medical

audiotape,

were

shown

told

between
all three
initially
When
experimental).
signi?
was
observed
each
group
test
The McNemar
other.
sign

to measure

between
data.

not

promotion.

by y; analysis,
one
(two control,
were
differences

compared
was
used

which

health

length
tests.

non-parametric

in the

were

results
of

on

Data
using

and were

the patient
questionnaire
focus of the study was

that a main

have

consultation

of

to see

able

accurate
not

would

with
of whether
question
more
occurred.
health
promotion
one patient
entered
the consulting

was

research

case

in one
times

consultations

length was not attempted,

in the analysis.
included

Each

the task

the main

appointments
more
than

room

exit

and

Entry
with

was

of these

seconds
stopwatches
displayed
to the nearest minute.
More
rounded

by using
duration

longer
When

In four

In three
impossible.
to a receptionist,
and

timed

equal

the patients'
of the
layout

observing
cases
the

this

surgery made
was delegated

about

types of session.
of consultation
duration
three

the
possible
assistant
by a research

measured

in total

with

doctor,

the

time
any
of a similar

the chance
increasing
300 consultations

of the

and

behaviour,
and
factors

seasonal

Roughly
from
each

in each

numbers

a doctor's

for

Second
control session
(n=1432)
(B)
(A)

276(18-7)
56(3-8)
Recordingof weight
taken
19(1-3)

267(18-6)
84(5-9)
20(1-4)

66(4-5)
Smoking
Alcohol
13(0-9)
31(2-1)
Diet
20(1-4)
4(0-3)
Exercise
10(0-7)
25(1-7)
147(9-9)

67(4-7)
20(1-4)
14(1-0)
19(1-3)
2(0-1)
6(0-4)
23(1-6)
126(8-8)

taken)

Discussion about immunisation

Discussion about cervical cytology (smear not taken)
above
items
One ormore of

228

Experimental
(n=1411)
(C)

p Value

336(23-8)
NS
98(6-9)NS
NS
21(1-5)NS

(A)z?(B)
<0-001
NS

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volume

(B)v(C)

<0001

NS
NS

NS
104(7-4)
NS
46(3-3)
<0-01
NS
<0-05
35(2-5)
NS
NS
NS
34(2-4)
<0-001
<0-001
NS
21(1-5)
NS
NS
16(1-1)
NS
NS
NS
38(2-7)
<0-001
NS
218(15-5)

BMJ

(A)z'(C)

304

<0 <0-01
001
<0-001
<0-01

NS
<0-001

25 January

1992

table m?Percentages
(whole numbers) of patients
sessions (denominators for each question varied)

Was smoking mentioned?

Current smoker
Current smokers reporting advice
Blood pressure measured (ages 35-65 only):
Today
Today or within past five years
Was alcohol mentioned?
Was diet mentioned?
Did doctor talk about general health?
Did doctor talk about previous health problems?

One ormore health education items on audiotape

One or more health education items inmedical records

First
control session

Second
control session
(B) (A)

First
control
session
=
(n 229)

Second
control
session
(n=180)

Experimental
session
(n=275)

58(25-3)
23(10-0)

44(24-4)
14(7-8)

78(28-4)
30(10-9)

(A) ?(B)

(A) ?(C)

(B)zKQ

12-4(125/1009)
28-6(294/1028)
20-7 (61/294)

12 1 (95/786)
25-8(212/822)
19-8 (42/212)

16-9(153/906)
27-6 (258/934)
31-8 (82/258)

NS
NS
NS

<005
NS
<001

<005
NS
<001

25-9(110/425)
87-7(373/425)
4-5 (47/1054)
10-6(112/1052)
55-8 (584/1046)
32-7(341/1042)

24-2 (83/343)
900 (309/343)
5-0 (42/839)
11-3(951/839)
50-4(415/824)
34-2(281/821)

38-5(158/410)
96-8 (397/410)
7-0 (67/956)
11-4(108/950)
59-1(555/939)
40-8 (382/937)

NS
NS
NS
NS
<0-05
NS

<0001
<0001
<005
NS
NS
<0001

<0001
<0001
NS
NS
<001
<001

variation

in data

65-8%
first

more

sessions,
The

questionnaire
consultations
(72-1%,

of

by Cohen's
Agreement

health

for

and, for patients

aged 35-65, whether
at the
had
been
measured
pressure
or within
the past five years.
consultation

their

discussed

index

blood

III gives

the

results

Current

smokers,

who

were

were
surgery,
about
smoking

from

the questionnaire.
in all
equally
prevalent
more
to report
likely

much

of

types
advice

the

in

sessions

experimental

(32% compared with 20% and 21% in control sessions).

blood

More

was

measurement

pressure

which
sessions,
experimental
of 35-65
year olds
reporting

in the
reported
the proportion

increased

a procedure

such

in the

past five years to 97% (compared with 88% and 90% in

control
greatest
ence was
control

was
consumption
the differ?
though

alcohol

sessions,
with
the first
only
significant
compared
wrere more
health
session.
Previous
problems

to be discussed
likely
discussion
of general

in

36

the

health

but
sessions,
no
consistent

longer
showed

was

available.
was

audiotape
direct observation

Mean

sessions.

one

and

On

audiotape.

in

more

than

McNemar's

that

test).
sources

two
and

0*30,

twice

the proportions
items of health
and

0-34

in first
sessions

experimental
education

items

the

audiotape
McNemar's

were
than

sign

test)

in the notes

extent

of
differ

control,

agreement

al?
For
in
was

(p<0*01;
between

x
(Cohen's
second
control,

0-41,
and

health
Similarly,
respectively).
on
more
detected
frequently
in the medical
record
(p<001;
but

second

control,

the extent

Sixty

volume

304

25 January

records

and
control,
were
used

1992

229

(0*41)

audiotaped
interobserver

0-84).
(0-74,
taken from

of agreement

did

experimental
to measure

sessions).
interobserver

no differences

showed
second

mix

in

the

or

and

control

first

to seasonal

due

between

sessions

control

only

session,
Further

factors.

of patients

in the experimental
was
the
comparable

and

nearly
of session.

types
assistants

to be

an experi?
monitoring
as their
tasks
included

they were

of whether

mental

control

administering
of data
ency

session,
at the practice.
consist?
the project
The
on examinations
and health
education

between

patient

the

records

that

suggests
record did

medical
The

level

led us

the same
possible
with
each doctor
was

Although
fered between
bias

measure.

once

The
have

the
to

rates

of surgery,
if completion
of
one

of

and were

number
our

of three

the

effect

have

As

was
of

far

as

concerned
interobserver

in the
already
reluctant

the questionnaire
dif?
be a source
this would
the

factors

reason

likeliest

affected

average

so

for health
may

intervals.
assistant

types

The

control

control

between
10 minute

and

in extraction

in recording
sessions
and

difference

research

patients
sessions
had

naire

the

response

several

that

only moderate
in classification

reduced.

only
with

associated

the

from

was

errors

promotion
at
booked

raters

between

of agreement
record

to underestimate

health

the medical

extraction

occur.

not

These

and

questionnaire
bias
in

the medical

education.

of

health

not differ (Cohen's x 0-41, 0-30, and 0-34 in first

BMJ

unaware

variability

on

detected

sessions,
experimental
not
reach
significance.

not

did

were

being
rates in all three
identical
prescribing
not possible
It was
for the research

sessions

the

recorded

The

activities
x statistic

sessions

of

did
though
of consultations
each
the number
type of session
was detected
on audiotape
which
health
education

the

control

by

there was more

assessments

both

activity
differences

examination

a slightly
different
was probably
which
for the mix
support

on

or more
notes

the

five

Twenty
to measure

used

classification
problem
the experimental
and

that measured

IV shows

Table

extraction

an increase
This
in recording
of health
study found
in the
activities
by general
promotion
practitioners
at longer intervals
level of
booked
sessions
and a higher
of such activities
of
by patients.
reporting
Comparison

of consultation

v 7-36 minutes),
(mean 7-03 minutes
was consistent
and
between
control

including
recorded
in

education

length
than

less

slightly

this difference

experimental
of consultations

promotion

684
included
audiotaped
the medical
from
information

for which

consultations
record

that were

sessions

items.

of Cohen's
Interpretations
'7
Landis
and Koch.

from

pattern.
The

and

on

Advice
sessions).
in the 10 minute

for

but only moderate

findings

Discussion

specific items of health education had been

Table

a mean

(0-86)

high

by
pairs
score

after
completed
in
and 67-3%
58-0%,

control,

p<0001,

respectively;

whether

examined
between

agreement. This was found to be high for both health

such

reporting

was

were

were

Records

JC, agreement
x statistic,
and

education

consultations

180(263)
67(9-8)

or

calculated.

of examination

Total
(n=684)

and experimental
sessions
were
Patients
asked
df=2).

second

control,

patients
was

extraction.
LH

and

PM,
AW,
measured

education

experimental
activities.

p Value

Experimental
session-?-?
(C)

items on audiotape

table
iv?Numbers
(percentages) of consultations with one or more health education
analysis and inmedical record

to questions about health promotion after control and experimental

responding positively

for

was
questionnaire
to
that it sought
the differences

experimental

and

the question?
completed
to do so again.
booked
per session might

of patients
as this was
results
patients)

was
second

slightly
in the experimental

(by an
sessions.

less

It is highly unlikely that this change alone would alter

the

behaviour

no empirical
fore conclude
ment

in the consultation,
and
We
there?
this suggestion.
support
between
that the association
appoint?
in the consultation
and health
promotion
of

length
is real and causal.

was

that

doctors

studies

such

This content downloaded from 144.37.1.110 on Fri, 08 May 2015 20:03:30 UTC
All use subject to JSTOR Terms and Conditions

the most
Perhaps
surprising
in contact
small
increase

finding
between

and

patient
health

doctor

promotion,

considerable
that

suggesting

previously
compromised
also confirm
that other

lack of

by

prescribing,
of time.
availability
most
The
striking

in

increases
was

this

activity
Our findings

time.

of doctors'

aspects
are not

notably

behaviour,
to changes

sensitive

patients
sessions
years

that

suggests
can

screening
available.

similar

et al10 but not

procedure
opportunistic
to work
if sufficient
time

plausible
been met.

that

was

increase

out

operating

the

this

confirmed

carried

In

for

be made

by Ridsdale
in
study

their

10 minute
the

need

sessions

at

booked

is

reported
by Morrell
et al.u As Ridsdale
a practice

already
it is
system
had already

appointment
for case finding
10 minute

intervals

that smoking
and alcohol
consump?
patients
reported
in 17% and 7% of consultations
tion were mentioned
are

These

respectively.
of

centages
contribute
that
the

consultation

so

it is not

were

in

for previous

the

and suggest
complaint,7
to broaden
is being
used

this

Records

were

not

of lifestyle
how
far

factors

and

way.

recording
to estimate

possible
as a screening
procedure.
et al found
that more
vaginal

raised

Morrell

per?
variables

these

topics

examinations

were

in sessions
booked
performed
and suggested
intervals
that this was
smears
cervical
taken.10 We
being

these

at

10 minute
of more

because

no

found

such

in many
because
the
association,
practices
possibly
was conducted
cervical
programme
cytology
separately
It was
from
routine
consultations.
disappointing,
that discussion

however,
as such opportunistic
effective.18
An

incidental

reminders
was

finding
included

consultations
audio

of this

did

topic
have been
over

that

a health

not

increase,
to be
shown
as many
on
topic

twice

education

with
the medical
record.
analysis
compared
on medical
the validity
of audit relying
Patient
satisfaction
analysis.19
questionnaires

tape

This

questions

record
are

seen

increasingly
audit.20 We
have

the content

assessing
This

and

as

other

an

of

these

in

method
appropriate
a place
also to have
of consultations.

shown

studies

have

examined

term

short

in appointment
It is possible
of changes
length.
a
that long term effects
of such a change might
include
rates by patients.
to
in consultation
reduction
Studies

effects

examine

this

doctor

issue
in the

sustainable

also

appointment
consultation

seen

are

tension.

whether
effect

in

changes
or if they

are

to be

of
in

an

on
important
impact
in the consultation.
Priori?

have
length
activities
promotion

health

assess

to novelty
term.

long
our findings
show
that an extension
and a more
modest
increase
length

In summary,

ties

could
are due

behaviour

for hyper?

and screening
smoking
results
shown
for other

such
topics,
methods
for additional

Negative

as exercise,
health

the need
emphasise
care. Most
in primary
activity
promotion
to book patients
at a rate of eight or
doctors
continue
more
an hour,
think
and most
that longer
appoint?
are able to do so
ments
who
be beneficial.
Those
would
of

should

therefore

appointments.
more
doctors
annual
reduction
contract*

be encouraged
Health
service

to change
policy

to 10 minute
should

enable

to respond
in this way.
In areas with
rates this can only be achieved
consultation
in

list

size.21

is a paradox
of
on health
its emphasis
It

that, despite
that their
result in doctors
tion, itmay
feeling
workload
does not permit
longer consultations.

the

Appendix
GUIDELINES FOR EXTRACTING DATA FROMMEDICAL RECORD
record that an examination
has been
Examinations?Only
if there is clear evidence
of this in the medical
performed
or may
not be a record of an
If a phrase may
record.
examination
do not include.
For
"red eye, 2
example,
days" does not necessarily
imply that the doctor has made
an ophthalmological
examination.
"Tenderness"
should be
as an examination
The
interpreted
finding.
following
will be classified as health promotion
examinations
activities:
a
smear.
blood pressure; weight;
cervical
taking
Health
education?When
is made
of diet,
any mention
or exercise
record as health
education.
alcohol,
smoking,
amount
of numbers
of cigarettes
of
smoked,
Recording
alcohol consumed,
such as
etc, would be included. Comments
or "advised
to swim" would
"increase fibre intake," "swims,"
An exercise related event
health education.
twisted knee playing football) does not consti?
(for example,
tute health education.
or
Examination
of breasts, weight,
blood pressure
should not be coded as health education,
but
of these topics should be so classified.
entry of a discussion
as health
Discussion
of immunisation
should be recorded
actual immunisation
should not. Cervical cytology
education;
a smear has been
should not be included when
taken or
also be considered

estimated

in which

consultations

to the presenting
the extra
time available

examined

to

close

are grateful
We
for the support of participating
general
their staff, and their patients.
The study was
practitioners,
funded by the Health Promotion
Research Trust.

in

in health
change
promotion
was screening
That nearly
for hypertension.
all
consulted
in the experimental
aged 35-65 who
a blood pressure
check
in the past five
reported

activity

et al

to

led

high
by a
new

promo?
increased

results recorded. Cervical cytology should be noted, however,

smear
if smears have been otherwise
discussed?for
example,
or smear recently taken, etc. Up to
due, smear to be booked,
four of the following may be recorded per consultation:
diet;
tuition of breast
alcohol;
exercise;
immunisation;
smoking;
discussion
self examination;
about cervical cytology;
discus?
sion about weight.
1World Health Organisation. Primary health care.Presented at the international
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consultation.J R Coll Gen Pract 1979;29:201-5.
5 Tones BK. Health promotion?a new panacea.Journal of theInstituteofHealth
Education 1985;23:16-21.
6 Stott NCH. Primary health care.Bridging thegap between theoryand practice.
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7 BoultonMG, Williams A. Health education in general practice consultations:
doctors' advice on alcohol, diet and smoking. Health EducationJournal
1983;42:57-63.
8 Wallace PG, Brennan PJ, Haines AP. Are general practitioners doing enough
to promote healthy lifestyle?Findings of theMedical Research Council's
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9 Fleming DM, LawrenceMSTA, CrossKW. List size, screeningmethods, and
other characteristics of practices in relation to preventive care. BMJ
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10Morrell DC, Evans ME, Morris RW, Roland MO. The "five minute"
consultation: Effect of time constraint on clinical content and patient
satisfaction.BMJ 1986;292:870-3.
11 Roland MO, Bartholomew J, CourtenayMJF, Morris RW, Morrell DC. The
"fiveminute" consultation: effect of time constraint on verbal communica?
tion.BMJ 1986;292:874-6.
12 Ridsdale L, CarruthersM, Morris R, Ridsdale J. Study of the effect of time
availabilityon the consultation.J R Coll Gen Pract 1989;39:488-91.
13Wilson A. Extending appointment length?the effect inone practice.J R Coll
Gen Pract 1989;39:24-5.
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BMJ 1985;290:1322-4.
15Wilson A, McDonald P, Hayes L, Cooney J. Longer booking intervals in
general practice: effects on doctors' stress and arousal. Br J Gen Pract
1991;41:184-7.
16 Siegel S, CastellanNJ. Non-parametricstatisticsfor thebehavioralsciences.2nd
ed. New York:McGraw-Hill, 1988.
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data. Biometrics 1977;33:159-74.
18 Pierce M, Lundy S, Palanisamy A, Winning S, King J. Prospective
randomisedcontrolled trialof call and recall for cervical cytology screening.
BMJ 1989;299:160-2.
19Mant D, McKinlay C, Fuller A, Randall T, Fulford EM, Muir J. Three year
follow up of patientswith raisedblood pressure identifiedat health checks in
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(Accepted30 October 1991)

230

BMJ

volume

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All use subject to JSTOR Terms and Conditions

304

25 January

1992