Metropolitan General Practices Research Articles

The feasibility and impact of a brief behavioural intervention for anxiety in later life: perceptions of general practice nurses

Background Anxiety is prevalent in older people and is associated with adverse health outcomes. Early detection and intervention are imperative, yet clinically significant anxiety in older people is often under-diagnosed. When diagnosed, pharmacotherapy is often the initial treatment, but resistance due to stigma, polypharmacy concerns, and side effects are common among the elderly. Non-pharmacological interventions such as deep breathing and progressive muscle relaxation may offer more acceptable and cost-effective options to managing anxiety. While primary care is ideal for addressing anxiety in older adults, it is important to assess the feasibility and acceptability of nurse-led interventions in general practice. Objective To explore the perspectives of General Practice Nurses (GPNs) on the feasibility and acceptability of implementing a guided relaxation intervention for older people living with symptoms of anxiety, in Australian metropolitan and regional settings. Methods GPNs were trained and then administered a guided relaxation intervention to older people at three metropolitan general practices and one large rural practice encompassing four sites. Subsequently, five GPNs participated in semi-structured interviews exploring the acceptability and feasibility of implementing the intervention. Interviews were recorded, transcribed and findings were mapped to four key domains of interest: “Screening”, “Training and Delivery”, “Perceived impact of the Intervention” and “Barriers to the intervention”. Results Overall, GPNs reported that the intervention was easy to implement, was well received, helped build relationships and enabled conversations about mental health and well-being. They noted broader applicability of acquired knowledge and skills with other clients. Conclusion The intervention shows promise in promoting and supporting healthcare capabilities in primary care. GPNs are ideally placed to detect clinical symptoms of anxiety among older people and deliver brief well-being initiatives. However, to sustain and scale well-being interventions structured skill development, commitment from general practices, and policy shifts such as government rebates for GPNs are required.

The barriers and enablers of older person health assessments in Australian primary care: clinician and patient perspectives.

Health assessments (HAs) were introduced for at-risk patients, including older people, to have their health comprehensively monitored by their GP, to assess specific areas of health, such as risk factors for chronic disease and psychosocial problems, which may be overlooked in shorter consultations. Two forms of older person HAs are available for GPs to perform annually, HAs for non-Indigenous older Australians aged >75 (75+ HA) and for Aboriginal and Torres Strait Islander Australians aged >55 years (55+ ATSIHA). The present study aimed to explore the perspectives of older Australians undertaking HA (both 75+HA and 55+ ATSIHA) and clinician perspectives (GPs and practice nurses [PNs]) to enhance the items covered within the HA and develop targeted education resources to improve uptake of HAs. A qualitative study design incorporating semi-structured interviews and narrative inquiry was performed, inviting patients who have undergone HAs (75+HA and 55+ ATSIHAs) across two metropolitan general practice clinics. Clinicians who completed the HAs were also invited to participate in this study. A total of 15 clinicians (11 GPs and 4 PNs) and 15 patients participated in this study. Thematic analysis was used to identify barriers and enablers of HAs. Common barriers to both patients and clinicians include time, language, lack of relevance, and fear of the unknown. Identification of risk factors and the opportunity to discuss topics not covered in shorter consults were common enablers for both patients and clinicians. Four major patient barriers identified in this study include communication, accessibility, lack of engagement, and lack of patient preparation. The comprehensive nature of HAs was a major enabler for both clinicians and patients.

Disruption caused by the COVID-19 pandemic response from a Western Australian metropolitan general practice perspective: a qualitative descriptive study.

In 2020 and 2021, Western Australia (WA) was an early adopter of the 'COVID zero' policy, eliminating community transmission and pursuing vaccine roll out to enable a 'soft landing' once coronavirus disease 2019 (COVID-19) infiltrated the community in 2022. Optimisation and augmentation of general practice services were at the forefront of policies. This study explores metropolitan general practice responses to the resulting disruption caused. Qualitative descriptive methodology, purposive sampling and template analysis were used. Semi-structured interviews were undertaken from March to June 2021 with teams from six general practices in metropolitan WA; six general practitioners, four practice nurses and three practice managers. Staff at all levels responded rapidly amid uncertainty and workload challenges with marked personal toll (anxiety and fear of exposure to risks, frustrations of patients and balancing work and family life). Self-reliance, teamwork and communication strategies built on inclusivity, autonomy and support were important. Responding to changes in general patient behaviour was to the fore. Increasing use of telehealth (telephone and video) became important to meet patient needs. Lessons learned from what was implemented in early-stage lockdowns provided practices with preparedness for the future, and smoother transitions during subsequent lockdowns. The study demonstrates the self-reliance, teamwork and adaptability of the general practice sector in responding to a sudden, unexpected major disruption, yet maintaining ongoing service provision for their patients. Although the COVID-19 landscape has now changed, the lessons learned and the planning that took place will help general practice in WA adapt to similar future situations readily.

Factors affecting patient decisions to undergo testing for cancer symptoms: an exploratory qualitative study in Australian general practice.

Patients presenting to their GP are often concerned their symptoms may be due to cancer. However, there is a lack of evidence on the factors that influence patient decisions to undergo investigation for suspected cancer in the general practice setting. To identify the factors influencing patient decisions to undertake investigations for suspected cancer in general practice. An exploratory qualitative, semi-structured interview study of patients attending rural and metropolitan general practices in Victoria, Australia. A purposive sample of 15 general practice patients aged ≥40 years participated. Thematic analysis of transcripts drew on interpretative description methodology and shared decision-making (SDM) theory. Cancer-related concerns such as 'cancer worry' prompt patients to seek investigations from their GP. Participants prefer that their symptoms are investigated regardless of cancer risk. The perceived 'best test' provides the most reassurance. Trust and SDM enhance dialogue between patients and GPs about diagnostic testing strategies. Deterrents to testing included out-of-pocket costs, waiting time, travel time, and competing work and family demands. There may be a mismatch between efforts to rationalise investigation use and patient preferences for investigation. SDM that incorporates patient concerns, facilitators, and barriers to testing may ensure appropriate and timely investigation of cancer symptoms.

Quantitative respirator fit tests for P2/N95 in Australian general practice.

The authors report the results of a pilot trial of quantitative N95 respirator mask fit testing in metropolitan general practice and how fit test failures were managed.

The development of Future Health Today: piloting a new platform for identification and management of chronic disease in general practice.

Chronic disease identification and management is a significant issue in Australia, with general practice being the primary contact point for those at risk of, or living with, chronic disease. However, there is a well-described gap between guideline recommendations for chronic disease management and translation in the general practice setting. In 2018, a group of researchers, clinicians and software developers collaborated to develop a tool to support the identification and management of chronic disease in general practice, with the aim to create a platform that met the needs of general practice. The co-design process drew together core principles and expectations for the establishment of a technological platform, called Future Health Today (FHT), which would sit alongside the electronic medical record (EMR) management system within general practice. FHT used algorithms applied to EMR data to identify patients with, or at risk of, chronic disease and requiring review. Using chronic kidney disease as a clinical focus, the FHT prototype was piloted in a large, metropolitan general practice, and a large regional general practice. Based on user feedback, the prototype was further developed and improved. This paper provides a report on the key features and functionalities that participants identified and implemented in practice.

Correlation of patient- and clinician-assessment of pain: comparing physiotherapy and general practice.

The clinical work of GPs and physiotherapists frequently involves the assessment of patient pain. In this study, we aimed to determine the correlation of patient- and clinician-assessment of severity of pain through quantitative analysis of patient- and clinician-assessed pain scores collected at metropolitan general practice and physiotherapy clinics. Prior to a consultation, 30 patients were asked to complete a short general health survey within which they answered questions regarding current pain and, if in pain, the severity of that pain on the visual analogue scale. Following the consultation, their clinicians were asked questions on their observation of the patients, including whether they observed that their patients were in pain and, if so, how severe on the visual analogue scale. Statistical analysis of these data showed that although there was a correlation between the physiotherapist- and patient-assessed pain scores, there was no correlation between the GP- and patient-assessed pain scores. Accurately establishing the severity of patient pain can be difficult. These results suggest that GPs routinely underestimate the severity of patient pain. If the severity of patient pain is clinically relevant, GPs could improve the accuracy of assessment by asking patients directly about that aspect of pain.

223Atrial fibrillation screen, management and guideline recommended therapy (AF SMART II) in the rural primary care setting: eHealth tools to support all stages of screening

Abstract Funding Acknowledgements National Heart Foundation of Australia: CVRN Grant and Vanguard Grant; investigator-initiated grant from Pfizer-BMS; AliveCor provided free devices BACKGROUND Internationally, most atrial fibrillation (AF) management guidelines recommend screening for AF in people aged ≥65 years, as well as treatment with oral anticoagulants (OAC) for those at high stroke risk ( CHA2DS2-VA ≥2). However, in practice, gaps remain in both screening and treatment. In Australian general practice in 2017, the estimated rate of AF screening was 11%, and only about 60% of diagnosed AF patients received guideline-based OAC. Our 2018 screening study using eHealth tools in metropolitan general practices increased screening to 16% of eligible patients, leading to further refinement of the eHealth tools. PURPOSE To investigate the impact of an AF screening program in rural general practices, using a suite of custom-designed eHealth tools designed to increase the proportion screened and treated for AF in accordance with guidelines. METHODS General practices (n = 8) in rural New South Wales, Australia participated in the study between September 2018 – June 2019. General practitioners (GPs) and practice nurses conducted opportunistic screening of eligible patients (i.e. aged ≥65 years without existing AF diagnosis) using a smartphone electrocardiogram during practice visits. Practices were also provided with 1) an electronic screening prompt (which appeared when an eligible patient’s file was opened); 2) electronic decision support based on ESC/Australian treatment guidelines; and 3) regular customised data reports aimed at quality improvement (Figure 1). A clinical audit tool was used to extract deidentified data from practices. RESULTS A total of 3,103 eligible patients (mean age 75.1 ± 6.8 years, 47% male) who attended the 8 practices during the study period were screened (median screening period 4.6 months). Practices screened a median of 35% of eligible patients (range 9-51% per practice), with 4/8 practices screening >40% of eligible patients. 36 (1.2%) new cases of AF were confirmed (mean age 77.0 years, 64% male, mean CHA2DS2-VA = 2.9). GPs (n = 22) screened 30% (range 1-182 per GP) of patients and nurses (n = 40) screened 70% (range 1-192 per nurse). OAC treatment rates of patients with AF with CHA2DS2-VA≥2 were 82% (screen-detected), 78% (clinically-detected during study period) and 75% (pre-existing AF), with no significant differences between groups. CONCLUSIONS In the rural general practice setting, an AF screening program supported by eHealth tools resulted in 35% of eligible people screened, which is substantially higher than the 16% achieved in our previous study. Half the practices screened 40-50% of eligible patients, suggesting this may represent a ‘ceiling’ of patients captured by opportunistic AF screening programs. OAC treatment rates were higher than previous studies at baseline and were trending upwards during the study. eHealth tools, particularly including customised data reports as part of an audit and feedback system, may be a valuable addition to future screening programs. Abstract Figure 1 - screening process

A randomised controlled trial of SMS reminders for routine asthma care in an Australian general practice.

Asthma self-management strategies remain core components of evidence-based asthma care. Despite this, only 14% of Australian adults with asthma have written action plans. We aimed to evaluate whether targeted SMS reminders to attend an asthma review could improve asthma action plan and spirometry completions for general practice patients who do not have current asthma action plans. A randomised controlled trial comparing targeted SMS reminders with usual care was performed from May to September, 2016, in a metropolitan general practice in South East Queensland. By the three-month follow-up, 35 of 79 patients allocated to intervention had completed action plans in comparison to five of 59 patients allocated to usual care (P < 0.0001). There were more recorded instances of spirometry per patient performed during the follow-up period for intervention (37/79), compared with usual care (8/59; P<0.0001). SMS reminders may be a useful tool in the spectrum of care needed for optimal asthma management in general practice.

P1935Use of a smartphone electrocardiogram, electronic prompts and electronic decision support for atrial fibrillation screening in metropolitan general practices

P1935Use of a smartphone electrocardiogram, electronic prompts and electronic decision support for atrial fibrillation screening in metropolitan general practices

Use of a Smartphone Electrocardiogram, Electronic Prompts and Electronic Decision Support for Atrial Fibrillation Screening in Metropolitan General Practices

Background: Atrial fibrillation (AF) screening has an important role, promoting early diagnosis and stroke prevention through guideline-recommended oral anticoagulant (OAC) therapy.

Case finding for the primary prevention of fragility fractures with FRAX (without BMD) in those over 70 years: Reducing the reliance on BMD as the primary tool

Objective(s): To develop and evaluate age-stratified fracture risk score thresholds without dual X-ray absorptiometry (DXA) to manage osteoporosis. Methods: A multi-centered cohort study of persons over 70 years recruited from metropolitan General Practices. Participants had osteoporosis risk assessment, DXA, health questionnaire, and FRAX Hip (HF) and Major Osteoporotic fracture (MOF) risk scores without DXA T-scores. Age-stratified fracture risk score thresholds (low, moderate and high risk of osteoporosis) were compared with measured BMD based guidelines for osteoporosis management. Results: 130/531 (24.5%) participants had osteoporosis. Our thresholds achieved a correct clinical decision compared to BMD in 83-84% of cases; avoided 249 (56%) of unnecessary DXAs; and, missed osteoporosis in 5-6% of cases. The FRAX HF and MOF were +30% and +7% more accurate than recommended guidelines in detecting osteoporosis. Conclusions: For those over 70 years of age, our proposed fracture risk score thresholds can reasonably guide osteoporosis management and reduce unnecessary DXA.

The AgED Study. Age-related eye disease (AgED) in South Australian general practice: are we blind to early detection and intervention?

The AgED Study aimed to evaluate the detection, awareness and management of age-related eye disease (AgED) in South Australian general practice. Three South Australian metropolitan general practices were recruited and all patients aged 75 years and older were invited to participate. A cross-sectional postal questionnaire and retrospective audit of consenting patients' medical records was performed. On average, patients had their last eye check 9 months ago; the majority (64.9%) performed by an optometrist. Only 7.6% had visited their GP for their last eye check, mostly (90.5%) for a mandatory 'Fitness to Drive' medical assessment. There were marked differences in GP recording v. self-reported AgED and a marked discrepancy in the prevalence rates of AgED, visual impairment and blindness in this study compared with Australian population-based prevalence surveys. Despite the lack of GP documentation of eye disease, the majority of patients engaged in timely eye checks with either an optometrist or ophthalmologist, and their overall visual function and vision-related quality of life (QoL) were satisfactory.

Exploring the myths of morphine in cancer: views of the general practice population.

Morphine is widely used in cancer care, and understanding the concerns and perceptions of patients, family and friends is vital to managing pain and distress effectively. The 'myths of morphine' have frequently been discussed in medical literature, yet the extent to which such views are held is not clear. This qualitative project explores the perceptions and attitudes of the wider community towards morphine use in cancer care, to understand this 'mythology' according to those who in the future may themselves require its use. Semi-structured interviews were held with patients presenting to a metropolitan general practice clinic in Melbourne, Australia. A grounded theory framework underpinned the data collection and thematic analysis undertaken. Interviewees (15) were aged 24-81, with a variety of experiences with cancer care and previous morphine use. Interviewees were highly supportive of morphine use in cancer care, with this attitude founded on the perceived severity of cancer pain and the powerful nature of morphine. They described a number of reasons morphine may be used in cancer care: to treat pain, to enable peace and also as a treatment for cancer. The public view of morphine to emerge from this study is markedly different from that discussed in the myths of morphine. It is viewed as a medication that has the ability to provide peace and control both pain and the course of cancer. The participants in this study described a wish for greater involvement in pain control decisions, perceiving morphine as a facilitator rather than a barrier to good cancer care.

A mobile phone application for the assessment and management of youth mental health problems in primary care: health service outcomes from a randomised controlled trial of mobiletype

BackgroundGPs detect at best 50c of mental health problems in young people. Barriers to detecting mental health problems include lack of screening tools, limited appointment times and young people’s reluctance to report mental health symptoms to GPs. The mobiletype program is a mobile phone mental health assessment and management application which monitors mood, stress and everyday activities then transmits this information to general practitioners (GPs) via a secure website in summary format for medical review. The current aims were to examine: (i) mobiletype as a clinical assistance tool, ii) doctor-patient rapport and, iii) pathways to care.MethodsWe conducted a randomised controlled trial in primary care with patients aged 14 to 24 years recruited from rural and metropolitan general practices. GPs identified and referred eligible participants (those with mild or more mental health concerns) who were randomly assigned to either the intervention group (where mood, stress and daily activities were monitored) or the attention-comparison group (where only daily activities were monitored). Both groups self-monitored for 2 to 4 weeks and reviewed the monitoring data with their GP. GPs, participants and researchers were blind to group allocation at randomisation. GPs assessed the mobiletype program as a clinical assistant tool. Doctor-patient rapport was assessed using the General Practice Assessment Questionnaire Communication and Enablement subscales, and the Trust in Physician Scale (TPS). Pathways to care was measured using The Party Project’s Exit Interview.ResultsOf the 163 participants assessed for eligibility, 118 were randomised and 114 participants were included in analyses (intervention n = 68, attention-comparison n = 46). T-tests showed that the intervention program increased understanding of patient mental health, assisted in decisions about medication/referral and helped in diagnosis when compared to the attention-comparison program. Mixed model analysis showed no differences in GP-patient rapport nor in pathways to care.ConclusionsWe conducted the first RCT of a mobile phone application in the mental health assessment and management of youth mental health in primary care. This study suggests that mobiletype has much to offer GPs in the often difficult and time-consuming task of assessment and management of youth mental health problems in primary care.Trial registrationClinicalTrials.gov NCT00794222

Self-monitoring Using Mobile Phones in the Early Stages of Adolescent Depression: Randomized Controlled Trial

BackgroundThe stepped-care approach, where people with early symptoms of depression are stepped up from low-intensity interventions to higher-level interventions as needed, has the potential to assist many people with mild depressive symptoms. Self-monitoring techniques assist people to understand their mental health symptoms by increasing their emotional self-awareness (ESA) and can be easily distributed on mobile phones at low cost. Increasing ESA is an important first step in psychotherapy and has the potential to intervene before mild depressive symptoms progress to major depressive disorder. In this secondary analysis we examined a mobile phone self-monitoring tool used by young people experiencing mild or more depressive symptoms to investigate the relationships between self-monitoring, ESA, and depression.ObjectivesWe tested two main hypotheses: (1) people who monitored their mood, stress, and coping strategies would have increased ESA from pretest to 6-week follow-up compared with an attention comparison group, and (2) an increase in ESA would predict a decrease in depressive symptoms.MethodsWe recruited patients aged 14 to 24 years from rural and metropolitan general practices. Eligible participants were identified as having mild or more mental health concerns by their general practitioner. Participants were randomly assigned to either the intervention group (where mood, stress, and daily activities were monitored) or the attention comparison group (where only daily activities were monitored), and both groups self-monitored for 2 to 4 weeks. Randomization was carried out electronically via random seed generation, by an in-house computer programmer; therefore, general practitioners, participants, and researchers were blinded to group allocation at randomization. Participants completed pretest, posttest, and 6-week follow-up measures of the Depression Anxiety Stress Scale and the ESA Scale. We estimated a parallel process latent growth curve model (LGCM) using Mplus to test the indirect effect of the intervention on depressive symptoms via the mediator ESA, and calculated 95% bias-corrected bootstrapping confidence intervals (CIs).ResultsOf the 163 participants assessed for eligibility, 118 were randomly assigned and 114 were included in analyses (68 in the intervention group and 46 in the comparison group). A parallel process LGCM estimated the indirect effect of the intervention on depressive symptoms via ESA and was shown to be statistically significant based on the 95% bias-corrected bootstrapping CIs not containing zero (–6.366 to –0.029). The proportion of the maximum possible indirect effect estimated was κ2 =.54 (95% CI .426–.640).ConclusionsThis study supported the hypothesis that self-monitoring increases ESA, which in turn decreases depressive symptoms for young people with mild or more depressive symptoms. Mobile phone self-monitoring programs are ideally suited to first-step intervention programs for depression in the stepped-care approach, particularly when ESA is targeted as a mediating factor.Trial RegistrationClinicalTrials.gov NCT00794222; http://clinicaltrials.gov/ct2/show/NCT00794222 (Archived by WebCite at http://www.webcitation.org/65lldW34k)

A mobile phone application for the assessment and management of youth mental health problems in primary care: a randomised controlled trial.

BackgroundOver 75% of mental health problems begin in adolescence and primary care has been identified as the target setting for mental health intervention by the World Health Organisation. The mobiletype program is a mental health assessment and management mobile phone application which monitors mood, stress, coping strategies, activities, eating, sleeping, exercise patterns, and alcohol and cannabis use at least daily, and transmits this information to general practitioners (GPs) via a secure website in summary format for medical review.MethodsWe conducted a randomised controlled trial in primary care to examine the mental health benefits of the mobiletype program. Patients aged 14 to 24 years were recruited from rural and metropolitan general practices. GPs identified and referred eligible participants (those with mild or more mental health concerns) who were randomly assigned to either the intervention group (where mood, stress, and daily activities were monitored) or the attention comparison group (where only daily activities were monitored). Both groups self-monitored for 2 to 4 weeks and reviewed the monitoring data with their GP. GPs, participants, and researchers were blind to group allocation at randomisation. Participants completed pre-, post-, and 6-week post-test measures of the Depression, Anxiety, Stress Scale and an Emotional Self Awareness (ESA) Scale.ResultsOf the 163 participants assessed for eligibility, 118 were randomised and 114 participants were included in analyses (intervention group n = 68, comparison group n = 46). Mixed model analyses revealed a significant group by time interaction on ESA with a medium size of effect suggesting that the mobiletype program significantly increases ESA compared to an attention comparison. There was no significant group by time interaction for depression, anxiety, or stress, but a medium to large significant main effect for time for each of these mental health measures. Post-hoc analyses suggested that participation in the RCT lead to enhanced GP mental health care at pre-test and improved mental health outcomes.ConclusionsMonitoring mental health symptoms appears to increase ESA and implementing a mental health program in primary care and providing frequent reminders, clinical resources, and support to GPs substantially improved mental health outcomes for the sample as a whole.Trial RegistrationClinicalTrials.gov NCT00794222.

Prescribing history to identify candidates for chronic condition medication adherence promotion.

Poor adherence to long-term prescription medication is a frequent problem that undermines pharmacological control of important risk factors such as hypertension. A medication possession ratio (MPR) can be calculated from Practice Management System (PMS) data to provide a convenient indicator of adherence. We investigate how well prior MPR predicts later MPR, taking MPR&lt;80% as indicative of 'non-adherence,' to assess the potential value of MPR calculation on PMS data for targeting adherence promotion activities by general practices. We examine PMS data for two New Zealand metropolitan general practices, one with a predominantly Pacific caseload, across 2008 and 2009. We find prevalence of non-adherence in 2009 to be 51.63% (95% confidence interval [CI] 47.9-55.3) for patients at the Pacific practice and 28.09% (95% CI 25.0-31.1) at the other practice for patients who are demonstrably active with the practice in 2009. The positive predictive value (PPV) of 2008 non-adherence for 2009 non-adherence is 71.80% (95% CI, 66.5-77.1) and negative predictive value (NPV) 61.52% (95% CI 56.9-66.1) for the Pacific practice; PPV is 61.38% (95% CI 54.6-68.2) and NPV is 82.19% (95% CI 79.2-85.2) for the other practice. The results indicate good potential for decision support tools to target adherence promotion.

Accurate sampling in general practice waiting room surveys: methodological issues.

This is a pilot study to test the validity of using one research assistant to train and support reception staff at five clinics to obtain waiting room data in general practice surveys. A research assistant trained reception staff at five randomly chosen general practices to administer a survey to all eligible women over a two-week period. Practices were audited daily by their appointment books and where possible by billing records to check total numbers of eligible women to determine the denominator of the sample. Five metropolitan general practices in one divisional area. Twenty-five receptionists distributed surveys to 1,298 women. Number of eligible women missed at each clinic. The number of potential subjects missed by the reception staff ranged from nil to 18% with the appointment book audit. A second audit using billing records at three clinics revealed inaccuracies of up to 50%. The ability to accurately capture eligible patients for waiting room surveys depends on good administrative systems within the practice and motivated staff. It is important for general practice researchers to consider and account for eligible participants who are missed from the denominator with a waiting room survey method. Valid sampling using this method can be achieved in certain practices, however this may limit the generalisability of the findings.

Predictors of Patient Enablement: The Role of Doctors' Helpgiving Style, Patient and Visit Characteristics

Patient enablement is a possible outcome of primary health care consultations and has been employed as a marker of effective helpgiving. We studied predictors of patient enablement, investigating the relative contribution of patient characteristics (gender, age, occupational status, and perceived health status), visit characteristics (length of consultation, duration of physician-patient relationship, and frequency of consultations), and the physician's reported helpgiving style (level of encouragement of patient participation in the consultation). The Helpgiving Practices Scale and Patient Enablement Instrument were completed by 103 patients from eight metropolitan general practices. Patients with better perceived health status and lower occupational status felt more enabled following their consultations. Frequency of consultations employed as a measure of "knowing a doctor well" was also significantly associated with post-consultation enablement. General practitioners' encouragement of patients to participate in their health care then added significantly to the explained variance in patient enablement. Results of this study indicate that the Patient Enablement Instrument is a useful measure of quality of care with scores being less positively skewed than those of frequent employed satisfaction measures.