Performance indicator scoring.

We read with interest the paper in the May issue on the theme of performance indicator scoring by Houghton and Rouse.1 We were surprised that they did not refer to a conceptually similar attempt we made to develop a composite performance indicator — the National Health Service Practice Performance Index (NHSPPI) — in three areas of England (including their own) and one in Scotland.2 As Houghton and Rouse assumed, we found that NHSPPI correlated significantly, and negatively with a weighted deprivation index (Spearman’s correlation coefficient r = -0.57). It also correlated negatively with the proportion of other language patients in the practice (r = -0.44) and positively with list size (r = 0.25). The performance indicator was thus inherently unfair on practices working in deprived areas, whereas an alternative measure which we have called the Consultation Quality Index (CQI) appears independent of deprivation scores (r = 0.06).3 The CQI combines measures of enablement (a better outcome measure than satisfaction), consultation length (a proxy for holism), and how well patients know their doctor (a proxy for continuity). Current work in Glasgow by Mercer suggests that a measure of empathy — the consultation and relational empathy (CARE) measure — correlates well with both enablement (r = 0.66) and consultation length (r = 0.42), and raises the possibility of adding a fourth dimension to the CQI.4 We are concerned that many or most of the income-generating performance indicators in the 2004 Contract reward disease-centred measurements, but virtually none attempt to measure ‘patientcentredness’. It is easy to understand why developing measures of patientcentredness has proved so difficult to do, and we have recently reviewed the problems in this field.5 But just because the task is difficult, it does not mean that it is not important and well worth doing; indeed finding a way forward in this field is one of the outstanding opportunities for qualitative and quantitative researchers to work together.