Summary of the impact

The ability of healthcare professionals to empathise with patients has been shown to enhance patient satisfaction, improve symptoms and promote well-being. Research at University of Glasgow has developed the Consultation and Relational Empathy (CARE) Measure — the first validated, patient-rated questionnaire developed in a primary care setting that measures patient perceptions of healthcare professionals' empathy and quality of care. The CARE Measure is formally embedded into healthcare professional training standards through its inclusion in Scottish General Practitioner (GP) appraisals and the Royal College of General Practitioners Membership (MRCGP) and Interim Membership by Assessment of Performance (iMAP) processes; through these means more than 8,000 GPs are using the CARE Measure. It has also been incorporated into the Scottish Government's policy on Healthcare Quality and adopted by the General Medical Council and the Chartered Society of Physiotherapy.

Underpinning research

Empathy is recognised as a vital interpersonal skill that enables healthcare professionals to provide optimal care for patients.¹ Between 2000 and 2003, Mercer led the development and validation of a novel and suitable tool to assess clinician empathy; the Consultation and Relational Empathy (CARE) Measure. The research steps undertaken between 2000-2003 were:

Firstly, following an extensive literature review, Mercer highlighted the importance of empathy in healthcare, whilst confirming a lack of validated measures suitable for use in primary care¹. Secondly, Mercer led the initial development and preliminary validation of the CARE Measure in primary care.² An important aspect of this was the collaborative approach taken to the measure's development and testing, which involved patients and practitioners from both high and low socioeconomic deprivation areas.² The aim of developing the measure in this manner was to ensure it was meaningful to all patients, irrespective of their deprivation level, which was deemed to be important given the wide health inequalities that exist in Scotland and indeed the UK. Thirdly, Mercer led a major study on more than 3,000 patients (again in areas of high and low deprivation) which confirmed the validity and reliability of the CARE Measure in General Practice, and its ability to effectively discriminate between qualified GPs; thus establishing its utility in GP assessment.³ This research, carried out at the University of between 2000-2003 and published in international peer-reviewed journals, laid the academic foundation for the subsequent adoption of the measure `by RCGP Scotland for use in GP Appraisal. The utility of the CARE Measure in assessment of GPs in training was then established in research led by Murphy and colleagues at NHS Education for Scotland, (NES) in collaboration with Mercer.⁴ On the basis of this cumulative research, the CARE Measure was subsequently adopted as part of work-based assessment of GPs in training in the UK.

The utility of the CARE Measure in secondary care was established between 2003-2008 in work led by Mercer in collaboration with Murphy and others.^5,6 This established validity of the measure in both primary and secondary care.

Since 2008, the CARE Measure has been validated in other professional groups, including Nurses and a wide range of Allied Health professionals. The work is funded by the Scottish Government and led by Dr Edward Duncan at Stirling University, in collaboration with Mercer. Publications are in preparation.

Key University of Glasgow Researchers

Stewart Mercer (Clinical Fellow, [2000-2003]; Senior Clinical Fellow [2003-2008], now Chair in Primary Care Research) led the development of the CARE Measure; Professor Graham Watt Professor of General Practice [1994-present]) provided mentoring input, but did not have specific expertise in questionnaire design or validation. He was a co-author on two publications.^2,3 Alex McConnachie (Consultant Statistician [1996-2008]) provided statistical expertise in one publication.³

Key External Collaborators

Dr Margaret Maxwell and Dr David Heaney (both University of Edinburgh), gave advice on the methodology of validation of the CARE Measure between 2000-2003. They were co-authors on two of the CARE Measure publications.^2,3 Douglas Murphy (University of Dundee) was involved in work on GPs in training.⁴ Mercer led the validation work in secondary care, with input from Murphy on the statistical analysis.^5,6 Dr Edward Duncan (The Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling) was the Principal Investigator on a Scottish Government funded project, involving University of Glasgow, to validate the CARE Measure in other professional groups. Publications are in preparation.

References to the research

Details of the impact

Practitioner empathy involves an ability to understand the patient's situation, perspective and feelings, the capability to communicate and confirm this with the patient, and subsequently apply this understanding in a therapeutic manner. Before 2000 there were no validated measures to assess empathy that were suitable for use in routine healthcare across a range of settings. Research at University of Glasgow has developed the first validated patient-rated questionnaire in a primary care setting that measures patient perceptions of healthcare professionals' empathy and quality of care for general practice.

The CARE Measure is freely available to download from the University of Glasgow website.^a The image to the right illustrates the questions involved in the measure. Since 2004, the CARE Measure has formed an integral component of professional bodies and government initiatives (details of which are provided below):

• RCGP professional training standards, to facilitate assessment, appraisal and revalidation
• Scottish Government policy on Healthcare Quality
• Chartered Society of Physiotherapy patient experience reporting

In addition, funding was provided by the Scottish Government to establish a website in 2012 as part of the validation work in Allied Health Professionals, led by Duncan in collaboration with Mercer.^b This website facilitates the collection and use of CARE Measure data from medical, Nursing and Allied Health Professional practitioners, allowing registered users to compare their data with that of their peers, to identify any potential areas of improvement. Between going live in September 2012 and 31^st July 2013, there were 1180 registered users, primarily doctors.^c

Incorporation of the CARE Measure in RCGP professional training standards to facilitate assessment, appraisal and revalidation

The MRCGP exam is a compulsory assessment system that complies with the standards set by the UK's GMC. It confirms a doctor's competence in the speciality of General Practice and ability to practice independently in the UK. Completion of the MRCGP is a pre-requisite for the certificate of completion of training (CCT) and full RCGP membership. Since August 2007, the CARE Measure (renamed Patient Satisfaction Questionnaire (PSQ) by the RCGP^d) has been used as a compulsory evidence-based tool in the Workplace-Based Assessment component of the MRCGP Exam^e. In this capacity, the PSQ allows patient feedback to be gathered on empathy and relationship-building with each GP trainee. Two cycles of the PSQ are used during the training period: once in GP placement in Speciality Training year 1 or year 2 and once in Speciality Training year 3.^e The RCGP estimates that with approximately 3,000 GP trainees each year, an average of 33,000 cycles of PSQ were completed by trainees between 1^st Jan 2008 and 31^st July 2013.^e The decision by RCGP to adopt the CARE Measure was based on its proven ability to effectively discriminate between doctors [references 3 and 4, above].

iMAP is the process whereby independent practitioners on the GP register may become members of the RCGP. Assessment for membership on this basis requires the completion of fifteen compulsory modules, one of which specifically addresses the PSQ. The PSQ was initially the only tool to facilitate this when iMAP was launched in 2007.^f It is now one of seven tools approved; encouraging its uptake, it is the only tool available free of charge.^g The RCGP estimates that since 2007, approximately 30% of applicants to iMAP used the PSQ.^f The decision by RCGP to adopt the CARE Measure was based on its proven ability to effectively discriminate between doctors [references 3 and 4, above].

Revalidation is the process by which all 60,000 licensed doctors must demonstrate to the GMC that they are up to date and fit to practice; this ensures compliance with the relevant professional standards, and is thus compulsory to maintain a license to practice. To determine its suitability for use in revalidation, the CARE Measure has twice been comprehensively reviewed by the RCGP; in 2009 it was one of nine patient feedback tools reviewed,^h and in 2010 it was one of ten reviewed.^h Subsequently, the CARE Measure has been fully endorsed by RCGP as a `fit for purpose' patient survey for use in the revalidation process.^h,i The CARE Measure is used by GPs in Scotland as both a patient satisfaction survey and for appraisal and revalidation; it is listed in the Scottish Online Appraisal Resource (the key online information point for GP Appraisal).^j,k Since 2004, it has been accredited for use in appraisal of all GPs in Scotland.^l The decision by the GMC to adopt the CARE Measure was based on its proven ability to effectively discriminate between doctors [references 3-6, above].

Implementation of the CARE Measure into government policy

In Scotland, the CARE Measure is detailed in the Government's Quality Strategy (2010).^m The Quality Strategy aims to allow those involved in Scotland's healthcare — namely all healthcare professionals (numbering 100,000), partners and the public — to work towards achieving three Quality Ambitions of Safe, Person-Centred and Effective healthcare. The Quality Strategy specifies the use of the CARE Measure as a tool to capture patients' assessments of their relationships with healthcare professionals, allowing an understanding of health outcomes and patient experience to be determined, and for improvement to be informed where required.^m Inclusion of the CARE Measure has made Scotland the first country in the world to include staff empathy as a component of healthcare quality. The decision by the Government to adopt the CARE Measure was based on its proven ability to effectively discriminate between practitioners [references 3-6, above], and by a series of high-level meetings and discussion between Mercer and the Scottish Government between 2009-2010, including the Chief Executive of NHS Scotland at the time (Dr Derek Feeley) and the then Cabinet Secretary and Minister for Health, Nicola Sturgeon.

Implementation of the CARE Measure as a validated Patient Reported Experience Measure

Since 2012, the Chartered Society of Physiotherapy has recommended the CARE Measure to their 52,000 members (98% of UK physiotherapists).ⁿ In this context, the CARE Measure is being used by the Chartered Society of Physiotherapy as the primary validated Patient Reported Experience Measure, to assess and improve Physiotherapy services along with the overall patient journey.ⁿ The CARE Measure became a recommendation after a 2009 Scottish pilot study (collaboration between University of Glasgow and University of Stirling) associated with Physiotherapy training and person centred care, which subsequently led to involvement in validation work in Allied Health Professionals.

Sources to corroborate the impact

a. CARE Measure, University of Glasgow webpage

b. CARE Measure Website

c. Evidence to substantiate available on request (Organisation: CARE Measure.org)

d. PSQ Form, RCGP

e. Evidence to substantiate available on request (Organisation: RCGP)

f. Evidence to substantiate available on request (Organisation: RCGP)

g. iMAP Handbook, RCGP, April 2013

h. Evidence to substantiate available on request (Organisation: RCGP)

i. Patient feedback tools `fit for purpose', RCGP

j. Scottish Online Appraisal Resource Guidance (p18), RCGP Scotland

k. Guidance on revalidation, RCGP Scotland

l. Evidence to substantiate available on request (Organisation: RCGP Scotland)

m. The Healthcare Quality Strategy for NHS Scotland (May 2010)

n. Evidence to substantiate available on request (Organisation: Chartered Society of Physiotherapy)