Quantitative and qualitative assessment of women's experience of a ...

British Journal of Obstetrics and Gynaecology September 2001, Vol. 108, pp. 993±999

Quantitative and qualitative assessment of women's experience of a one-stop menstrual clinic in comparison with traditional gynaecology clinics Jafaru I. Abu a, Marwan A. Habiba b,*, Richard Baker c, Aidan W. F. Halligan b, Nicholas J. Naftalin d, Ronald Hsu e, Nicholas Taub f Objective A quantitative and qualitative evaluation of the views of patients attending two types of clinics for menstrual disorders. Methods Semi-structured qualitative interview and quantitative questionnaire. Setting Five traditional general gynaecology clinics and a one-stop menstrual clinic, where investigations are performed and results given to patients on the same day. Participants Two hundred and thirty-nine women (126 from the gynaecology clinic and 113 from the menstrual clinic) were recruited into the quantitative study; 18 and 26 patients from the gynaecology and the menstrual clinic, respectively, were interviewed for the qualitative study. Main outcome measures Women's views about their care and progress towards resolution of their problem. Results Following the initial consultation, 106 (84%) of the gynaecology clinic, and 98 (87%) of the menstrual clinic patients completed the ®rst part of the questionnaire. Of those, 75 (71%) and 79 (81%) patients from the two types of clinic, respectively, completed a follow up questionnaire one year later. There were statistically signi®cant differences in all the components of the ®rst part of the questionnaire (information, continuity, waiting, organisation, and limbo) in favour of the one-stop menstrual clinic. After one year, there was a statistically signi®cant difference in one of the components, patient centeredness, but not in overall process co-ordination. The interviews showed that patients attending the menstrual clinic appreciated getting the results of their investigations on the same day. They also found the organisation of the one-stop menstrual clinic more closely suited to their needs and as a result were more likely to feel they were making progress. Conclusion Women were consistently more positive about their experience in the one-stop clinic. One-stop clinics organised to meet the needs of patients might be appropriate for other clinical conditions. The combination of quantitative and qualitative methods is an effective method of assessing patients' views of health services.

INTRODUCTION Menstrual disorders are common and are associated with considerable clinical and social morbidity 1. Menor-

a

Department of Obstetrics and Gynaecology, Leicester Royal In®rmary, UK b Department of Obstetrics and Gynaecology, University of Leicester, UK c Clinical Governance Research and Development Unit, Department of General Practice and Primary Health Care, University of Leicester, UK. d Leicester Royal In®rmary NHS Trust, UK e Leicestershire Health, UK f Trent Institute for Health Services Research, and Department of Epidemiology and Public Health, University of Leicester, UK * Correspondence: Dr M. A. Habiba, Department of Obstetrics and Gynaecology, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal In®rmary, Leicester LE2 7LX, UK. q RCOG 2001 British Journal of Obstetrics and Gynaecology PII: S 0306-545 6(01)00217-0

rhagia alone represents 12% of all referrals to gynaecology outpatient clinics 2. One in 20 women aged 30 to 49 years consults her general practitioner each year because of excessive menstrual blood loss 1,3. For this group of patients, the traditional gynaecology clinic often involves several visits for consultations and investigations before the initiation of therapy. The one-stop menstrual clinic was established at the Leicester Royal In®rmary in March 1996 to provide same-day investigations including haematology, pelvic ultrasound scan, hysteroscopy and endometrial biopsy. This allows prompt initiation of treatment. Upon referral and prior to attendance all patients receive an information pack, and are asked to complete a detailed medical history questionnaire. The clinic is consultant-based, and all investigation results are given to patients by telephone on the day of attendance at 4:30-5:00 pm. We report here the views of women who attended the onestop menstrual clinic and those with similar conditions who attended traditional gynaecology clinics.

www.bjog-elsevier.com

994 J. I. ABU ET AL. Table 1. Components of the PCD used at study entry. Patients were asked to mark their responses as strongly agree, agree, neutral, disagree or strongly disagree. Component 1. Information ®tting in 1. I sometimes felt that the doctor was not very good at listening to me. 2. The doctors did not fully involve me in decisions about my care. 3. Sometimes I could not completely understand what the doctor told me. 4. Sometimes I felt that the doctor did not see my condition as being very important. 5. I felt I had enough time to discuss my condition during my consultation. 6. The doctor always gave me a lot of support. 7. I got enough advice on how to look after myself. 8. I came away from outpatient/specialist clinic appointments with some of my questions unanswered. Component 2. Continuity, choice of doctor 1. I saw the doctor that I needed to see. 2. It was dif®cult to get to see the doctor of my choice. 3. I had to see junior doctors when I wanted to see the Consultant doctor. Component 3.Waiting for appointment 1. It was easy to get an appointment quickly at the outpatient/specialist clinic. 2. I was kept informed of what was happening in between being told that I would need to go to the outpatient/specialist clinic, and going to my ®rst appointment. 3. I didn't have to wait too long before I went to my ®rst appointment at the outpatient/ specialist clinic. Component 4. Clinic organisation 1. I always felt that the receptionists were very helpful. 2. The receptionists sometimes could make me feel that I was not important. 3. I did not have to wait too long in the outpatient/ specialist clinic. 4. I would have preferred a little more privacy in the outpatient/specialist clinic. Component 5. ªLimboº 1. I felt I was left ªin limboº after I was told that I would need to go to the outpatient/specialist clinic. 2. Once I was told that I would need to go to the outpatient/specialist clinic, I felt that I was ªout of the handsº of the GP. 3. I didn't know how long I would have to wait for my First appointment at the outpatient/specialist clinic. Component 6. Results a 1. I think it was unnecessary for them to repeat some of the tests. 2. They did not fully explain why they were doing some of the tests. 3. I was told exactly what to expect when having tests. 4. I have always been quickly noti®ed of the results of tests. a

Addition to the original version of the patient career diary.

METHODS The women included in this prospective study were recruited from those who attended the one-stop menstrual clinic and those with similar complaints who attended the traditional gynaecology clinic. The referral criteria for the one-stop menstrual clinic were women aged 35 or older, with heavy and/or irregular periods with or without associated dysmenorrhoea. A similar group (premenopausal women aged $35, presenting with regular or irregular heavy periods with or without dysmenorrhoea) was identi®ed from those attending the gynaecology clinics. Of women attending the gynaecology clinic 30.1% had dysmenorrhoea, 39.6% menorrhagia, and 60.3% irregular periods; the corresponding ®gures for women attending the one-stop menstrual clinic were 38%, 45.1%, and 54.8%. In order to enable a broad representation of the gynaecology clinic, women were recruited from ®ve separate traditional gynaecology clinics: three at the Leicester Royal In®rmary, and two peripheral clinics at Coalville Community Hospital, and Loughborough General Hospital. Eligible patients were identi®ed and invited by a researcher to take part in the study, and written consent was obtained.

Quantitative and qualitative methods were used to assess patients' views. The ®rst involved the collection of information by administration of a patient career diary 4. Consecutive patients attending the clinics who met the inclusion criteria were included, aiming to recruit 100 patients for each type of clinic. We used the section of the diary concerned with the patient's ®rst outpatient attendance (Table 1), and at the end of one year following the initial consultation (Table 2). The ®rst section has 21 questions grouped into ®ve components: information, continuity, waiting for an appointment, clinic organisation and limbo (or progress through the system). Since the one-stop menstrual clinic offered more rapid feedback of test results, we added four questions (component 6) to the ®rst part of the diary using the same response format, all concerned with patients' views on the tests they underwent (Table 1). The second component comprises eleven questions grouped into two sections: patient centeredness, and overall process co-ordination. Each question has a ®ve-point response format from strongly agree to strongly disagree, enabling a score to be calculated for each scale; the results were transferred to a scale of 0 (most negative views) and 100 (most positive views). After attending the clinic women were given a patient q RCOG 2001 Br J Obstet Gynaecol 108, pp. 993±999

WOMEN'S EXPERIENCE OF A ONE-STOP MENSTRUAL CLINIC 995 Table 2. Components of the PCD used at one year follow up. Patients were asked to mark their responses as strongly agree, agree, neutral, disagree or strongly disagree. Component 1. Overall process co-ordination 1. The staff involved in my care always seemed to work together very ef®ciently. 2. I have always felt as though I was being treated as an individual. 3. Overall I made very smooth progress through the health service. 4. My care was perfectly coordinated from start to ®nish. Component 2. Patient centeredness 1. Sometimes I could not completely understand what the doctors told me. 2. I have had to go through the same information several times with different staff. 3. Sometimes it was dif®cult to get to see the medical staff that I needed to see. 4. Sometimes I felt a little as though I was left ªin limboº. 5. Sometimes it could be confusing to see different doctors.

career diary questionnaire to complete. They were asked to return it in pre-paid envelopes. The one-year follow up questionnaire was sent through the post, and reminders by letter or telephone were sent if needed. The second part of the study involved qualitative semistructured interviews. The interviewer was blind of the responses contained in the patient career diary. A sample (n ˆ 49) of women attending both types of clinics was approached for interview to ensure the inclusion of those with a variety of menstrual disorders, ethnic groups and socio-economic backgrounds. All interviews took place in the hospital in a quiet room separate from the outpatient consultation rooms. Five patients (one from the onestop menstrual clinic and four from the gynaecology clinic) declined to be interviewed. Forty-four patients were interviewed by one of the authors (J.A.). A topic guide (Table 3) was initially developed and assessed in pilot interviews with the aim of encouraging women to talk extensively about their experience and views of the care they received. We also interviewed some patients at follow up appointments in order to check the validity of Table 3. The topic guide for the semi-structured interviews. Structure of the clinic General atmosphere. Interaction with receptionists and nurses. Consultation Questions and re¯ections. How rushed in relation to consultation and tests. Perceived knowledge of the doctor about the problem. Interaction with the doctor. Information Before, on arrival and during consultation. About tests and treatment plans. Communication of test results. Others How the consultation has affected anxiety levels. Level of satisfaction with the care received. Suggestions for improvement.

q RCOG 2001 Br J Obstet Gynaecol 108, pp. 993±999

the ®ndings of the interviews after the ®rst appointment. All the interviews were recorded on audiotape and transcribed. The transcripts were independently reviewed on repeated occasions by J.A. and R.B. to de®ne and code concepts that consistently emerged 5. Any differences between the reviewers were resolved through discussion. Themes were then derived from the concepts identi®ed. Sections of the transcripts were grouped by `cutting and pasting' in a computer ®le to physically juxtapose material, allowing particular themes to be considered together and be further developed through challenge from negative cases 6,7. The responses to the patient career diary questionnaires were analysed using a standard statistical package (MINITAB Version 13). The differences between the medians was calculated as the median of the pairwise differences between one patient in the onestop menstrual clinic group and one patient in the gynaecology clinic group 8. The Mann-Whitney U test was used, and non-parametric 95% con®dence intervals were calculated. RESULTS Patient career diary A total of 239 patients were recruited into the quantitative study. One hundred and six of the 126 women (84%) recruited from the traditional gynaecology clinic, and 98 of 113 (87%) recruited from the one-stop menstrual clinic completed the patient career diary. There was no signi®cant difference in mean (range) age: gynaecology clinic 42.3 years (35-54.8); one-stop menstrual clinic 42.1 years (35.4-53). There was no signi®cant difference in socio-economic background (as indicated by their postcode) between the two groups 9, nor in ethnicity (gynaecology clinic: 95.1% Caucasian, 4.9% Asian. one-stop menstrual clinic: 93.5% Caucasian, 6.5% Asian or other non-Caucasian). There was a proportionately higher non-response rate amongst non-Caucasians, but this was not different in relation to the type of clinic attended (33% and 25% of non-responders in the gynaecology clinic and the one-stop menstrual clinic, respectively, were Asian). Patients' responses demonstrated statistically signi®cant differences in their perception of the care received in the different clinics. This spanned all components of the ®rst part of the patient career diary, and one of the components of the follow up patient career diary after one year of their ®rst attendance (Table 4). Qualitative interviews Forty-four patients participated in the qualitative interviews, 22 from the one-stop menstrual clinic and 13 from the traditional gynaecology clinic at their ®rst visit, and a further four and ®ve patients at follow up visits at the onestop menstrual clinic and gynaecology clinic, respec-

996 J. I. ABU ET AL. Table 4. The scores of patients' responses to the PCD after the initial visit and one year later. Scores were transformed onto a 0±100 scale. 0 represents the most negative and 100 the most positive views. Missing data were dealt with using mean substitution. n ˆ number of patients completing each component of the questionnaire. IQR ˆ interquartile range. The difference between the medians is calculated for all pairwise differences. The Mann-Whitney U test was used for the analysis. Variables

Initial visit Provision of information, ®tting in Continuity of care, choice of doctor Waiting for appointment Clinic organisation Limbo Investigations and being told of results After one year Overall process co-ordination Patient centeredness

No. of women

Median score [IQR]

GC

MC

GC

MC

104 92 105 105 102 86

97 83 94 98 95 97

71.87 [53.24±81.92] 75.00 [58.33±83.33] 50.00 [29.17±66.67] 68.75 [56.25±81.25] 58.33 [41.67±66.67] 75.00 [50±75]

84.38 [71.87±96.88] 91.67 [75±100] 75.00 [56.25±83.33] 87.50 [75±93.75] 58.33 [50±87.5] 83.33 [75±93.75]

75 74

79 78

75.00 [56.25±81.25] 62.50 [45±76.25]

75.00 [62.5±87.5] 70.00 [55±90]

Median difference (95% CI)

P GC

12.50 (6.25 ± 18.30) 16.67 (8.33 ± 25.00) 25.00 (16.67 ± 33.33) 12.5 (12.50 ± 18.75) 8.33 (8.33 ± 16.67) 16.67 (8.33 ± 20.83) 0.00 (0.00 ± 8.34) 7.50 (0.00 ± 15.00)

, 0.001 , 0.001 , 0.001 , 0.001 , 0.001 , 0.001 0.168 0.024

tively. Three of the gynaecology clinic patients, and four of the one-stop menstrual clinic patients were non-Caucasian. The themes that emerged from the follow up interviews were similar to those from the ®rst visit, therefore, all were analysed together. Three principal themes emerged from the interviews: 1. patient centeredness, 2. the one-stop concept speci®cally; and 3. progress towards resolving the patient's problem. For convenience, GC refers to traditional gynaecology clinic patient and MC refers to one-stop menstrual clinic patient in the following excerpts from interviews.

have to wait made them feel forgotten:

Patient centeredness Women expressed their views about the extent to which the organisation of clinics and their interaction with staff were centred on their needs. In general, women attending the one-stop menstrual clinic were more likely to view the care they received as centred on their needs. Furthermore, if women felt that care was centred on their needs, they felt less anxious:

Patients attending the one-stop menstrual clinic received more information beforehand than those attending the gynaecology clinics. Many found the detailed questionnaire provided by the clinic prior to their ®rst visit helpful. Those attending the gynaecology clinic had a different experience.

GC20: ªeveryone was really quite friendly right from the receptionist¼ but yeah it seems very busy though¼º MC9: ªThey make you feel at ease because when you ®rst come in, I mean, obviously you are nervous and that but I found them all very helpful and they made you feel, you know, not to panic and whatever¼I thought it was lovelyº. Differences between the perceived patient-centeredness of the clinics were evident in comments about waiting at the clinic. Although the one-stop menstrual clinic appointments were longer, most respondents did not mind waiting. Several noted that the clinic visit took less time than they had anticipated. In contrast, many patients mentioned long waiting times in the traditional gynaecology clinics. Uncertainty of how long they would

GC46: ªI think when you have to wait a long time, if people don't keep coming up and reassuring you that you've not been forgotten, I think you do feel a bit sort of you know em. Somebody only came up to me once to sort of say oh there's a long wait. When I ®rst came, they didn't say there was going to be a long waitº. MC17: ªI haven't waited long at all, I mean my appointment was for half past seven and it's what now, it's nearly half past nine so the whole process has only took two hour which I think is very goodº.

MC14: ª¼the booklet was very clearly laid out explaining all the different tests that they would probably do today, you know, from the time of arrival right through to when they ring with the results. And I also had to ®ll in a record sheet of my periods up to when I was coming here, so that was nice as well because that sort of prepared me as well before I actually came. I think the whole has been nicely handled yeahº. GC46: ªI just got a letter to say there would be an appointment in four months time. That was itº. Patients' expressed views re¯ect their perception of the patient-centeredness of the consultation: GC40: ª¼but I did have the feeling that they want to ®nish the process as quickly as possible and move on to the next patient¼I suppose he said what he needed to say. I don't know¼you just get used to being rushed I suppose, you're rushed everywhere aren't you everyq RCOG 2001 Br J Obstet Gynaecol 108, pp. 993±999

WOMEN'S EXPERIENCE OF A ONE-STOP MENSTRUAL CLINIC 997

where you go so¼º MC17: ª¼ I spent more time with him than I thought I was going to. I thought I'll be in and he'll just ask a few questions and I'd be out but no he seemed to want to listen¼º Continuity contributed to the perception of patientcenteredness. Patients attending the gynaecology clinics were more likely to comment on the lack of continuity. Some were even confused as to whom they actually saw. While on the other hand, patients attending the one-stop menstrual clinic felt more relaxed, more comfortable, and less apprehensive: GC76: ª¼I saw another doctor which wasn't the same doctor who checked me the ®rst time so I wasn't very comfortable¼Oh I can't remember his nameº. MC36: ª¼I think you sort of get that sort of like you feel more comfortable don't you instead of seeing different doctors ¼ because I mean obviously everybody comes and they are sort of nervous, they feel apprehensive as well so yes I did feel more comfortable with just seeing the one consultant yeahº. The one-stop clinic In addition to having views on the way in which clinics were organised and care centred around them, patients also had very different impressions depending on the type of clinic they attended: assessment over several visits in the gynaecology clinics or assessment during a single visit, but longer stay in the one-stop menstrual clinic. Patients attending the one-stop menstrual clinic generally appreciated receiving their investigation results and agreeing the management plan on the same day: MC14: ªTo know that all these tests, including the blood test, I will get the results by ®ve o'clock this evening, is a real relief to meº. A sense of reassurance was lacking in patients who attended the gynaecology clinic, as they were uncertain as to when they would know the outcome of the tests, and what the underlying pathology was. GC47: ª¼I am waiting for the results of the tests, so I am not particularly reassured. I don't know what's going to happen until I get the results¼ it's four weeks for another appointment once you have the results backº. Patients of the one-stop clinic found the post-consultation telephone call an acceptable logical extension of the clinic setting. However, some would have preferred faceto-face consultation about their test results: MC17: ªI'd rather have done it face to face actually q RCOG 2001 Br J Obstet Gynaecol 108, pp. 993±999

than over the telephone. I think when you're on the telephone you tend to forget what you wanna ask himº. But others did not share this view: MC14: ªI suppose because it's going to be quick and the only other way round would be for me to hang about here until like four, ®ve o'clock. ¼I think in the circumstances, yes, it's probably the best way to do it because you can go home and relax and you know that at ®ve o'clock you will get the phone call. I'm sure that if something untoward had actually cropped up you know they would have a way of telling youº. Progress towards resolving the problem This theme was concerned with the consequences of the extent to which patients felt that care and clinic organisation was centred on their needs, and the ef®ciency of assessment and investigation leading to a decision about further clinical management. These factors in¯uenced patients' perception of progress towards the resolution of their problems. Many patients in the one-stop menstrual clinic expressed this by saying they felt sorted out: they had a clear idea about the process, and as a result of the quick diagnosis had a more con®dent outlook. There was a clear advantage to the one-stop menstrual clinic in this respect. Patients attending this clinic were usually impressed about getting their results quickly, and recognised how this could bene®t their psychological state: MC14: ªIt was nice and to have all these tests all done together and not have to wait like a few weeks here and a few weeks there then go for the next one. I know that whatever happens I shall go forward from here and feel more con®dent¼ But everything's all done today¼I've been well impressed how quick it's all gone through and everything they said they'd do they've doneº. In contrast, patients attending gynaecology clinics were less likely to feel `sorted out': GC40: ª¼it seems to be quite a long and tedious procedure. I had several tests in the medical centre and then half a year later I came here and then some weeks later I have to go to the hospital which I don't know what the tests were going to be like¼It's quite a long time, I mean to be honest I don't know exactly what they're gonna do ¼ but you know I think four weeks is a long while to wait for a test resultº.

DISCUSSION In this study we used the patient career diary and structured interviews to assess the views of patients attending

998 J. I. ABU ET AL.

the one-stop menstrual clinic compared with a similar group of patients attending traditional gynaecology clinics. The patient career diary is a validated instrument designed to measure patients' views about the care that they receive 4. The results indicate that patients attending the one-stop menstrual clinic had more positive views about their experience as well as signi®cantly higher scores than those attending the traditional gynaecology clinics in all the components of the ®rst part of the patient career diary, which relates to their experience of the clinic attended. This indicates a clear preference for the one-stop approach to care. However, the impact seems to become diluted with the involvement of more care providers over time. The ®ndings of the qualitative investigation con®rmed that women generally found the one-stop menstrual clinic more suited to their needs, and also explained why patients attending the two types of clinic had different feelings about their care. The central ®nding was that women who attended the one-stop menstrual clinic were more likely to feel they were making progress towards recovery or adjustment to their health. The completion of all investigations on the same day in the one-stop menstrual clinic was the key to this. The test results were also given to them over the telephone on the same day and many women accepted this as a logical extension of the services provided by the one-stop menstrual clinic 10. However, the way in which the clinic was organised also in¯uenced the extent to which women felt they had made progress. The important aspects of clinic organisation included provision of information to women, continuity of care and unhurried consultations. All these may be regarded as aspects of patient-centeredness. Thus, the differences in the views of patients attending the two types of clinics were not con®ned to whether they obtained the results of investigations and agreed a management plan on a single day, but also on whether the clinic was organised in accordance to their needs. Furthermore, these two factors in¯uenced the extent to which women felt that they were making progress. If one-stop menstrual clinics are to be set up in other hospitals or clinical areas, attention should be given not only to ensuring that results are available within a single day but also that the clinic is organised to meet the needs of patients. Some quali®cations about this study should be acknowledged. Patients were not randomised to the two types of clinics since they had been referred, usually by their general practitioners. However, the two groups were similar in age, socio-economic background and clinical condition. Since we included patients from several gynaecology clinics, the ®ndings do not represent the particular characteristics of merely a single clinic. Therefore, our ®ndings are likely to be broadly representative of patients' views of the one-stop menstrual clinic in comparison with gynaecology clinics

in general, although further studies involving a wider range of patients and larger numbers of one-stop menstrual clinics are desirable. It is a limitation of our study that only one one-stop menstrual clinic was assessed; however the issues that patients raised were process rather than practitioner speci®c and, as such, are likely to be widely generalisable. The clinic shared the same surroundings and facilities as the other clinics based at the Leicester Royal In®rmary, and is comparable to those of the peripheral clinics. The gender of the consultant is unlikely to have in¯uenced patients' perception as all consultants involved (except for one gynaecology clinic consultant) were male. Information about clinical outcome would be useful. But this is likely to be favourable for our one-stop clinic which from its outset adopted evidence based guidelines. We performed a study of the relative cost of the two types of clinics. This concluded that the one-stop approach is cost neutral to the health service. The cost to the health service of the one-stop clinic including hysteroscopy and ultrasound was £65.73 per patient, whereas the aggregated cost, if the procedures were carried out separately, was £63.96. The direct and indirect costs incurred by a woman attending the one-stop clinic was £18.85, compared with a total cost of £45.25 if she were to attend hospital on separate occasions for a clinical consultation, ultrasound, and for a hysteroscopy 11. It is signi®cant that women continued to perceive advantages of the one-stop clinic after one year of their ®rst attendance. However, it is important to emphasise that while this approach optimises patient management within hospital, is not an overall solution to the variety of other issues that will arise when patients interact with other providers, an issue that is particularly relevant to women with protracted problems. The study demonstrates the advantages of using both quantitative and qualitative methods to investigate patients' views. The quantitative approach identi®ed signi®cant differences in the views of patients attending the two types of clinics. The interviews also identi®ed differences in the views of the two groups of patients but in addition helped to explain the differences noted using the quantitative approach. The use of both methods has provided evidence about the advantages of one-stop menstrual clinics from the patients' perspective and guidance on how such clinics should be organised. We suggest this approach in future studies of patients' views of health care. Acknowledgements The authors would like to thank all the women who took part in the interviews. We are also grateful to Mrs A. Mason-Birks for data entry and transcribing the interviews. The Leicestershire Research and Ethics Committee q RCOG 2001 Br J Obstet Gynaecol 108, pp. 993±999

WOMEN'S EXPERIENCE OF A ONE-STOP MENSTRUAL CLINIC 999

approved this study. The research was supported by Searle, UK, and by Pharmacia and Upjohn Limited. References 1. Nuf®eld Institute for Health. University of Leeds and the NHS Centre for Reviews and Dissemination, University of York, Research Unit, Royal College of Physicians. The management of menorrhagia. Effective Health Care. University of Leeds, 1995. 2. Bradlow J, Coulter A, Brooks P. Patterns of Referral. Oxford: Health Services Research Unit, 1992. 3. Of®ce of Population Censuses and Surveys. Morbidity Statistics from General Practice. Royal College of General Practitioners, Department of Health and Social Security. London: HMSO, 1986. 4. Baker R, Preston C, Cheater F, Hearnshaw H. Measuring patients' attitudes to care across the primary/secondary interface: the development of the patient career diary. Quality in Health Care 1999;8:154±160.

q RCOG 2001 Br J Obstet Gynaecol 108, pp. 993±999

5. Strauss A, Corbin J. Basics of qualitative research, Grounded Theory Procedures and Techniques. Newbury Park: Sage Publications, 1990. 6. Britten N, Jones R, Murphy E, Stacy R. Qualitative research methods in general practice and primary care. Fam Pract 1995;12:104±114. 7. Miles MB, Huberman AM. Qualitative Data Analysis. Thousand Oaks: Sage Publications, 1994. 8. Altman DG, Machin D, Bryant TN, Gardner MJ. Statistics with Con®dence. London: BMJ Publishing Group, 2000. 9. Townsend P, Phillimore P, Beattie A. Health and Deprivation: Inequality in the North. London: Routledge, 1998. 10. Rao JM. Follow up by telephone. BMJ 1994;309:1527±1528. 11. Habiba MA, Nicholls S, Naftalin NJ, Halligan AWF. Development of a one-stop menstrual disorder clinic: lessons learned and their application to the development of clinical governance within an obstetric service. In: von Eiff W, editor. International Hospital Comparison, Volume 2. GuÈtersloh: Bertelsmann Foundation Publishers, 2000:278±322. Accepted 29 May 2001